the post stroke checklist - snsa.org.sg...male 75 (75.0) female 25 (25.0) missing/no response 0...

The Post Stroke Checklist

Singapore National Stroke Association, 2014 Stroke Club 1

Christopher Chen, FRCP, FAMS

Department of Pharmacology, National University of Singapore

Singapore

DISCLOSURES

This study was sponsored by Allergan, Inc., Irvine, CA.

Writing and editorial assistance was provided by Allergan, Inc., Irvine,

CA.

All authors met the ICMJE authorship criteria.

Neither honoraria nor payments were made for authorship.


BACKGROUND

• Stroke is the second leading cause of death and one of the leading

contributors to adult disability worldwide

− Poses a significant personal, social, and financial global burden

− 4th highest cause of death in Singapore, accounting for 9.0% of total

deaths - second highest cause of premature mortality

− 4th highest cause of disease burden overall in Singapore

− The Singapore Ministry of Health recognizes that stroke is one of the

four main chronic diseases affecting Singaporeans

• The effects following a stroke can last for many years and may result

in a number of disabilities and impairments that can decrease the

quality of a person’s life


BACKGROUND

• Although national stroke guidelines in Singapore and elsewhere in

the world advocate long term care of stroke patients, there is no

standardized process for long-term follow-up care to assess and

address the holistic needs of stroke survivors

• Long-term care for stroke survivors is fragmented and lacks an

evidence-based, easy-to-use tool to identify persistent long-term

problems and streamline referral for treatment

• A lack of standardized long-term post stroke assessment leads to

missed rehabilitation and recovery opportunities for stroke survivors


DEVELOPING THE PSC

• To address the lack of long-term stroke management worldwide an

international, multidisciplinary group of stroke experts (Global Stroke

Community Advisory Panel [GSCAP]) was formed

• GSCAP, supported by measurement experts, recognized the need for

the PSC and subsequently developed the tool


BACKGROUND

• The Post Stroke Checklist (PSC) was developed to help healthcare

professionals identify post stroke problems amenable to treatment

and assist with subsequent referral (if necessary)

• The PSC is a simple, “easy to use” checklist covering broad aspects

of quality of life after stroke

− Identifies treatment opportunities where an evidence based intervention

is available and would be of value to the stroke survivor

− Includes 11 concepts/items

− Each item comprises a dichotomous ‘yes’/’no’ response scale and

provides referral recommendations (adapted locally) for each problem

identified

• Administered to stroke survivors in the community setting by a

healthcare professional 6 to 12 months post-stroke, and annually

thereafter


THE POST STROKE CHECKLIST (PSC)


APPROACH AND EXECUTION

• Pilot studies were conducted in the United Kingdom and Singapore

− The goal was to evaluate the feasibility and usefulness of the PSC in

clinical practice and assess its relevance to stroke survivors

• In Singapore, 100 patients were recruited from the Cognitive

Outcomes After Stroke (COAST) study, an on-going investigation of

stroke patients identified from the acute stroke service

− Ethical approval was obtained from the National Healthcare Group

Domain Specific Review Board (NHG DSRB) in Singapore

− Patients were eligible to participate if they had experienced a cerebral

infarction or intracerebral hemorrhage between 9 and 36 months ago

− Expressive dysphasic patients were included, provided they were able to

respond to the PSC items



• Clinicians were instructed to take the following steps when

administering the PSC:

− Read each question as worded

− If patient has difficulty in understanding, repeat the question as worded

− If the patient continues to have difficulty in understanding, rephrase a

key word in the question

− If the patient continues to have difficulty in understanding, rephrase the

whole question

• During administration of the PSC to English-speaking patients in

Singapore, a trained researcher was present in the room, as an

observer

− Noted any issues with the checklist administration

− Recorded the duration of the assessment visit and the time taken to

administer the checklist.




Clinician

administers the

PSC to patient

Patient and

clinician complete

satisfaction with

PSC

questionnaires

If patient does not

understand, the clinician

repeats and rephrases

as needed

Descriptive statistics used to analyze quantitative data

Outcomes:

• Patient and Clinician satisfaction with the PSC (3 questions,

0-10 rating scale)

• Clinician satisfaction with the PSC (Pragmatic Content and

Face Validity Test (PRAC-Test)

• Time taken to administer the PSC (observer-recorded)

• Duration of the patient visit (observer-recorded)

• Number and type of referrals (based on completed PSC)

Qualitative data analysis of the PSC administration

Outcomes:

• Comprehension of the PSC to patients

• Issues with PSC administration

Independent researcher

observes PSC

administration (English speaking patients only)

