A Clinician's Roadmap to the Research and Data Acquisition Process Within the Veterans Health System.

Objective Identify and address potential obstacles to initiation of older population-related research within the NF/SG VHS through the provision of a concise flowchart. Setting North Florida/South Georgia Veterans Health System (NF/SG VHS). Practice Description The Department of Veterans Affairs (VA) Research Service with connection to the University of Florida facilitates research that contributes to improving the delivery of inpatient/outpatient care to veterans and their families. Practice Innovation A compendium of a senior care pharmacist's experiences will be compiled and reviewed by other specialists within the field while attempting to submit research protocols for publication within the VHS through the use of data platforms such as VINCI (VA Informatics and Computing Infrastructure) and the Corporate Data Warehouse. Main Outcome Measurements Impact of navigating research websites affiliated with and directly pertaining to the NF/SG VHS upon clinicians attempting to begin research processes within the institution. Results It was determined that for the most expeditious publication experience to result the following six steps had to be pursued sequentially: VA Institutional Review Board (IRB) Net documentation/ submission, local myIRB submission, Data Access Request Tracker/VINCI access request, setup of VINCI workspace, drafting of VINCI cohort specification, data analysis and tracking, statistical methods, abstract, and manuscript production. Conclusion This study outlines a consistent/clear method from first-hand experiences on how to navigate, more efficiently, complex research processes to produce successful future impacts on patient care.

Study protocol of a telephone problem-solving intervention for Spanish-speaking caregivers of veterans post-stroke: an 8-session investigator-blinded, two-arm parallel (intervention vs usual care), randomized clinical trial.

BACKGROUND: Stroke is one of the leading causes of death and the main cause of long-term disability in the United States. The significant risk factors of stroke among Hispanics are well-documented. The majority of stroke survivors return home following a stroke and are cared for by family caregivers. Due to the abrupt nature of strokes, caregivers experience unexpected changes and demands that oftentimes lead to caregiver burden and depression. Given the significant risk factors for stroke in Hispanics and the influence of culture in family norms and family management, we developed a telephone and online problem-solving intervention for Spanish-speaking stroke caregivers. This study tests the impact of a telephone and online problem-solving intervention for Spanish-speaking stroke caregivers on caregiver outcomes. METHODS: The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 290 caregivers from 3 Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a problem-solving intervention that uses telephone and online education and care management tools on the previously developed and nationally available RESCUE en Español Caregiver website. In the usual care group, participants receive the information and/or support caregivers of veterans with stroke normally receive through existing VA resources (e.g., stroke-related information and support). The primary outcome is change in caregiver's depressive symptoms at 1- and 12-weeks post-intervention. Secondary outcomes include changes in stroke caregivers' burden, self-efficacy, problem-solving, and health-related quality of life (HRQOL) and veterans' functional abilities. We will also determine the budgetary impact, the acceptability of the intervention and participation barriers and facilitators for Spanish-speaking stroke caregivers. DISCUSSION: This is an ongoing study. It is the first known randomized controlled trial testing the effect of a telephone and online problem-solving intervention in Spanish for caregivers of veterans post-stroke. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post-stroke. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03142841- Spanish Intervention for Caregivers of Veterans with Stroke (RESCUE Español). Registered on February 23, 2018. Protocol version 8. 08.11.2022.

Deprescribing Strategies for Opioids and Benzodiazepines with Emphasis on Concurrent Use: A Scoping Review.

While the Food and Drug Administration's black-box warnings caution against concurrent opioid and benzodiazepine (OPI-BZD) use, there is little guidance on how to deprescribe these medications. This scoping review analyzes the available opioid and/or benzodiazepine deprescribing strategies from the PubMed, EMBASE, Web of Science, Scopus, and Cochrane Library databases (01/1995-08/2020) and the gray literature. We identified 39 original research studies (opioids: n = 5, benzodiazepines: n = 31, concurrent use: n = 3) and 26 guidelines (opioids: n = 16, benzodiazepines: n = 11, concurrent use: n = 0). Among the three studies deprescribing concurrent use (success rates of 21-100%), two evaluated a 3-week rehabilitation program, and one assessed a 24-week primary care intervention for veterans. Initial opioid dose deprescribing rates ranged from (1) 10-20%/weekday followed by 2.5-10%/weekday over three weeks to (2) 10-25%/1-4 weeks. Initial benzodiazepine dose deprescribing rates ranged from (1) patient-specific reductions over three weeks to (2) 50% dose reduction for 2-4 weeks, followed by 2-8 weeks of dose maintenance and then a 25% reduction biweekly. Among the 26 guidelines identified, 22 highlighted the risks of co-prescribing OPI-BZD, and 4 provided conflicting recommendations on the OPI-BZD deprescribing sequence. Thirty-five states' websites provided resources for opioid deprescription and three states' websites had benzodiazepine deprescribing recommendations. Further studies are needed to better guide OPI-BZD deprescription.

