Papers by Dominique A Cadilhac
Stroke, Sep 1, 2019
T he greater burden of stroke in women than in men has recently been recognized as a major concer... more T he greater burden of stroke in women than in men has recently been recognized as a major concern worldwide. 1 Women generally have a poorer health-related quality of life (HRQoL) than men, both in the short-and long-term after stroke. 2,3 Despite the increased interest in sex differences, the reasons for worse HRQoL in women have been inadequately investigated. Existing studies of sex differences in HRQoL after stroke have several limitations. 2,3 Most only incorporate short-term outcomes (up to 6 months), as shown in a systematic review of sex differences in HRQoL following stroke. 2 Many investigators also did not report sex-specific findings, used modeling that was not focused on the sex difference (ie, step-wise regression), or reported sex differences as incidental findings. 2 Of a small number of studies specifically designed to examine sex differences, most were based in hospital or restricted to a specific type of stroke or to certain age groups. 2 These limitations are problematic as selection bias may adversely affect the conclusions. 4 Although population-based stroke incidence studies 5 are the most generalizable and ideal study designs to examine sex differences, 6 few incorporate assessment of Background and Purpose-Women are reported to have poorer health-related quality of life (HRQoL) after stroke than men, but the underlying reasons are uncertain. We investigated factors contributing to the sex differences. Methods-Individual participant data on 4288 first-ever strokes (1996-2013) were obtained from 4 high-quality populationbased incidence studies from Australasia and Europe. HRQoL utility scores among survivors after stroke (range from negative scores=worse than death to 1=perfect health) were calculated from 3 scales including European Quality of Life-5 Dimensions, Short-Form 6-Dimension, and Assessment of Quality of Life at 1 year (3 studies; n=1210) and 5 years (3 studies; n=1057). Quantile regression was used to estimate the median differences in HRQoL for women compared to men with adjustment for covariates. Study factors included sociodemographics, prestroke dependency, stroke-related factors (eg, stroke severity), comorbidities, and poststroke depression. Study-specific median differences were combined into pooled estimates using random-effect meta-analysis. Results-Women had lower pooled HRQoL than men (median difference unadjusted 1 year, −0.147; 95% CI, −0.258 to −0.036; 5 years, −0.090; 95% CI, −0.119 to −0.062). After adjustment for age, stroke severity, prestroke dependency, and depression, these pooled median differences were attenuated, more greatly at 1 year (−0.067; 95% CI, −0.111 to −0.022) than at 5 years (−0.085; 95% CI, −0.135 to −0.034). Conclusions-Women consistently exhibited poorer HRQoL after stroke than men. This was partly attributable to women's advanced age, more severe strokes, prestroke dependency, and poststroke depression, suggesting targets to reduce the differences. There was some evidence of residual differences in HRQoL between sexes but they were small and unlikely to be clinically significant.
Stroke, Aug 15, 2023
BACKGROUND: Fractures are a serious consequence following stroke, but it is unclear how these eve... more BACKGROUND: Fractures are a serious consequence following stroke, but it is unclear how these events influence health-related quality of life (HRQoL). We aimed to compare annualized rates of fractures before and after stroke or transient ischemic attack (TIA), identify associated factors, and examine the relationship with HRQoL after stroke/TIA. METHODS: Retrospective cohort study using data from the Australian Stroke Clinical Registry (2009–2013) linked with hospital administrative and mortality data. Rates of fractures were assessed in the 1-year period before and after stroke/TIA. Negative binomial regression, with censoring at death, was used to identify factors associated with fractures after stroke/TIA. Respondents provided HRQoL data once between 90 and 180 days after stroke/TIA using the EuroQoL 5-dimensional 3-level instrument. Adjusted logistic regression was used to assess differences in HRQoL at 90 to 180 days by previous fracture. RESULTS: Among 13 594 adult survivors of stroke/TIA (49.7% aged ≥75 years, 45.5% female, 47.9% unable to walk on admission), 618 fractures occurred in the year before stroke/TIA (45 fractures per 1000 person-years) compared with 888 fractures in the year after stroke/TIA (74 fractures per 1000 person-years). This represented a relative increase of 63% (95% CI, 47%–80%). Factors associated with poststroke fractures included being female (incidence rate ratio [IRR], 1.34 [95% CI, 1.05–1.72]), increased age (per 10-year increase, IRR, 1.35 [95% CI, 1.21–1.50]), history of prior fracture(s; IRR, 2.56 [95% CI, 1.77–3.70]), and higher Charlson Comorbidity Scores (per 1-point increase, IRR, 1.18 [95% CI, 1.10–1.27]). Receipt of stroke unit care was associated with fewer poststroke fractures (IRR, 0.67 [95% CI, 0.49–0.93]). HRQoL at 90 to 180 days was worse among patients with prior fracture across the domains of mobility, self-care, usual activities, and pain/discomfort. CONCLUSIONS: Fracture risk increases substantially after stroke/TIA, and a history of these events is associated with poorer HRQoL at 90 to 180 days after stroke/TIA.
