Building cohesion in distributed telemedicine teams: findings from the Department of Veterans Affairs National Telestroke Program.

Background: As telemedicine adoption increases, so does the importance of building cohesion among physicians in telemedicine teams. For example, in acute telestroke services, stroke specialists provide rapid remote stroke assessment and treatment to patients at hospitals without stroke specialty care. In the National Telestroke Program (NTSP) of the U.

A qualitative study of clinical champions in context: Clinical champions across three levels of acute care.

Objectives: To compare activities and field descriptions of clinical champions across three levels of stroke centers.

Methods: A cross-sectional qualitative study using quota sampling was conducted. The setting for this study was 38 acute stroke centers based in US Veterans Affairs Medical Centers with 8 designated as Primary, 24 as Limited Hours, and 6 as Stroke Support Centers.

A cluster-randomised quality improvement study to improve two inpatient stroke quality indicators.

Background: Quality indicator collection and feedback improves stroke care. We sought to determine whether quality improvement training plus indicator feedback was more effective than indicator feedback alone in improving inpatient stroke indicators.

Methods: We conducted a cluster-randomised quality improvement trial, randomising hospitals to quality improvement training plus indicator feedback versus indicator feedback alone to improve deep vein thrombosis (DVT) prophylaxis and dysphagia screening.

Health care systems redesign project to improve dysphagia screening.

The purpose of this project was to improve dysphagia-screening processes in a tertiary Veterans Affairs Medical Center. The dysphagia-screening tool was redesigned on the basis of frontline clinician feedback, clinical guidelines, user satisfaction, and multidisciplinary expertise. The revised tool triggered a speech-language consult for positive screens and demonstrated higher scores in user satisfaction and task efficiency.

National implementation of acute stroke care centers in the Veterans Health Administration (VHA): formative evaluation of the field response.

Background: In 2011, the Veterans Health Administration (VHA) released the Acute Ischemic Stroke (AIS) Directive, which mandated reorganization of acute stroke care, including self-designation of stroke centers as Primary (P), Limited Hours (LH), or Supporting (S).

Objectives: In partnership with the VHA Offices of Emergency Medicine and Specialty Care Services, the VA Stroke QUERI conducted a formative evaluation in a national sample of three levels of stroke centers in order to understand barriers and facilitators.

Design And Approach: The evaluation consisted of a mixed-methods assessment that included a qualitative assessment of data from semi-structured interviews with key informants and a quantitative assessment of stroke quality-of-care data reporting practices by facility characteristics.

Implementation of a stroke self-management program: A randomized controlled pilot study of veterans with stroke.

Secondary stroke prevention is championed as guideline care; yet there are no systematic programs offered. We developed a stroke self-management program to address this gap and pilot test the program. We conducted a randomized controlled trial at two Veterans Administration (VA) hospital sites where we recruited patients with an acute stroke to receive either the stroke program or an attention-control protocol over a 12-week period following hospital discharge.

Pre-post evaluation of automated reminders may improve detection and management of post-stroke depression.

Background: Post-stroke depression (PSD) occurs in at least one-third of stroke survivors, is associated with worse functional outcomes and increased mortality, and is frequently underdiagnosed and undertreated.

Objective: To evaluate the effectiveness of an electronic medical record-based system intervention to improve the proportion of veterans screened and treated for PSD.

Design: Quasi-experimental study comparing PSD screening and treatment among veterans receiving post-stroke outpatient care one year prior to the intervention (the control group) to those receiving outpatient care during the intervention period (the intervention group); contemporaneous data from non-study sites included to assess temporal trends in depression diagnosis and treatment.

Current blood pressure self-management: a qualitative study.

Blood pressure (BP) self-management is advocated to manage hypertension and reduce the risk of a future stroke. The purpose of this study was to identify BP self-management strategies used by individuals who had sustained a stroke or transient ischemic attack (TIA). As part of a mixed-methods study, we conducted six focus groups and achieved saturation with 16 stroke survivors and 12 TIA survivors.

Comparison of two approaches to screen for dysphagia among acute ischemic stroke patients: nursing admission screening tool versus National Institutes of Health stroke scale.