Effect of a telephone and web-based problem-solving intervention for stroke caregivers on stroke patient activities of daily living: A randomized controlled trial.

OBJECTIVE: To test for effects of a problem-solving intervention for stroke caregivers on stroke survivor activities of daily living. DESIGN: Two-arm parallel randomized clinical trial with repeated measures at 11 weeks and 19 weeks. SETTING: Medical centers for US military Veterans. SUBJECTS: Caregivers of stroke survivors. INTERVENTION: A registered nurse guided caregivers in using problem-solving strategies emphasizing creative thinking, optimism, planning, and expert information to address challenges associated with caregiving. Caregivers in the intervention completed one telephone orientation session followed by eight online, asynchronous messaging center sessions. The messaging center sessions involved (a) education on the Resources and Education for Stroke Caregivers' Understanding and Empowerment website (https://www.stroke.cindrr.research.va.gov/en/), (b) supportive communication between the nurse and caregiver, (c) nurse and caregiver interactions to improve problem-solving, and (d) maintain adherence to discharge planning instructions. MAIN OUTCOME: The Barthel Index was used to measure activities of daily living. RESULTS: 174 participants (standard care n = 88, intervention n = 86) were enrolled at baseline. There were no significant differences between groups at baseline. Change scores in activities of daily living between baseline and 11 weeks were significantly higher in the intervention group than the standard care group (group difference = 6.43, 95% confidence interval: 1.28, 11.58). Group differences in change scores between baseline and 19 weeks were not statistically significant (group difference = 3.89, 95% confidence interval: -3.58, 11.36). CONCLUSIONS: This web-based caregiver intervention improved stroke survivor activities of daily living by 11 weeks, but intervention effects were undetectable after 19 weeks.

Annual Foot Exams are Associated with Reduced Incident Amputation among Older Veterans with Diabetes.

We conducted a secondary data analysis to evaluate the association between annual foot exams and incident lower extremity amputations (LEA) among older veterans with diabetes during FY2007-FY2014. Older Veterans with at least one primary care provider visit each year (N = 664,162) and at least one foot exam each year (N = 72,892) and the overlap were identified from the 5 years prior to the study period of interest (FY2002-FY2006 (N = 71,122)). After excluding incident LEA related to cancer and trauma, 71,018 veterans (mean age +/- SD, % male) were included in the final cohort, which was followed from FY2007-FY2014 to evaluate the influence of subsequent annual foot exams and incident LEA. Consistent annual foot exams were protective for incident LEA in older veterans with diabetes, adjusted OR was 0.85 (97% CI: 0.74-0.96). Results indicate that adherence to annual foot exam guidelines can reduce incident LEA in older veterans with diabetes.

The RESCUE problem solving intervention for stroke caregivers: A mixed-methods pilot study.

PURPOSE/OBJECTIVE: Stroke caregivers face many challenges after a family member experiences stroke. Because caregivers play such a crucial role in health care, there is a need for more interventions in web-based formats that focus on caregiver psycho-education and skills building. A pilot study was devised to determine the feasibility, acceptability, and value of an active, 4-week telephone and web-based intervention for stroke caregivers. METHOD/DESIGN: A one-group, pretest-posttest design with a mixed-methods approach was used. Qualitative data supplemented the quantitative findings. Community-dwelling caregivers of stroke patients were recruited from the Veterans Health Administration. Quantitative data were collected pre and postintervention. Semistructured interviews were completed with a subsample of caregivers to capture more detail about the acceptability and value of the intervention. RESULTS: Ninety-three caregivers were recruited; 72 caregivers completed the intervention and 21 withdrew (77% completion rate). From pre- to posttest, caregiver depression (p = .008) and caregiver burden (p = .013) decreased. Problem-solving abilities and health-related quality of life showed no change. Seventy-eight percent of caregivers rated the intervention sessions with the nurses as very helpful or extremely helpful, and 76% reported using the problem-solving strategies a moderate amount to extremely often. Interviews suggest that the intervention was valuable and led to new strategies to relieve stress and prioritize health. CONCLUSIONS/IMPLICATIONS: The intervention was feasible to implement and acceptable to caregivers. This intervention shows promise for fulfilling a need for more web-based interventions that focus on skills building and psycho-education, but more rigorous testing is needed to determine effectiveness. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Interventions for Informal Caregivers of Stroke Survivors: Is There Racial and Ethnic Representation in Stroke Caregiver Studies?

