Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

Background: In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway. Objectives: To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which...

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Autores principales:	Rebecca J Fisher, Niki Chouliara, Adrian Byrne, Trudi Cameron, Sarah Lewis, Peter Langhorne, Thompson Robinson, Justin Waring, Claudia Geue, Lizz Paley, Anthony Rudd, Marion F Walker
Formato:	article
Lenguaje:	EN
Publicado:	NIHR Journals Library 2021
Materias:	stroke community-based rehabilitation early supported discharge realist evaluation implementation mixed methods Public aspects of medicine RA1-1270
Acceso en línea:	https://doaj.org/article/167a51898189419a934a0c01f1210503
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id	oai:doaj.org-article:167a51898189419a934a0c01f1210503
record_format	dspace
institution	DOAJ
collection	DOAJ
language	EN
topic	stroke community-based rehabilitation early supported discharge realist evaluation implementation mixed methods Public aspects of medicine RA1-1270
spellingShingle	stroke community-based rehabilitation early supported discharge realist evaluation implementation mixed methods Public aspects of medicine RA1-1270 Rebecca J Fisher Niki Chouliara Adrian Byrne Trudi Cameron Sarah Lewis Peter Langhorne Thompson Robinson Justin Waring Claudia Geue Lizz Paley Anthony Rudd Marion F Walker Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study
description	Background: In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway. Objectives: To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness. Design: A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes. Setting and interventions: Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England. Participants: Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services. Data and main outcome: Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness. Results: A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway. Limitations: Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory. Conclusions: The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness. Trial registration: Current Controlled Trials ISRCTN15568163. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.
format	article
author	Rebecca J Fisher Niki Chouliara Adrian Byrne Trudi Cameron Sarah Lewis Peter Langhorne Thompson Robinson Justin Waring Claudia Geue Lizz Paley Anthony Rudd Marion F Walker
author_facet	Rebecca J Fisher Niki Chouliara Adrian Byrne Trudi Cameron Sarah Lewis Peter Langhorne Thompson Robinson Justin Waring Claudia Geue Lizz Paley Anthony Rudd Marion F Walker
author_sort	Rebecca J Fisher
title	Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study
title_short	Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study
title_full	Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study
title_fullStr	Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study
title_full_unstemmed	Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study
title_sort	large-scale implementation of stroke early supported discharge: the wise realist mixed-methods study
publisher	NIHR Journals Library
publishDate	2021
url	https://doaj.org/article/167a51898189419a934a0c01f1210503
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spelling	oai:doaj.org-article:167a51898189419a934a0c01f12105032021-11-25T10:41:32ZLarge-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study2050-43492050-435710.3310/hsdr09220https://doaj.org/article/167a51898189419a934a0c01f12105032021-11-01T00:00:00Zhttps://doi.org/10.3310/hsdr09220https://doaj.org/toc/2050-4349https://doaj.org/toc/2050-4357Background: In England, the provision of early supported discharge is recommended as part of an evidence-based stroke care pathway. Objectives: To investigate the effectiveness of early supported discharge services when implemented at scale in practice and to understand how the context within which these services operate influences their implementation and effectiveness. Design: A mixed-methods study using a realist evaluation approach and two interlinking work packages was undertaken. Three programme theories were tested to investigate the adoption of evidence-based core components, differences in urban and rural settings, and communication processes. Setting and interventions: Early supported discharge services across a large geographical area of England, covering the West and East Midlands, the East of England and the North of England. Participants: Work package 1: historical prospective patient data from the Sentinel Stroke National Audit Programme collected by early supported discharge and hospital teams. Work package 2: NHS staff (n = 117) and patients (n = 30) from six purposely selected early supported discharge services. Data and main outcome: Work package 1: a 17-item early supported discharge consensus score measured the adherence to evidence-based core components defined in an international consensus document. The effectiveness of early supported discharge was measured with process and patient outcomes and costs. Work package 2: semistructured interviews and focus groups with NHS staff and patients were undertaken to investigate the contextual determinants of early supported discharge effectiveness. Results: A variety of early supported discharge service models had been adopted, as reflected by the variability in the early supported discharge consensus score. A one-unit increase in early supported discharge consensus score was significantly associated with a more responsive early supported discharge service and increased treatment intensity. There was no association with stroke survivor outcome. Patients who received early supported discharge in their stroke care pathway spent, on average, 1 day longer in hospital than those who did not receive early supported discharge. The most rural services had the highest service costs per patient. NHS staff identified core evidence-based components (e.g. eligibility criteria, co-ordinated multidisciplinary team and regular weekly multidisciplinary team meetings) as central to the effectiveness of early supported discharge. Mechanisms thought to streamline discharge and help teams to meet their responsiveness targets included having access to a social worker and the quality of communications and transitions across services. The role of rehabilitation assistants and an interdisciplinary approach were facilitators of delivering an intensive service. The rurality of early supported discharge services, especially when coupled with capacity issues and increased travel times to visit patients, could influence the intensity of rehabilitation provision and teams’ flexibility to adjust to patients’ needs. This required organising multidisciplinary teams and meetings around the local geography. Findings also highlighted the importance of good leadership and communication. Early supported discharge staff highlighted the need for collaborative and trusting relationships with patients and carers and stroke unit staff, as well as across the wider stroke care pathway. Limitations: Work package 1: possible influence of unobserved variables and we were unable to determine the effect of early supported discharge on patient outcomes. Work package 2: the pragmatic approach led to ‘theoretical nuggets’ rather than an overarching higher-level theory. Conclusions: The realist evaluation methodology allowed us to address the complexity of early supported discharge delivery in real-world settings. The findings highlighted the importance of context and contextual features and mechanisms that need to be either addressed or capitalised on to improve effectiveness. Trial registration: Current Controlled Trials ISRCTN15568163. Funding: This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 22. See the NIHR Journals Library website for further project information.Rebecca J FisherNiki ChouliaraAdrian ByrneTrudi CameronSarah LewisPeter LanghorneThompson RobinsonJustin WaringClaudia GeueLizz PaleyAnthony RuddMarion F WalkerNIHR Journals Libraryarticlestrokecommunity-based rehabilitationearly supported dischargerealist evaluationimplementationmixed methodsPublic aspects of medicineRA1-1270ENHealth Services and Delivery Research, Vol 9, Iss 22 (2021)

Large-scale implementation of stroke early supported discharge: the WISE realist mixed-methods study

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