First Do No Harm: An Opinion on Bundled Care for Stroke Patients.

The Center for Medicare and Medicaid Innovation under the Centers for Medicare and Medicaid Services has invited institutions to demonstrate ways to bundle services into a 90-day episode of acute care that will lower costs and hospital re-admission rates. While these goals are laudable, they overlook the need for and value attained in postacute treatment. This article argues for elimination of the diagnosis of stroke from the proposed demonstration project due to misaligned financial incentives that will severely compromise patient outcomes.

Ethical issues in the care of patients with stroke: A scoping review.

AIMS AND OBJECTIVES: The aim was to identify and analyse the ethical issues in the care of patients with stroke (PwS). The goal was to understand the nature of the existing knowledge on the topic and to identify whether there are ethical issues specific to the care of PwS. BACKGROUND: Stroke is a disease with possible multiple effects on the patient's overall condition and experienced ethical issues in the care. Additionally, stroke impacts the life of the significant other. For health professionals, the care of PwS is challenging at different stages of the care process. The care of stroke includes several ethically sensitive situations from the perspectives of all participants. DESIGN: Scoping review. METHODS: The review was conducted following the five-stage methodological framework of Arksey and O'Malley (2005). The literature search was conducted in several electronic databases and complemented with a manual search, resulting in 15 reviewed articles. The analysis was conducted by charting descriptive numerical data and by content analysis of the narrative representations. RESULTS: The studies focused on hospital or rehabilitation contexts and a high number of studies had a qualitative approach. Three main themes were identifiable: "decision-making as an ethically challenging act," "care process-specific ethical issues" and "environmental ethical issues." CONCLUSIONS: Ethical issues occur at different stages of the care process of PwS and from the viewpoints of all those involved. However, not all the recognised ethical issues were stroke specific. As the number of the reviewed articles was limited, more research is needed for a comprehensive understanding of the topic. RELEVANCE TO CLINICAL PRACTICE: Individual health professionals may use the results in observing their own action from an ethical perspective and to deepen the ethical understanding of the care of PwS. In health care organisations, the results may be used in developing the ethical quality of care.

Discourses in stroke rehabilitation as they present themselves in current physiotherapy and occupational therapy.

Aim This study aims to discuss current perceptions of rehabilitation and how present rehabilitation practice is affected by dominating discourses in Danish society by exploring discourses expressed in official publications and the constructed journal notes of occupational and physiotherapists' practice of stroke rehabilitation. Method The frame of reference is Fairclough's critical discourse analysis. The analysis comprises seven official documents relevant to stroke rehabilitation provided in Danish health services in 2012-2013. Also, notes written by occupational therapists and physiotherapists in medical records of 10 patients with a stroke diagnosis admitted to hospital in 2012. The documents included were read thoroughly. The texts were analyzed deductively, focusing on discursive practice on articulated understandings of rehabilitation, health practice approaches, and social practice. Results The dominating discourses seem to be Western neoliberalism organizational, medical and ethical discourses. The macro level of discourses consisted of political documents addressing rehabilitation nationally. The meso level mainly concerned medical discourses within stroke rehabilitation whereas the micro level represented local medical and ethical discourses. Conclusion The neoliberal discourse supports the medical discourse with strong emphasis on evidence-based interventions. In contrast to ethical discourses, documentation of rehabilitation practice marked more attention being paid to facilitating the patient's independence than to enabling the regaining of meaningful activities and participation. Implications for Rehabilitation Individualized rehabilitation must be organized with flexibility as it is a complex process Critical reflectiveness among health professionals is needed to provide individualized rehabilitation of high quality A broader range of stake holders, including patient organizations, are in demand within health policy making The discourses that construct rehabilitation policy and practices are sometimes in conflict, which may impact on, and impede, the rehabilitation for the individual patient.

Is therapeutic judgement influenced by the patient's socio-economic status? A factorial vignette survey.

Background In Denmark patients are entitled to rehabilitation regardless of socio-economic status (SES). During this process therapists have to balance cost effectiveness with providing equal treatment. Aim To investigate whether occupational therapists and physiotherapists were influenced by the patient's SES. Material and method An experimental factorial vignette survey was used. Four different vignettes describing fictitious patient cases with different SES variables were randomly allocated to therapists working in somatic hospitals. Thereafter, the therapists judged specific clinical situations and general attitudes in relation to the patient's SES. Chi-square was used to test the statistical association between the variables. Results No statistically significant associations were found between the specific clinical situations and the patient's SES. A statistical significant association was found between general attitudes and the patient's SES. Subgroup analysis revealed a statistically significant association between the therapist's gender, age, and the therapeutic judgement in relation to SES. Conclusion In the specific clinical situations, Danish therapists seem to maintain their professional ethical principles, although they might face ethical dilemmas during their clinical decision-making. In order to prevent and resolve these dilemmas, they have to be made explicit. However, further research on how SES influences the health care professional's judgement is warranted.