PURPOSE: The specific aims of this scoping review of the literature are to (1) map the current scope of literature regarding nonpharmacological interventions for informal stroke caregivers and (2) explore the degree to which racial/ethnic minority groups were represented in nonpharmacological interventions for stroke caregivers in the United States. DESIGN AND METHODS: Arksey and O'Malley's methodological framework was used to conduct this scoping review. The framework entails formulating research questions, developing criteria for selecting relevant studies, charting the data, and synthesizing results. FINDINGS: The scoping review yielded 11 studies that varied in intervention design, methods of implementation, and outcome measurements. The review indicated that racial and ethnic minorities were less likely to be represented in nonpharmacological intervention studies for stroke caregivers. CONCLUSION: Currently, there is sparse research that focuses on interventions with family caregivers of varying racial/ethnic groups in the United States.

Palliative care aspects of wound healing in complex patients: a case report.

DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

Types of stroke-related deficits and their impact on family caregiver's depressive symptoms, burden, and quality of life.

BACKGROUND: Stroke caregiving has been associated with higher rates of caregiver burden, depression, and lower quality of life compared to non-caregivers. Little is known about relationships between stroke survivors' Cognitive/Emotional and Motor/Functional deficits and caregivers' outcomes. OBJECTIVE: To determine the relationship between stroke survivors' Cognitive/Emotional deficits and Motor/Functional deficits and caregivers' depression, burden, and quality of life. METHOD: This is a retrospective secondary data analysis. The sample consisted of 109 caregivers of stroke survivors. Step-wise linear multiple regression analyses were conducted to determine if Cognitive/Emotional deficits and/or Motor/Functional deficits, were predictive of caregivers' depressive symptoms, burden, physical quality of life, and mental quality of life. RESULTS: The Cognitive/Emotional deficits category was a better predictor than the Motor/Functional deficit of caregivers' depressive symptoms, burden, and mental quality of life. The Cognitive/Emotional deficit score positively predicted both depression (ß = .49, p < .001) and burden (ß = 0.39, p < .001) and negatively predicted mental quality of life (ß = -0.42, p < .001), though it did not significantly predict physical quality of life (ß = -0.01, p = .90). The motor/functional deficits failed to significantly predict any of the caregiver outcomes (all p-values >.05). CONCLUSIONS: The Cognitive/Emotional deficits appear to impact caregiver well-being more than the Motor/Functional deficits. Understanding the impact of Cognitive/Emotional and Motor/Functional deficits on caregivers can help clinicians identify caregivers at the highest risk for negative outcomes.

Feasibility and acceptability of a telephone and web-based stroke caregiver intervention: a pilot randomized controlled trial of the RESCUE intervention.

OBJECTIVE: Assess the feasibility and acceptability of an Internet and telephone support and problem-solving intervention for stroke caregivers. DESIGN: Randomized controlled pilot trial with four arms: four-week intervention (n = 13), eight-week intervention (n = 13), eight-week attention control (n = 13), and standard care (n = 14). SETTING: Southeastern U.S. Veterans Health System. PARTICIPANTS: Informal caregivers of Veterans who suffered a stroke in the preceding 2.5 years were enrolled over an 18-month period. INTERVENTIONS: Intervention participants received RESCUE, a support and problem-solving intervention delivered via telephone and Internet by registered nurses. Attention control participants received active listening with no advice delivered by nurses via telephone. MAIN MEASURES: Feasibility of a larger trial was assessed via recruitment and retention. Acceptability was assessed using an adapted enactment tool and qualitative interviews. Changes in caregiver depressive symptoms and burden were measured by the Center for Epidemiologic Studies Depression Scale and Zarit Burden Interview. The study was not powered for significance testing. RESULTS: Of 340 eligible caregivers, 53 (16%) agreed to participate. Among those enrolled, 51 (96%) completed the study. Caregiver mean age was 60.3 (10.1), 49 (93%) were female and 36 (68%) were white. At baseline, 21 (39%) caregivers had high risk of depression and 18 (33%) had significant burden. Acceptability and enactment tool findings indicated positive participant responses to the intervention. Most rated the amount of sessions the "right amount". Qualitative analysis revealed the intervention was valued by and acceptable to caregivers. CONCLUSIONS: Findings indicate the RESCUE intervention is feasible and acceptable to caregivers and warrants further testing.