International Journal of Stroke, 2018
International Journal of Stroke, Aug 1, 2018
Stroke, Feb 1, 2013
Introduction: Multiple data collections can be a burden for clinicians. In 2009, the Australian S... more Introduction: Multiple data collections can be a burden for clinicians. In 2009, the Australian Stroke Clinical Registry (AuSCR) was established by non-government and research organizations to provide quality of care data unavailable for acute stroke admissions. We show here the reliability of linking complimentary registry data with routinely collected hospital discharge data submitted to governmental bodies. Hypothesis: A high quality linkage with a > 90% rate is possible, but requires multiple personal identifiers common to each dataset. Methods: AuSCR identifying variables included date of birth (DoB), Medicare number, first name, surname, postcode, gender, hospital record number, hospital name and admission date. The Victorian Department of Health emergency department (ED) and hospital discharge linked dataset has most of these, with first name truncated to the first 3 digits, but no surname. Common data elements of AuSCR patients registered at a large hospital in Melbourne, Victoria (Australia) between 15 June 2009 and 31 December 2010 were submitted to undergo stepwise deterministic linkage. Results: The Victorian AuSCR sample had 818 records from 788 individuals. Three steps with 1) Medicare number, postcode, gender and DoB (80% matched); 2) hospital number/admit date; and 3) ED number/visit date were required to link AuSCR data with the ED and hospital discharge data. These led to an overall high quality linkage of >99% (782/788) of AuSCR patients, including 731/788 for ED records and 736/788 for hospital records. Conclusion: Multiple personal identifiers from registries are required to achieve reliable linkage to routinely collected hospital data. Benefits of these linked data include the ability to investigate a broader range of research questions than with a single dataset. Characters with spaces= 1941 (limit is 1950)
International Journal of Health Policy and Management
Background: Internationally, Mobile Stroke Unit ambulances (MSUs) have changed prehospital acute ... more Background: Internationally, Mobile Stroke Unit ambulances (MSUs) have changed prehospital acute stroke care delivery. MSU clinical and cost-effectiveness studies are emerging, but little is known about important factors for achieving sustainability of this innovative model of care. Method: Mixed-methods study from the Melbourne MSU (operational since November 2017) process evaluation. Participant purposive sampling included clinical, operational and executive/management representatives from Ambulance Victoria (emergency medical service provider), the MSU clinical team, and receiving hospitals. Sustainability was defined as ongoing MSU operations, including MSU workforce and future model considerations. Theoretically-based on-line survey with Unified Theory of Acceptance and Use of Technology, Self Determination Theory (Intrinsic Motivation) and open-text questions targeting barriers and benefits was administered (June-September 2019). Individual/group interviews were conducted, eli...
Journal of Stroke, 2022
Background and Purpose Changes to hospital systems were implemented from March 2020 in Australia ... more Background and Purpose Changes to hospital systems were implemented from March 2020 in Australia in response to the coronavirus disease 2019 pandemic, including decreased resources allocated to stroke units. We investigate changes in the quality of acute care for patients with stroke or transient ischemic attack during the pandemic according to patients’ treatment setting (stroke unit or alternate ward).Methods We conducted a retrospective cohort study of patients admitted with stroke or transient ischemic attack between January 2019 and June 2020 in the Australian Stroke Clinical Registry (AuSCR). The AuSCR monitors patients’ treatment setting, provision of allied health and nursing interventions, prescription of secondary prevention medications, and discharge destination. Weekly trends in the quality of care before and during the pandemic period were assessed using interrupted time series analyses.Results In total, 18,662 patients in 2019 and 8,850 patients in 2020 were included. ...