SINGAPORE PSC PILOT STUDY


Patient characteristics Singapore (N=100)

n (%)

Age of patient:

Mean (SD) 61 (10.9)

Min-Max 24-95

Missing/No response 1

Patient gender:

Male 75 (75.0)

Female 25 (25.0)

Missing/No response 0 (0.0)

Years since most recent stroke event:

Mean (SD) [2] 1 (0.4)

Min-Max [3] 0-3

Missing/No response 7

Type of healthcare professional

visited by the patient for post-stroke

monitoring or treatment:

Stroke specialist 29 (29.0)

General Practitioner 17 (17.0)

General Neurologist 12 (12.0)

Cardiologist 12 (12.0)

Outpatient Polyclinic 9 (9.0)

Missing/No response 5 (5.0)

Endocrinologist 1 (1.0)

Rehabilitation specialist 1 (1.0)

Community Stroke Team 1 (1.0)

Other 13 (1.0)

Patient characteristics Singapore (N=100)

n (%)

Type of Co-morbidity:

Cardiovascular 91 (91.0)

Neurological 85 (85.0)

Endocrinological/Nutritional 47 (47.0)

Gastroenterological 7 (7.0)

Urological/Renal 5 (5.0)

Opthalmological 5 (5.0)

Respiratory 4 (4.0)

Rheumatological 3 (3.0)

Haematological 1 (1.0)

Other 11 (11.0)

Missing data/No treatment 5 (5.0)

Current post stroke treatment:

Pharmacological Treatment 85 (85.0)

Anti-platelet 81 (81.0)

Anti-hypertensive 37 (37.0)

Anti-cholesterol 35 (35.0)

Anti-hyperglycemic 17 (17.0)

Anti-coagulant 6 (6.0)

Current post stroke physical

therapy 0 (0.0)

Missing data/No treatment 15 (15.0)

RESULTS – ADMINISTRATION TIME

• Of 45 observed PSC administrations, the mean (SD)

duration of the patient visit

− 17 (7.8) minutes

• Of 45 observed PSC administrations, the mean (SD)

duration taken to administer the PSC

− 8 (3.8) minutes


RESULTS – PATIENT UNDERSTANDING


PSC Item

Patient

understood the

item on the first

reading by the

clinician

Patient

understood after

the item was

repeated

Patient

understood after

an item word was

rephrased the

whole question

was rephrased

Patient did not

understand the

item at all

Secondary Prevention 29 (64.4) 1 (2.2) 8 (17.8) 0 (0.0)

Activities of daily living 43 (95.6) 2 (4.4) 0 (0.0) 0 (0.0)

Mobility 42 (93.3) 3 (6.7) 0 (0.0) 0 (0.0)

Spasticity 44 (97.8) 1 (2.2) 1 (2.2) 0 (0.0)

Pain 44 (97.8) 1 (2.2) 0 (0.0) 0 (0.0)

Incontinence 39 (86.7) 1 (2.2) 5 (11.1) 0 (0.0)

Communication 43 (95.6) 1 (2.2) 1 (2.2) 0 (0.0)

Mood 43 (95.6) 1 (2.2) 1 (2.2) 0 (0.0)

Cognition 42 (93.3) 2 (4.4) 0 (0.0) 0 (0.0)

Life after stroke 42 (93.3) 1 (2.2) 1 (2.2) 0 (0.0)

Relationship with family 43 (95.6) 0 (0.0) 0 (0.0) 0 (0.0)

RESULTS – PATIENT RESPONSES


Problems Male (N=75)

n (%)

Female (N=25)

n (%)

Total (N=100)

n (%)

1. Absence of Secondary

Prevention 11 (14.7) 4 (16.0) 15 (15.0)

2. Activities of Daily Living 11 (14.7) 7 (28.0) 18 (18.0)

3. Mobility 19 (25.3) 7 (28.0) 26 (26.0)

4. Spasticity 18 (24.0) 4 (16.0) 22 (22.0)

5. Pain 24 (32.0) 8 (32.0) 32 (32.0)

6. Incontinence 10 (13.3) 7 (28.0) 17 (17.0)

7. Communication 8 (10.7) 3 (12.0) 11 (11.0)

8. Mood 22 (29.3) 10 (40.0) 32 (32.0)

9. Cognition 29 (38.7) 7 (28.0) 36 (36.0)

10. Life After Stroke 18 (24.0) 7 (28.0) 25 (25.0)

11. Relationship with Family 11 (14.7) 4 (16.0) 15 (15.0)

RESULTS – PATIENT SATISFACTION


Patient satisfaction with PSC

(0-10 numerical rating scale)

Male (N=75)

n (%)

Female (N=25)

n (%)

Total (N=100)

n (%)

Q1 How satisfied are you with the overall assessment

you have just received?

