Understanding determinants of acute stroke thrombolysis using the tailored implementation for chronic diseases framework: a qualitative study.

BACKGROUND: The Tailored Implementation in Chronic Disease (TICD) framework is a comprehensive framework describing the determinants of implementation success that has been used extensively in primary care settings. We explored the utility of the TICD to identify determinants of practice in an acute setting, namely guideline concordant acute stroke thrombolysis in a low-resourced, predominately minority serving, large, Emergency Department (ED). METHODS: Through workshops and expert review, we developed an interview guide informed by the TICD framework. We then conducted semi-structured interviews with data collected through written transcripts, audio transcripts or interviewer notes based on participant availability. Three independent coders then performed a content analysis using template analysis, but open to new determinants that arose from the data, into the TICD framework. RESULTS: We performed a total of 15 semi-structured interviews with ED acute stroke providers including medical technicians, nurses, and physicians. We found that guideline factors, individual health professional factors, and patient factors domains were barriers to guideline concordant acute stroke thrombolysis. The domain professional interactions was a facilitator to treatment. We identified three determinants, healthcare professional burnout, health care professional turnover and surrogate decision making, that are not part of the TICD framework. CONCLUSIONS: Most determinants of acute stroke thrombolysis are included within the TICD framework. Inclusion of healthcare professional burnout, healthcare professional turnover and surrogate decision making may assist in expanding the TICD to time-sensitive ED conditions. Further work is needed to confirm this finding and to establish whether the TICD is applicable for use in non-time sensitive ED conditions. Interventions that address guideline, individual health professional and patient factors may improve guideline concordant acute stroke thrombolysis.

Community Interventions to Increase Stroke Preparedness and Acute Stroke Treatment Rates.

PURPOSE OF REVIEW: Acute stroke treatments reduce the risk of post-stroke disability. These treatments, tissue plasminogen activator (tPA) and intra-arterial treatment, are highly time-dependent; thus, one of the main barriers to treatment is pre-hospital delay. Stroke preparedness is defined as the ability to recognize stroke symptoms and the intent to activate emergency medical services (EMS). This review describes types of acute stroke treatment and preparedness interventions, including recent mass media interventions to increase acute stroke treatment rates, and adult and youth community interventions to increase stroke preparedness. RECENT FINDINGS: The mass media campaigns show mixed results regarding acute stroke treatment rates, possibly attributed to the various media platforms utilized and resources available. The adult and youth community interventions reveal an overall increase in stroke symptom recognition and behavioral intent to call EMS. However, most of these community interventions were not grounded in health behavior theory, and they were tested in single group, pre-post test study designs that assessed behavioral rather than clinical outcomes. The delivery of stroke preparedness information by youth to adults, for example via home assignments, is a promising and innovative approach to stroke preparedness. Mass media and community interventions show promise to increase stroke preparedness and acute stroke treatment rates. The development of health behavior theory-based interventions that are tested via scientifically rigorous study designs are needed to prioritize which interventions should be disseminated to culturally and socially similar communities.

The impact of weight loss on health-related quality-of-life: implications for cost-effectiveness analyses.

PURPOSE: To assess the impact of weight loss on health-related quality-of-life (HRQL), to describe the factors associated with improvements in HRQL after weight loss, and to assess the relationship between obesity as assessed by body mass index (BMI) and HRQL before and after weight loss. METHODS: We studied 188 obese patients with BMI ≥ 32 kg/m(2) with one or more comorbidities or ≥35 kg/m(2). All patients had baseline and follow-up assessments of BMI and HRQL using the EuroQol (EQ-5D) and its visual analog scale (VAS) before and after 6 months of medical weight loss that employed very low-calorie diets, physical activity, and intensive behavioral counseling. RESULTS: At baseline, age was 50 ± 8 years (mean ± SD), BMI was 40. 0 ± 5.0 kg/m(2), EQ-5D-derived health utility score was 0.85 ± 0.13, and VAS-reported quality-of-life was 0.67 ± 0.18. At 6-month follow-up, BMI decreased by 7.0 ± 3.2 kg/m(2), EQ-5D increased by 0.06 [interquartile range (IQR) 0.06-0.17], and VAS increased by 0.14 (IQR 0.04-0.23). In multivariate analyses, improvement in EQ-5D and VAS were associated with lower baseline BMI, greater reduction in BMI at follow-up, fewer baseline comorbidities, and lower baseline HRQL. For any given BMI category, EQ-5D and VAS tended to be higher at follow-up than at baseline. CONCLUSION: Measured improvements in HRQL between baseline and follow-up were greater than predicted by the reduction in BMI at follow-up. If investigators use cross-sectional data to estimate changes in HRQL as a function of BMI, they will underestimate the improvement in HRQL associated with weight loss and underestimate the cost-utility of interventions for obesity treatment.