Postdischarge Intervention for Stroke Caregivers: Protocol for a Randomized Controlled Trial.

BACKGROUND: The majority of stroke survivors return to their homes and need assistance from family caregivers to perform activities of daily living. These increased demands coupled with the lack of preparedness for their new roles lead to a high risk for caregivers developing depressive symptoms and other negative outcomes. Follow-up home support and problem-solving interventions with caregivers are crucial for maintaining stroke survivors in their homes. Problem-solving interventions are effective but are underused in practice because they require large amounts of staff time to implement and are difficult for caregivers logistically. OBJECTIVE: The aim of this study is to test a problem-solving intervention for stroke caregivers that can be delivered over the telephone during the patient's transitional care period (time when the stroke survivor is discharged to home) followed by 8 asynchronous online sessions. METHODS: The design is a two-arm parallel randomized clinical trial with repeated measures. We will enroll 240 caregivers from eight Veterans Affairs (VA) medical centers. Participants randomized into the intervention arm receive a modified problem-solving intervention that uses telephone and web-based support and training with interactive modules, fact sheets, and tools on the previously developed and nationally available Resources and Education for Stroke Caregivers' Understanding and Empowerment Caregiver website. In the usual care group, no changes are made in the information, discharge planning, or care the patients who have had a stroke normally receive, and caregivers have access to existing VA resources (eg, caregiver support line, self-help materials). The primary outcome is a change in caregiver depressive symptoms at 11 and 19 weeks after baseline data collection. Secondary outcomes include changes in stroke caregivers' burden, knowledge, positive aspects of caregiving, self-efficacy, perceived stress, health-related quality of life, and satisfaction with care and changes in stroke survivors' functional abilities and health care use. The team will also determine the budgetary impact, facilitators, barriers, and best practices for implementing the intervention. Throughout all phases of the study, we will collaborate with members of an advisory panel. RESULTS: Study enrollment began in June 2015 and is ongoing. The first results are expected to be submitted for publication in 2021. CONCLUSIONS: This is the first known study to test a transitional care and messaging center intervention combined with technology to decrease caregiver depressive symptoms and to improve the recovery of stroke survivors. If successful, findings will support an evidence-based model that can be transported into clinical practice to improve the quality of caregiving post stroke. TRIAL REGISTRATION: ClinicalTrials.gov NCT01600131; https://www.clinicaltrials.gov/ct2/show/NCT01600131. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/21799.

Using a Post Fall Assessment Simulation to Examine Nurse Thought Processes.

The prevalence of injurious falls is high in the Veterans Health Administration (VHA) and a major patient safety issue. The VHA is embracing technology such as simulation to improve patient care. Little is known regarding nurse thought processes while undergoing a post fall assessment simulation in the VHA. This article examines the benefit of using an evidence-based post fall simulation to improve nurse assessment skills while providing opportunity for practice without harm to patients.

A commentary on methodological issues in stroke caregiver research: lessons learned from three RESCUE intervention studies.

Stroke caregivers represent a distinct population and require unique considerations when conducting intervention research. Unfortunately, there are few published recommendations for conducting intervention trials with stroke caregivers. Thus, the goal of this paper is to provide foundational guidance for stroke caregiving researchers. We describe lessons learned from three trials of the RESCUE intervention to illustrate methodological issues in stroke caregiver research. We identify challenges encountered while conducting a clinical demonstration project, pilot study, and multi-site randomized controlled trial of a problem-solving and skills-building stroke caregiver intervention. We use our research experiences to exemplify or enhance understanding of each issue and describe the strategies we employed to overcome these obstacles. We present issues related to and recommendations for study design, theoretical frameworks, eligibility criteria, recruitment and retention, human subjects protection, intervention design, treatment fidelity, outcome measures, and qualitative methods. Identifying approaches to circumvent methodological challenges can help advance research on and implementation of stroke caregiver programs.

Research productivity following nursing research initiative grants.

