APHA Annual Meeting and Expo, Nov 2013 Boston, MA

1. Outcome Measure Use in Community-Based
Stroke Rehabilitation:
An Exploration of Therapists’ Current Practice
in Scotland.
Thilo Kroll , Helen Moore , Jacqui
1
2
Morris , Lisa Salisbury , Frederike
3
4
van Wijck , James Law , John
5
Dennis
1
1
Contact: t.kroll@ dundee.ac.uk
Social Dimensions of Health Institute, Universities of Dundee and St Andrews
2
Nursing Studies/ Interdisciplinary Social Sciences in Health, University of
Edinburgh, UK
3
Institute for Applied Health Research, Glasgow Caledonian University, Glasgow
4
School of Education, Communication and Language Sciences, Newcastle
University, Newcastle
5
NHS Greater Glasgow and Clyde, Glasgow
1
1.INTRODUCTION
3. RESULTS
Stroke rehabilitation needs to be evidence-based,
equitable and patient-centred and outcome measurement
must reflect these values.
113 therapists (51 PTs, 39 OTs, 23 SLTs) completed the
survey and 13 therapists took part in interviews.
Relevance: To be patient-centred, rehabilitation should
achieve outcomes that are of personal relevance to the
service user. Outcome measures should therefore reflect
the achievement of goals considered important by
individuals with stroke.
Accessibility: To be equitable, outcome measurement
should be sufficiently inclusive to engage people with a
range of stroke-related disabilities.
Converging evidence indicates a gap between UK policy
and clinical practice in terms of stroke outcome
assessment.
Aim: to examine the rationale for outcome measure
selection currently in use by UK rehabilitation
professionals (i.e. PT, OT, SLT) in community stroke
rehabilitation.
2. METHODS
Web-based survey:
Senior rehabilitation professionals (PTs, OTs, SLTs)
across all 14 Scottish health boards were invited to
Aim: to explore the viewpoints of people with
participate in a web-based survey.
aphasia after stroke on outcome measures, to
inform rehabilitation outcome
Questions covered whatpractice. measures are currently
in use, the top 5 reasons for selecting measures,
satisfaction with outcome measurement and
demographic characteristics.
The survey was piloted with 6 rehabilitation
professionals and refined via input from project
reference group members. Survey Monkey was used to
collect and conduct preliminary analysis of data.
Follow-up interviews:
A sub-set of therapists who took part in the survey were
also invited to take part in a 30 minute follow-up phone
interview to explore outcome measurement use in more
depth.
Framework analysis1 was used to analyse interviews.
The MOST COMMONLY USED instruments are:
PTs: Berg Balance Scale (80.4%), Tinetti Balance (74.5%),
Tinetti Gait (68.6%)
OTs: Rivermead Behavioural Memory Test (48.7%), Barthel
Index (46.1%)
SLTs: Therapy Outcome Measure (52.2%), Frenchay
Aphasia Screening Test (30.4%), non-validated (21.7%)
9.9% of therapists are using locally developed measures.
THE WIDER
PROJECT
The TOP 5 reasons for selecting which measure to use are:
•They are relevant to patients’ goals (n=68; 60.2%)
•They are easy to use (n=59; 52.2%)
•There is a good evidence base for using the instrument
(n=53; 46.9%)
•They are sensitive to change in patient performance
(n=51; 45.1%)
•They are specific to the outcomes being measured (n=49;
43.4%)
Phase 1 Service user
exploration:
Semi-structured
interviews with 33
stroke survivors (6
interviews used Talking
Mats) to explore their
views on what matters
after stroke and on
outcome assessment.
Accessibility was within the top 5 reasons for selecting an
outcome measure for only 8.5% of respondents and a
measure being aphasia friendly was within the top 5
reasons for selection for 2.5% of respondents.
Despite relevance to patients’ goals being the primary
driver in outcome measure selection, only 13.6% of
therapists endorsed ‘the measure elicits the views of
patients’ as within their top 5 reasons for selecting
outcome measures.
When asked about satisfaction with the range of measures
available, 37.5% of respondents expressed dissatisfaction
with the relevance of the range of measures available.
“Outcome measures are not patient-centred, and are rarely a
reflection of the patient's goals. They tend to be prescriptive and
focus on what a patient can or cannot do, rather than what they
need or want to be able to do” (SLT)
Interviews highlighted the tension for therapists between
best practice and systems constraints, such as difficulty
accessing measures due to financial constraints, lack of
time and environmental barriers to using measures.
5. CONCLUSION
•The findings show that practice, in line with policy, is shifting
towards greater patient-centredness in rehabilitation, with
relevance being a key factor in selecting outcome measures.
•Despite relevance being a key factor in selecting outcome
measures, over a third of therapists were dissatisfied with the
range of measures available in terms of relevance to their
patients. Therapists rarely felt that selecting measures which
elicit patient viewpoints was most important.
•The findings highlight a gap between UK policy and practice
in terms of inclusiveness, with accessibility of outcome
measures not being a key factor in outcome measure
selection.
This cross-sectional
Scotland-wide study
has 3 phases:
Phase 2 Therapy
practice exploration:
•survey of 120 AHPs
about use of outcomes
•follow-up phone
interviews with 13
AHPs
Phase 3 Synthesis
workshop:
Concept mapping
workshop bringing all
participants together
to explore findings and
generate future
recommendations.