International Journal of Stroke, 2016
Frontiers in Neurology, 2021
Introduction: Telemedicine can address limited access to medical specialists in rural hospitals. ... more Introduction: Telemedicine can address limited access to medical specialists in rural hospitals. Stroke provides an important case study because: it is a major cause of disease burden; effective treatments to reduce disability (e.g., thrombolysis) can be provided within the initial hours of stroke onset; careful selection of patients is needed by skilled doctors to minimize adverse events from thrombolysis; and there are major treatment gaps (only about half of regional hospitals in Australia provide thrombolysis for stroke). Few economic analyses have been undertaken on telestroke and the majority have been simulation models. The aim of this protocol and statistical analysis plan is to outline the methods for the cost-effectiveness evaluation of a large, multicentre acute stroke telemedicine program being conducted in Victoria, Australia.Methods: Using a historical- and prospective-controlled design, we will compare patient-level data obtained in the 12 months prior to the Victoria...
International Journal of Stroke, 2019
Rationale The comparative efficacy and cost-effectiveness of constraint-induced and multi-modalit... more Rationale The comparative efficacy and cost-effectiveness of constraint-induced and multi-modality aphasia therapy in chronic stroke are unknown. Aims and hypotheses In the COMPARE trial, we aim to determine whether Multi-Modal Aphasia Treatment (M-MAT) and Constraint-Induced Aphasia Therapy Plus (CIAT-Plus) are superior to usual care (UC) for chronic post-stroke aphasia. Primary hypothesis: CIAT-Plus and M-MAT will reduce aphasia severity (Western Aphasia Battery-Revised Aphasia Quotient (WAB-R-AQ)) compared with UC: CIAT-Plus superior for moderate aphasia; M-MAT superior for mild and severe aphasia. Sample size estimates A total of 216 participants (72 per arm) will provide 90% power to detect a 5-point difference on the WAB-R-AQ between CIAT-Plus or M-MAT and UC at α = 0.05. Methods and design Prospective, randomized, parallel group, open-label, assessor blinded trial. Participants: Stroke >6 months; aphasia severity categorized using WAB-R-AQ. Computer-generated blocked and s...
BMC Health Services Research, 2019
Background: Hospital costs for stroke are increasing and variability in care quality creates inef... more Background: Hospital costs for stroke are increasing and variability in care quality creates inefficiencies. In 2007, the Victorian Government (Australia) employed clinical facilitators for three years in eight public hospitals to improve stroke care. Literature on the cost implications of such roles is rare. We report changes in the costs of acute stroke care following implementation of this program. Methods: Observational controlled before-and-after cohort design. Standardised hospital costing data were compared pre-program (financial year 2006-07) and post-program (2010-11) for all admitted episodes of stroke or transient ischaemic attack (TIA) using ICD-10 discharge codes. Costs in Australian dollars (AUD) were adjusted to a common year 2010. Generalised linear regression models were used for adjusted comparisons. Results: A 20% increase in stroke and TIA episodes was observed: 2624 pre-program (age > 75 years: 53%) and 3142 postprogram (age > 75 years: 51%); largely explained by more TIA admissions (up from 785 to 1072). Average length of stay reduced by 22% (pre-program 7.3 days to post-program 5.7 days, p < 0.001). Six hospitals provided cost data. Average perepisode costs decreased by 10% (pre-program AUD7888 to post-program AUD7115). After adjusting for age, sex, stroke type, and hospital, average per-episode costs decreased by 6.1% from pre to post program (p = 0.025). When length of stay was additionally adjusted for, these costs increased by 10.8%, indicating a greater mean cost per day (p < 0.001). Conclusion: Cost containment of acute inpatient episodes was observed after the implementation of stroke clinical facilitators, likely associated with the shorter lengths of stay.
Journal of telemedicine and telecare, 2017
Scaling of projects from inception to establishment within the healthcare system is rarely formal... more Scaling of projects from inception to establishment within the healthcare system is rarely formally reported. The Victorian Stroke Telemedicine (VST) programme provided a very useful opportunity to describe how rural hospitals in Victoria were able to access a network of Melbourne-based neurologists via telemedicine. The VST programme was initially piloted at one site in 2010 and has gradually expanded as a state-wide regional service operating with 16 hospitals in 2017. The aim of this paper is to summarise the factors that facilitated the state-wide transition of the VST programme. A naturalistic case-study was used and data were obtained from programme documents, e.g. minutes of governance committees, including the steering committee, the management committee and six working groups; operational and evaluation documentation, interviews and research field-notes taken by project staff. Thematic analysis was undertaken, with results presented in narrative form to provide a summary of...