BACKGROUND: In 1995, VA's Office of Research and Development launched the Nursing Research Initiative (NRI), to encourage nurses to apply for research funding and to increase the role of nurse investigators in the VA's research mission. This program provides novice nurse researchers the opportunity to further develop their research skills with the guidance of a mentor. PURPOSE: Since the NRI's inception, its impact on the research career trajectory of budding nurse researchers had never been fully explored. METHODS: An electronic quality improvement survey was developed to collect information about the scope of work and research trajectory of VA nurse researchers undertaken since they received NRI funding. FINDINGS: NRI awardees demonstrated research productivity in several areas including research funding, peer-reviewed publications; participation on journal editorial boards and grant review committees; and mentorship. The majority of past NRI grant recipients (78%) have maintained employment within the VA system and benefit from the expertise, mentoring, and support of other nurse researchers. NRI grant recipients confirm the value of the VA NRI mentored grant funding mechanism and its association with a productive research trajectory with survey respondents demonstrating an average return on investment of $7.7 million in research funding per person. CONCLUSION: The experiences derived from the NRI accelerated the professional growth and research productivity of this group and it guided future opportunities to design, implement, and test nurse-led interventions.

Enabling Advance Directive Completion: Feasibility of a New Nurse-Supported Advance Care Planning Intervention.

Adults who complete an advance directive (AD) are not consistently offered information about the risks, benefits, or alternatives (RBA) of the life-sustaining medical procedures addressed on standardized forms. The current article describes a new patient-centered nurse-supported advance care planning (NSACP) intervention focused on providing information about RBA of life-sustaining procedures. Fifty participants (mean age = 50.26 years) at a Veterans Affairs medical center were randomized to the NSACP intervention or a comparison condition. Before randomization, 78% (n = 39) expressed interest in RBA information. Of participants in the NSACP group, 94% (n = 30) completed an AD. Participants who received NSACP made more decisions to decline life-sustaining treatment than those who were randomized to the comparison group. Promising feasibility data include brevity (mean = 46 minutes), high patient satisfaction, participant retention, and treatment fidelity. The NSACP holds promise as a brief, educational intervention to support patients in completing an AD. [Journal of Gerontological Nursing, 44(7), 31-42.].

The stroke caregiving trajectory in relation to caregiver depressive symptoms, burden, and intervention outcomes.

BACKGROUND: Caregiver depression and burden have a detrimental effect on stroke survivors' rehabilitation and are contributors to stroke survivors' hospital readmission and institutionalization. The stroke caregiving trajectory is unique compared to other illnesses, and the effect of length of caregiving on stroke caregiver outcomes is poorly understood. Interventions can improve caregiver outcomes, but the optimal timing of these interventions is unclear. OBJECTIVES: We sought to determine the relationship between: (1) length of caregiving and stroke caregiver depressive symptoms and burden, and (2) length of caregiving and amount of change in depressive symptoms and burden following the Resources and Education for Stroke Caregivers' Understanding and Empowerment (RESCUE) intervention - an online and telephone problem-solving, education, and support intervention. METHODS: We analyzed retrospective data collected from 72 stroke caregivers who participated in the RESCUE intervention. Outcomes were caregiver depressive symptoms and burden. Data were analyzed using mixed-effects regression analysis. RESULTS: Baseline depressive symptoms and burden were both negatively related to length of caregiving (p < 0.05). We found significant improvement in caregiver depressive symptoms and burden following an intervention. The interaction between changes in outcomes and length of caregiving was not significant for either depressive symptoms (p = 0.26) or burden (p = 0.10). CONCLUSIONS: This study contributes to the understanding of the relationship between length of caregiving and depression, burden, and intervention outcomes. Clinicians should recognize that the stroke caregiving trajectory can be nonlinear. Routine and repeated clinical assessment of caregiver well-being is needed, along with implementation of interventions when necessary, regardless of how much time has passed since the stroke.

Exploring the post-deployment reintegration experiences of veterans with PTSD and their significant others.

Veterans with family support have better functional recovery and reintegration outcomes. However, families' ability to support the veteran with PTSD's rehabilitation and reintegration oftentimes is hindered by interpersonal challenges. We report findings of a qualitative study that examined OEF/OIF veterans with PTSD/TBI and their significant others' (SOs') perceptions of family functioning. We conducted 24 in-depth interviews with 12 veteran/SO dyads using an adapted version of the Family Assessment Device Structured Interview. Descriptive qualitative analytic methods were used to analyze the data. Data show that the impact of deployment and the resulting changes in the individuals and the family dynamics lingered years after the veterans returned home and had a lasting influence on veterans' and SOs' perceptions of family functioning. Most couples acknowledged growth in their relationships several years postdeployment. However, many continued to struggle with disruptions generated by deployment. Four themes emerged from the data: individual changes, coping strategies, relationship changes, and a "new normal." Postdeployment family functioning was influenced by a dynamic interplay of individual and relationship factors and the development of coping strategies and a new normal. This study contributes to the understanding of the prolonged postdeployment family reintegration experiences of veterans and their SOs. Findings underscore the importance of continuing to advance the current knowledge base about the long-term impact of deployment on veterans and their families, especially factors that contribute to positive postdeployment family functioning. Additional empirical studies are needed to provide more in-depth understanding of the long-term postdeployment reintegration experiences of veterans and their families. (PsycINFO Database Record

Transient Ischemic Attack and Cognitive Impairment: A Review.