This study assessed the positive and negative predictive values and the sensitivity and specificity of a nursing dysphagia screening tool and the National Institutes of Health Stroke Scale (NIHSS) for the identification of dysphagia for veterans hospitalized with ischemic stroke.A secondary objective of this study was to evaluate the speech-language pathology consult rate before and after the nursing admission dysphagia screening tool. This retrospective cohort study evaluated veterans admitted to one Department of Veterans Affairs medical center with ischemic stroke during the 6 months both before and after the implementation of a nursing dysphagia screening tool, which was part of the admission nursing template.

Barriers and facilitators to exercise among stroke survivors.

Physical activity after stroke may prevent disability and stroke recurrence; yet, physical impairments may inhibit poststroke exercise and subsequently limit recovery. The goal of this study was to elicit barriers to and facilitators of exercise after stroke. We conducted three focus groups and achieved content saturation from 13 stroke survivors--eight men and five women--85% of whom were African American and 15% White, with a mean age of 59 years.

Case-finding algorithm for post-stroke depression in the veterans health administration.

Objectives: Post-stroke depression (PSD) is prevalent, often undiagnosed, and undertreated. The accuracy of detecting patients with post-stroke depression in administrative databases has not been examined.The objective was to validate a case-finding algorithm for post-stroke depression (PSD) among veteran stroke survivors.

Care management of poststroke depression: a randomized, controlled trial.

Background And Purpose: Poststroke depression is a prevalent and disabling disorder, yet evidence regarding the effectiveness of treating poststroke depression is inconclusive. Our objective was to determine the effectiveness of the Activate-Initiate-Monitor care management program for the treatment of poststroke depression.

Methods: We conducted a prospective, randomized, outcome-blinded trial in 188 ischemic stroke survivors identified at the time of admission to one of 4 Indianapolis hospitals.

How valid are family proxy assessments of stroke patients' health-related quality of life?

Background And Purpose: Proxy respondents are often needed to report outcomes in stroke survivors, but they typically systematically rate impairments worse than patients themselves. The magnitude of this difference, the degree of agreement between patients and proxies, and the factors influencing agreement are not well known.

Methods: We compared patient and family proxy health-related quality of life (HRQL) responses in 225 patient-proxy pairs enrolled in a clinical trial for poststroke depression.

Outcomes among family caregivers of aphasic versus nonaphasic stroke survivors.

Adverse consequences are known to occur in family members responsible for providing care to stroke survivors. However, the differential effect of aphasic versus nonaphasic stroke on caregivers has not been well studied. This study compares selected outcomes (e.

Performance of the PHQ-9 as a screening tool for depression after stroke.

Background And Purpose: The purpose of this study was to examine the performance of the Patient Health Questionnaire (PHQ)-9, a 9-item depression scale, as a screening and diagnostic instrument for assessing depression in stroke survivors.

Methods: As part of a randomized treatment trial for poststroke depression (PSD), subjects with and without PSD completed the PHQ-9, a 9-item summed scale, with scores ranging from 0 (no depressive symptoms) to 27 (all symptoms occurring daily). Subjects endorsing 2 or more symptoms of depression were administered the criterion standard Structured Clinical Interview for Depression (SCID).

A controlled trial of including symptom data in computer-based care suggestions for managing patients with chronic heart failure.

Background: Heart failure is common and associated with considerable morbidity and cost, yet physician adherence to treatment guidelines is suboptimal. We conducted a randomized controlled study to determine if adding symptom information to evidence-based, computer-generated care suggestions would affect treatment decisions among primary care physicians caring for outpatients with heart failure at two Veterans Affairs medical centers.

Methods: Physicians were randomly assigned to receive either care suggestions generated with electronic medical record data and symptom data obtained from questionnaires mailed to patients within 2 weeks of scheduled outpatient visits (intervention group) or suggestions generated with electronic medical record data alone (control group).

Integrating clinical nurse specialists into the treatment of primary care patients with depression.

Objective: To examine the effectiveness of integrating generalist and specialist care for veterans with depression.

Method: We conducted a randomized trial of patients screening positive for depression at two Veterans Affairs Medical Center general medicine clinic firms. Control firm physicians were notified prior to the encounter when eligible patients had PRIME-MD depression diagnoses.