(0 – extremely dissatisfied, 10 – extremely satisfied)

Mean (SD) 8.5 (1.4) 8.4 (1.6) 8.4 (1.4)

Median 9 8 8

Min-Max 5-10 5-10 5-10

Missing/No response 0 0 0

Q2 How satisfied are you that the checklist used by the

clinician during the assessment identified your needs

correctly?


Mean (SD) 8.4 (1.6) 7.9 (1.8) 8.3 (1.7)

Median 9 8 8

Min-Max 5-10 5-10 5-10


Q3 How likely do you think you will receive the type of

health and/or care services you think you need?

(0 – extremely unlikely, 10 – extremely likely)

Mean (SD) 7.8 (2.0) 8.2 (1.8) 7.9 (2.0)

Median 8 8 8

Min-Max 0-10 5-10 0-10


RESULTS – CLINICIAN SATISFACTION


Clinician satisfaction with PSC

(0-10 numerical rating scale)

Male Patient

(N=29)

n (%)

Female

Patient (N=11)

n (%)

Total

(N=40)*

n (%)

Q1 How satisfied are you with the overall use of the

Checklist during this assessment?


Mean (SD) 7.8 (1.3) 7.9 (1.3) 7.8 (1.3)

Median 8 8 8

Min-Max 5-10 6-10 5-10


Q2 How satisfied are you with the Checklist in helping

you identify the needs of this patient?


Mean (SD) 7.9 (1.5) 7.9 (1.6) 7.9 (1.5)

Median 8 9 8

Min-Max 4-10 5-10 4-10


Q3 How satisfied are you with the Checklist in helping

you make referrals for this patient?


Mean (SD) 7.6 (1.6) 7.3 (1.6) 7.5 (1.6)

Median 8 7 8

Min-Max 4-10 5-10 4-10


RESULTS – CLINICIAN SATISFACTION


Property of the PSC Singapore (N=5)

n, positive responses (%)

Useful 5 (100.0)

Informative 5 (100.0)

Enhances communication with patients 4 (80.0)

Practical 4 (80.0)

Exhaustive 4 (80.0)

Will help therapeutic decision making 3 (60.0)

Simple 3 (60.0)

Quick to complete 3 (60.0)

• All clinicians (n=5, 100%) felt they would like patients to complete the

PSC before the visit (in the waiting room)

• 80% of clinicians (n=4) would probably or definitely recommend the

PSC to a colleague, and their reaction would be quite positive

CONCLUSIONS

• The high overall satisfaction and positive feedback from patients and

clinicians indicate that the PSC is acceptable and useful for

identifying the needs of stroke survivors

− Findings also indicate that the PSC is easy and timely to administer and

generally well understood

• As the PSC is implemented into clinical practice, the tool will help

improve the long-term care of stroke survivors which will ultimately

improve their quality of life while easing the burden on their families

and caregivers


ENDORSEMENTS AND IMPLEMENTATION

Endorsements* World Stroke Organization

• Organizational website

National Stroke Association (United States) • Organizational website

• ProEd newsletter and Stroke Smart Magazine

• Stroke training initiatives

Canadian Best Practice Recommendations for Stroke Care • Organizational website

• Stroke discharge packs

• Stroke training initiatives

National Stroke Foundation (Australia) • Organizational websites

• Stroke discharge packs

Implementation* Clinical Sites • Hershey Medical Center (US)

• Danube University in Krems (Austria)

• East Midlands region (UK)

Regional Meetings • Asia Pacific Neuro-Rehab Ad Board (Hong Kong, India,

Taiwan, Korea, Singapore, and Thailand)

• Australian PSC Implementation Meeting

• Europe PSC Implementation Meeting

Dissemination • International Society of Physical Medicine and Rehabilitation

• Allergan Field Force


The PSC development manuscript has been published (Philp et al., 2013)

and the pilot manuscript submitted to journal

* Endorsements and implementation of the PSC are on-going with several

other sites and associations in US, Canada, Europe, and Australia

EASY ACCESS TO THE PSC AT

www.worldstrokecampaign.org


HOW MIGHT WE MOVE FORWARD IN

SINGAPORE?

− Would the PSC be useful in Singapore?

• Primary Care

• Step Down Care

• Specialist Services

− Do we need further studies in Singapore?

• Primary Care

− Feasibility

− Prevalence

− Referrals

− Improvement of patient outcomes

− Can the Stroke Association endorse the PSC?


the post stroke checklist - snsa.org.sg...male 75 (75.0) female 25 (25.0) missing/no response 0...

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