Transient ischemic attack (TIA) is a neurologic deficit resulting from focal ischemia in the brain, spinal cord, or retina. Historically, the definition included symptom resolution within 24 hours. However, recent studies investigating cognition after TIA suggest that deficits in executive function persist at 7 days post-TIA, although few studies have examined these effects long term. Recent advances in neuroimaging techniques provide emerging evidence of permanent microvascular tissue damage in the brain, suggesting that the effects of TIA may persist beyond resolution of focal symptoms. A further challenge is that there is debate concerning the clinical definition of TIA and the use of diagnostic neuroimaging studies and standardization of neuropsychological tests used to evaluate cognitive deficits in this population. Subtle changes in memory, attention, and problem-solving abilities may negatively influence an individual's ability to adopt positive health behaviors. Despite advances in the field, more research is needed; hence, the purpose of this article is to provide an overview of clinical factors for clinicians and researchers to consider when investigating cognitive deficits among post-TIA populations. Definitions of TIA are reviewed, and the importance of neuropsychological evaluation and neuroimaging correlates of TIA in establishing a positive diagnosis will be discussed. Nurses especially in advanced practice roles are uniquely positioned to assess and implement treatments in at-risk groups and therefore should be knowledgeable about these possible cognitive effects.

Evidence Summary and Recommendations for Improved Communication during Care Transitions.

BACKGROUND: Communication between levels of care can be complex for any patient. For the Servicemember or Veteran with complex medical issues, who needs transitioning between multiple levels of care, this communication involves detailed, individualized information pivotal to quality clinical outcomes and patient/family satisfaction. These complex cases also typically include communication between multiple family members. PURPOSE: The purpose was to summarize the evidence and present recommendations for facilitating effective transitions of patient care within the complex Veterans Affairs (VA) Polytrauma System of Care. DESIGN: Evidence Based Review. METHODS: Selected members of the VA Office of Nursing Service Polytrauma Field Advisory Committee conducted an evidence-based review, and queried a clinical panel of polytrauma nursing experts and direct care rehabilitation nurses. FINDINGS: Search results, key practice recommendations, a plan of care template, and future plans for dissemination and implementation are presented. CONCLUSIONS: Communication is a key to success when managing many details and requires both focus and knowledge of larger systems. CLINICAL RELEVANCE: Direct communication, using a standardized approach, is recommended for successful patient transitions.

The Impact of Technology-Based Interventions on Informal Caregivers of Stroke Survivors: A Systematic Review.

OBJECTIVE: This article is a systematic review of the impact of technology-based intervention on outcomes related to care providers for those who survived a stroke. MATERIALS AND METHODS: Literature was identified in the PubMed, PsycINFO, Scopus, and Cochrane databases for evidence on technology-based interventions for stroke survivors' caregivers. The search was restricted for all English-language articles from 1970 to February 2015 that implied technology-based interventions. This review included studies that measured the impact of these types of approaches on one or more of the following: depression and any of the following-problem-solving ability, burden, health status, social support, preparedness, and healthcare utilization by care recipient-as secondary outcomes. Telephone or face-to-face counseling sessions were not of interest for this review. The search strategy yielded five studies that met inclusion criteria: two randomized clinical trials and three pilot/preliminary studies, with diverse approaches and designs. RESULTS: Four studies have assessed the primary outcome, two of which reported significant decreases in caregivers' depressive symptoms. Two studies had measured each of the following outcomes-burden, problem-solving ability, health status, and social support-and they revealed no significant differences following the intervention. Only one study assessed caregivers' preparedness and showed improved posttest scores. Healthcare services use by the care recipient was assessed by one study, and the results indicated significant reduction in emergency department visits and hospital re-admissions. CONCLUSIONS: Despite various study designs and small sample sizes, available data suggest that an intervention that incorporates a theoretical-based model and is designed to target caregivers as early as possible is a promising strategy. Furthermore, there is a need to incorporate a cost-benefit analysis in future studies.