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Abstract
Introduction:
Although clinical guidelines recommend various care processes to improve outcomes of patients with stroke, evidence to support many of them, such as the management of post-stroke infections and the monitoring of abnormal physiological variables, are scarce. While for those care processes with more evidence, very few studies have quantified their variations across regions and what factors influence their implementation in clinical practice. This thesis aims to determine the utilisation of guideline-recommended care processes for patients with acute stroke, and explore various strategies that may improve their implementation.
Methods:
I conducted secondary analyses of a large clinical trial to explore the associations of care processes and clinical outcomes, using data of 11,093 patients with acute stroke from nine countries. These care processes included dysphagia screening, indwelling urinary catheterisation (IUC), and early detection of low blood pressure (BP) and oxygen saturation (SaO2) levels. To explore variations in the utilisation of care processes, I compared the evidence-based recommendations for stroke unit care across Australia/UK, China, India/Sri Lanka and South America. I also conducted a process evaluation of a ‘quality improvement’ intervention within an ongoing trial involving the management of patients with acute intracerebral haemorrhage in China, to explore what factors could improve the implementation of systems to improve the quality of care.
Results:
Patients who failed a dysphagia screen, had an IUC, had SBP <120mmHg or SaO2 <93% during the acute phase (up to 7 days after stroke onset) had increased odds of poor outcome. The utilisation of care processes varied across regions, with lower probabilities of reperfusion therapy and allied health care in low- and middle-income countries (LMICs) than high-income countries. Constant training with the clinicians, case reviews, optimisation of workflow within available resources, and having a dedicated team, may facilitate the implementation of evidence-based care.
Conclusions:
The utilisations of guideline-recommended care processes are associated with patient outcomes and vary across regions. Timely assessment and appropriate management should be provided to those with dysphagia, IUC, low BP, and low SaO2 levels, in an effort to improve their recovery after stroke. Future studies are needed to confirm the causality of these associations and to examine opportunities to promote the delivery of evidence-based stroke care, especially in LMICs.