European Journal of Neurology, Oct 15, 2020
Objectives There is a growing need for researchers to demonstrate impact, which is closely linked... more Objectives There is a growing need for researchers to demonstrate impact, which is closely linked with research translation. In Australia, the National Health and Medical Research Council funded a Centre of Research Excellence in Stroke Rehabilitation and Brain Recovery (CRE-Stroke) from 2015–2019 to enhance collaborations between researchers conducting different types of stroke rehabilitation research. CRE-Stroke has 5 research streams: Basic Science, Imaging Discovery, Clinical Trials, Implementation Science and Data Linkage. In order to guide strategies to boost research translation and impact, in 2016 researchers within the Implementation Science stream of CRE-Stroke sought to explore opinions held by researchers conducting pre-clinical and clinical stroke rehabilitation research about research translation. Method A mixed methods (explanatory sequential) study design was used, comprising a paper-based survey and semi-structured interviews. A convenience sample of researchers attending a CRE-Stroke Rehabilitation Workshop and Annual Scientific Meeting of the host organisation were invited to complete the survey. Researchers were asked to describe research translation, discuss who should be responsible to oversee research translation, and whether researchers believe they have the knowledge and skills to translate their research. Survey data from 57 participants were analysed descriptively and were used to inform development of the interview guide. Twenty-seven researchers were purposively selected to provide representation of the breadth of research studies being conducted within CRE-Stroke and were invited to participate in semi-structured interviews; 22 interviews were conducted. Interviews were audio-recorded and transcribed, checked for accuracy by participants, and data were thematically analysed by two reviewers. Results Research translation was described two ways: translating to other research and translating to clinical practice and policy. Most researchers (XX%) perceived they were responsible for translating their research via publication, and for 80% of survey participants, publication signalled a project’s completion. Some interview participants reinforced the view that the research team’s responsibility for translation ceased when results were published or incorporated into guidelines; others believed that researchers should ensure their findings were used in clinical practice, either independently or through collaborating with clinicians and implementation experts. Only 35% of the survey respondents reported having the skills and knowledge to translate their research beyond the narrow remit of publications and conference presentations. Researchers consistently stressed the difficulty and complexity of research-to-practice translation, and most felt inadequately skilled to coordinate clinical translation projects. In contrast, researchers’ self-reported lack of translation skills did not appear to adversely influence translation to other research projects. Conclusions Researchers consistently assume responsibility for disseminating their results via publications and conference presentations, and express confidence to translate their research findings to other research. However, translating to clinical practice is less straightforward, both in terms of required skills and lines of responsibility, because in Australia, no group has a clear mandate to ensure that research is translated to clinical practice. To support research translation within CRE-Stroke, a research translation template has been introduced and its use will be evaluated. CRE-Stroke also provides financial support for collaborative projects between researchers and clinicians to boost research and translation capacity.
International Journal of Stroke, Aug 1, 2018
Research Square (Research Square), Mar 30, 2023
Evidence from a body of research including a randomised controlled trial demonstrates that implem... more Evidence from a body of research including a randomised controlled trial demonstrates that implementation of nurse-led protocols to manage fever, hyperglycaemia (sugar) and swallowing following stroke signi cantly improves stroke care and patient outcomes. Worldwide, strategies are needed to increase the uptake of evidence-based stroke care to address variability in-hospital acute stroke care. There is little research on strategies for international upscale of evidence-based care that involves collaboration between researchers, non-government organisations, health services and not for pro t organisations. What this paper adds: A unique model of multi-stakeholder support, involving researchers, health services and a not-for pro t organisation, called 'cascading facilitation,' enabled global scale-up of evidence-based acute stroke protocols across 17 European countries. Evidence-based clinical change within hospitals, can be initiated and facilitated outside of the healthcare system, through a university-industry collaboration, where there is a shared goal of optimal care, clear roles and a multi-layered communication system. Cascading facilitation could be used for other global implementation evidence translation initiatives.
International Journal for Quality in Health Care
Variation in the delivery of evidence-based care affects outcomes for patients with stroke. A ran... more Variation in the delivery of evidence-based care affects outcomes for patients with stroke. A range of hospital (organizational), patient, and clinical factors can affect care delivery. Clinical registries are widely used to monitor stroke care and guide quality improvement efforts within hospitals. However, hospital features are rarely collected. We aimed to explore the influence of hospital resources for stroke, in metropolitan and regional/rural hospitals, on the provision of evidence-based patient care and outcomes. The 2017 National Audit organizational survey (Australia) was linked to patient-level data from the Australian Stroke Clinical Registry (2016–2017 admissions). Regression models were used to assess the associations between hospital resources (based on the 2015 Australian National Acute Stroke Services Framework) and patient care (reflective of national guideline recommendations), as well as 90–180-day readmissions and health-related quality of life. Models were adjus...
