Publications by authors named "Erin Lalor"

20 Publications

  • Page 1 of 1

Hospitals admitting at least 100 patients with stroke a year should have a stroke unit: a case study from Australia.

BMC Health Serv Res 2017 03 16;17(1):212. Epub 2017 Mar 16.

Stroke Foundation, Melbourne, 3000, Vic, Australia.

Background: Establishing a stroke unit (SU) in every hospital may be infeasible because of limited resources. In Australia, it is recommended that hospitals that admit ≥100 strokes per year should have a SU. We aimed to describe differences in processes of care and outcomes among hospitals with and without SUs admitting at least 100 patients/year.

Methods: National stroke audit data of 40 consecutive patients per hospital admitted between 1/7/2010-31/12/2010 and organizational survey for annual admissions were used. Descriptive analyses and multilevel regression were used to compare patient outcomes. Sensitivity analysis including only hospitals meeting all of the Australian SU criteria (e.g., co-location of beds; inter-professional team; weekly meetings; regular training) was performed.

Results: Two thousand eight hundred ninety-eight patients from 72/108 eligible hospitals completing the audit (SU = 60; patients: 2,481 [mean age 76 years; 55% male] and non-SU patients: 417 [mean age 77; 53% male]). Hospitals with SUs had greater adherence to recommended care processes than non-SU hospitals. Patients treated in a SU hospital had fewer new strokes while in hospital (OR: 0.20; 95% CI 0.06, 0.61) and there was a borderline reduction in the odds of dying in hospital compared to patients in non-SU hospitals (OR 0.57 95%CI 0.33, 1.00). Among SU hospitals meeting all SU criteria (n = 59; 91%) the adjusted odds of having a poor outcome was further reduced compared with patients attending non-SU hospitals.

Conclusion: Hospitals annually admitting ≥100 patients with acute stroke should be prioritized for establishment of a SU that meet all recommended criteria to ensure better outcomes.
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March 2017

World Stroke Day 2016 - "Face the facts: Stroke is treatable".

Int J Stroke 2016 10;11(8):844-845

Department of Neurology, University of Heidelberg, Heidelberg, Germany.

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October 2016

Do cognitive, language, or physical impairments affect participation in a trial of self-management programs for stroke?

Int J Stroke 2016 Jan;11(1):77-84

Flinders University, Adelaide, Australia.

Background: Research studies may have limited generalizability when survivors of stroke with physical, language, or cognitive impairments are excluded.

Aims: To assess whether presence of cognitive, language, or global impairments affects participation in self-management programs.

Methods: Stroke survivors were recruited in South Australia from seven hospitals or via advertisements into a randomized controlled trial (1:1:1 ratio) of a Stroke Self-Management Program, the Stanford chronic condition self-management program, or standard care. Impairment status was measured using: Cognistat (cognition), Frenchay Aphasia assessment (language), modified Rankin Score (mRS; where score 3-5 = global disability).

Primary Outcomes: participation (i.e. booked, accessed, and completed a program (defined as attending ≥ 50% of sessions)) and safety (i.e. adverse events). Outcomes were compared by impairment status.

Results: Among 315 people screened 143/149 eligible were randomized (median age 71 years; 41% male; with impairments: 62% cognitive, 34% language, 64% global disability). Participation did not differ by cognitive or language impairment status (cognitive 75%, no cognitive 68%, p = 0.54; language 78%, no language 69%, p = 0.42). However, participation did vary by global impairment status (global disability 61%, no disability 96%, p < 0.001). Participants with cognitive impairment experienced more adverse events (severe n = 9 versus no cognitive impairment n = 1).

Conclusion: Survivors of stroke with cognitive, language, or global impairments are able to participate in self-management programs and should be included in these types of research studies or programs. Reduced participation by those with global disability and the possibility of more adverse events in people with cognitive impairments needs to be considered.
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January 2016

AVERT2 (a very early rehabilitation trial, a very effective reproductive trigger): retrospective observational analysis of the number of babies born to trial staff.

BMJ 2015 Dec 11;351:h6432. Epub 2015 Dec 11.

University of Glasgow, Glasgow Royal Infirmary, Glasgow, UK.

Objective: To report the number of participants needed to recruit per baby born to trial staff during AVERT, a large international trial on acute stroke, and to describe trial management consequences.

Design: Retrospective observational analysis.

Setting: 56 acute stroke hospitals in eight countries.

Participants: 1074 trial physiotherapists, nurses, and other clinicians.

Outcome Measures: Number of babies born during trial recruitment per trial participant recruited.