WHERE TO NEXT?
We envisage that study
findings will pave the
way towards a more
inclusive and relevant
approach to assessment
for this population in the
community setting, and
improve their quality of
care.
REFERENCES
1. Ritchie, J., Spencer, L.,
& O’Connor, W. (2004).
Carrying out Qualitative
Analysis. In J. Ritchie & J.
Lewis (Eds.). Qualitative
Research Practice (pp.
219-262). London: Sage.

3. What matters to people after stroke?
Using an innovative communication framework
to involve people with aphasia in interviews
about stroke rehabilitation
Thilo Kroll , Jacqui Morris , Helen
1
2
Moore , Frederike van Wijck , Lisa
3
4
Salisbury , James Law , John
5
Dennis ,
1
1
Contact: t.kroll@ dundee.ac.uk
1.INTRODUCTION
Social Dimensions of Health Institute, Universities of Dundee and St Andrews
2
Institute for Applied Health Research, Glasgow Caledonian University, Glasgow
3
Nursing Studies/ Interdisciplinary Social Sciences in Health, University of
Edinburgh, UK
4
School of Education, Communication and Language Sciences, Newcastle
University, Newcastle
5
NHS Greater Glasgow and Clyde, Glasgow
1
3. A COMPLETED TALKING MAT
People with communication disabilities, including people
with aphasia after stroke may find it challenging to
communicate what are meaningful outcomes in
community stroke rehabilitation
Moreover, the views of people with severe communication
impairments are rarely considered in health and
rehabilitation-focused research.
THE WIDER
PROJECT CONTEXT
This Scotland-wide
study has 3 phases:
Including the views of those with severe communication
impairment is critical to gain a comprehensive
understanding of their priorities within rehabilitation and
their views on which outcomes are meaningful.
Aim: to explore the viewpoints of people with
aphasia after stroke on what matters to them most
to inform community rehabilitation practice.
2. METHOD
Participants with aphasia, currently engaged in community
stroke rehabilitation across Scotland, were recruited.
This study used Talking Mats™ 1, a communication
framework and speech therapy support tool, which
represents discussion topics pictorially as symbols placed
along a visual scale on a mat.
Talking Mats were used to adapt the format of interviews
previously conducted with a larger group of stroke
participants without aphasia, as part of phase 1 of this
Scotland-wide study (see right-hand panel of this poster).
All participants were asked:
What is important to
you in your life?
Symbols were generated on the basis of previous
responses from project interviewees and the issues most
assessed by therapists who participated in phase 2 of the
study (i.e. balance and gait).
Symbols were placed on one mat with a 3-point top-scale,
composed of ‘Important’, ‘I’m not sure’ and ‘Not important’
ratings.
Participants were encouraged to add their own symbols
whilst generating the mat if issues that were important to
them were not included in the pre-prepared symbols
selection.
4. RESULTS
6 participants with aphasia (4 male, 2 female, mean age 62,
range 32-75 y) took part in Talking Mats interviews. Factors
identified as important to participants after stroke in the wider
interview study were endorsed by participants with aphasia.
These factors can be mapped onto the 9 WHO ICF
participation domains2.
Phase 1 Service user
exploration:
Semi-structured
interviews with 34
stroke survivors to
explore their views on
what matters after
stroke and on outcome
assessment.
Phase 2 Therapy
practice exploration:
•survey of 113
Rehabilitation
Professionals about
What is important? All 6 participants rated being able to get outcome us
around, self-care and relationships with others as being •follow-up phone
important to them, as illustrated in the following quote:
interviews with 13
AHPs
Participant: Well, they’ve always
Int: How about
relationships? Are
they important to
your life?
been good to us really, we’ve
always had strong […] family are
always there
[SU places symbol at ‘important’].
Phase 3 Synthesis
workshop:
Concept mapping
workshop bringing all
What is not important? The least important items were being participants together to
able to multi-task and driving. Each was rated as important explore findings and
by one participant only. Communication, using the phone generate future
and writing messages were important for most but not all
recommendations.
participants. Interestingly, the two items assessed most often
WHERE TO NEXT?
by therapists (i.e. balance and gait), were each rated as
We envisage that study
important by one participant only.
findings will pave the
way towards a more
When completing the Talking Mat, items rated as ‘not
inclusive and relevant
important’ to participants were sometimes closely linked to the
approach to assessment
areas of reduced physical and communicative function.
for this population in the
community setting, and
improve their quality of
care.
5. CONCLUSION
•Views of people with aphasia on what matters most to them
in their rehabilitation may differ from therapists’ views.
•Talking Mats™ is a useful tool in eliciting the views of people
with aphasia about what matters most to them after stroke.
•The use of Talking Mats™ to answer the question “what is
important to you in your life” may miss the complex
relationship between importance of participation in a life role
and the barriers participants face in performing that role.
Downgrading “importance” may serve a self protective
function. It will be important for therapists to tease out areas
of actual importance from areas in which there are
participation barriers when discussing rehabilitation goals.
REFERENCES
Murphy J & Boa S. (2012)
Using the WHO-ICF with
Talking Mats as a goal
setting tool. AAC Journal
28(1) 52-60.
World Health Organisation
(2001). International
Classification of
Functioning, Disability and
Health.