Research Square (Research Square), Aug 2, 2022
Background: Evidence for digital health programs to support people living with stroke is limited.... more Background: Evidence for digital health programs to support people living with stroke is limited. We assessed the feasibility of a protocol and procedures for the Recovery-focused Community support to Avoid readmissions and improve Participation after Stroke (ReCAPS) intervention. Method: We conducted a mixed-method feasibility study. Participants with acute stroke were recruited from three hospitals (Melbourne, Australia). Eligibility: Adults discharged home within 10 days of hospital admission, modi ed Rankin Score 0-4, and prior use of Short Message System (SMS) or email. While in hospital participants contributed to structured person-centred goal setting with clinicians, provided responses to surveys including assessment of self-management skills and health-related quality of life. Participants were randomised 7-14 days after discharge via REDCap® (1:1 allocation). Following randomisation, the intervention group received a 12-week program of personalised electronic support messages (average 66 messages sent by SMS or email) aligned to their goals. The control group received six electronic administrative messages. Feasibility outcomes included: number of patients screened and recruited, study retainment, completion of outcome measures, number of electronic messages delivered, and acceptability of the ReCAPS intervention and trial procedures (participant satisfaction survey, clinician interviews and researcher communications). We undertook inductive thematic analysis of interview/open-text survey data, and descriptive analysis of closed survey questions. Results: Between November 2018 and October 2019, 312 patients were screened; 37/105 (35%) eligible patients provided consent (mean age 61 years; 32% female); 33 were randomised (17 to intervention). Outcome assessments at 12-weeks were completed by 88% of participants with 16 also completing the satisfaction survey (intervention=10). Overall, trial participants felt that the study was worthwhile and most would recommend it to others. Six clinicians participated in one of three focus group interviews; while they reported that the trial and the process of goal setting acceptable, they raised concerns regarding the additional time required to personalise goals. Conclusion: The study protocol and procedures were feasible with acceptable retention of participants. Consent and goal personalisation procedures should be centralised for the Phase III trial to reduce the burden on hospital clinicians.
Neuroepidemiology
Introduction: Observational studies are increasingly being used to provide evidence on the real-w... more Introduction: Observational studies are increasingly being used to provide evidence on the real-world effectiveness of medications for preventing vascular diseases, such as stroke. We investigated whether the real-world effectiveness of treatment with lipid-lowering medications after ischemic stroke is affected by prevalent-user bias. Methods: An observational cohort study of 90-day survivors of ischemic stroke using person-level data from the Australian Stroke Clinical Registry (2012–2016; 45 hospitals) linked to administrative (pharmaceutical, hospital, death) records. The use of, and adherence to (proportion of days covered <80% [poor adherence] vs. ≥80% [good adherence]), lipid-lowering medications within 90 days post-discharge was determined from pharmaceutical records. Users were further classified as prevalent (continuing) or new users, based on dispensing within 90 days prior to stroke. A propensity score-adjusted Cox regression was used to evaluate the effectiveness of l...
Background: Clinicians’ compliance with hospital protocols inclusion and exclusion criteria for t... more Background: Clinicians’ compliance with hospital protocols inclusion and exclusion criteria for the administration of Recombinant Tissue Plasminogen Activator (rt-PA) for ischaemic stroke is unknown. We compared hospital protocol rt-PA selection criteria with criteria reported to be used in practice. Methods: Stroke Unit Co-ordinators of all Australian hospitals known to provide rt-PA were mailed a survey. Respondents were asked to report on the inclusion/exclusion criteria used in practice when considering rt-PA administration and to provide their hospital rt-PA protocol. Chi-square tests were used to determine differences between individual hospital protocols and respondent’s self-reported selection criteria. Results: Protocols and completed surveys were received from 55 of the 87 hospitals (63%) containing 9 inclusion and 92 exclusion criteria. There were significant differences between two inclusion criteria: ‘clinical diagnosis of acute ischaemic stroke’ (Practice: 92.1% vs Pro...
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Papers by Dominique A Cadilhac