Results: With 198 site recruitment years and 2104 patients recruited during AVERT, 120 babies were born to trial staff. Births led to an estimated 10% loss in time to achieve recruitment. Parental leave was linked to six trial site closures. The number of participants needed to recruit per baby born was 17.5 (95% confidence interval 14.7 to 21.0); additional trial costs associated with each birth were estimated at 5736 Australian dollars on average.

Conclusion: The staff absences registered in AVERT owing to parental leave led to delayed trial recruitment and increased costs, and should be considered by trial investigators when planning research and estimating budgets. However, the celebration of new life became a highlight of the annual AVERT collaborators' meetings and helped maintain a cohesive collaborative group.

Trial Registration: Australian New Zealand Clinical Trials Registry no 12606000185561.

Disclaimer: Participation in a rehabilitation trial does not guarantee successful reproductive activity.
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December 2015

I am woman - Saving bodies and minds.

Int J Stroke 2015 Oct;10 Suppl A100

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October 2015

Understanding long-term unmet needs in Australian survivors of stroke.

Int J Stroke 2014 Oct 15;9 Suppl A100:106-12. Epub 2014 Jul 15.

Translational Public Health and Evaluation Unit, Stroke & Ageing Research, Southern Clinical School, Monash University, Melbourne, Victoria, Australia.

Background: Limited data exist on the long-term needs of community-dwelling stroke survivors. We aimed to describe factors associated with the extent to which needs were met in Australian survivors of stroke.

Method: Multifaceted strategies were used to obtain a national sample. Adults 12+ months poststroke and living in the community participated. Needs were assessed over the domains of health, everyday living, work, leisure, social support, and finances. Multivariable negative-binomial and logistic regression were used.

Results: Seven hundred sixty-five survivors completed surveys. Most (84%) reported having needs that were not being fully met (median 4 of 20, Q1, Q3: 1, 9). Variations occurred based on age, residential location, time since stroke, and disability level. Multivariable results showed that having fatigue, cognition or emotional problems, decreasing age, and increased disability were associated with increasing numbers of needs not being fully met (P < 0·001). Factors associated with needs not being fully met were as follows: (1) greater disability (adjusted odds ratio: 3·4, 95% confidence interval: 1·9, 6·0) and fatigue problems (adjusted odds ratio: 2·0, 95% confidence interval: 1·1, 3·4) (health domain); (2) greater disability (adjusted odds ratio: 7·0, 95% confidence interval: 3·0, 17·0) and being one to two-years poststroke (adjusted odds ratio: 3·4, 95% confidence interval: 1·5, 7·8) (work domain); and (3) increased disability (adjusted odds ratio: 3·8, 95% confidence interval: 2·2, 6·5) and memory problems (adjusted odds ratio: 2·1, 95% confidence interval: 1·0, 4·2) (leisure domain).

Conclusion: The extent to which long-term needs were met was influenced by a variety of factors, particularly age, disability levels, and residential location. Changes need to be made to the way and extent to which survivors are supported following stroke.
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October 2014

It's time for clinical guidelines to enter the digital age.

Med J Aust 2014 Apr;200(7):388

National Stroke Foundation, Melbourne, VIC, Australia.

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April 2014

Thrombolysis ImPlementation in Stroke (TIPS): evaluating the effectiveness of a strategy to increase the adoption of best evidence practice--protocol for a cluster randomised controlled trial in acute stroke care.

Implement Sci 2014 Mar 25;9:38. Epub 2014 Mar 25.

The University of Newcastle, (UoN) University Drive, Callaghan, NSW 2308, Australia.

Background: Stroke is a leading cause of death and disability internationally. One of the three effective interventions in the acute phase of stroke care is thrombolytic therapy with tissue plasminogen activator (tPA), if given within 4.5 hours of onset to appropriate cases of ischaemic stroke.

Objectives: To test the effectiveness of a multi-component multidisciplinary collaborative approach compared to usual care as a strategy for increasing thrombolysis rates for all stroke patients at intervention hospitals, while maintaining accepted benchmarks for low rates of intracranial haemorrhage and high rates of functional outcomes for both groups at three months.

Methods And Design: A cluster randomised controlled trial of 20 hospitals across 3 Australian states with 2 groups: multi- component multidisciplinary collaborative intervention as the experimental group and usual care as the control group. The intervention is based on behavioural theory and analysis of the steps, roles and barriers relating to rapid assessment for thrombolysis eligibility; it involves a comprehensive range of strategies addressing individual-level and system-level change at each site. The primary outcome is the difference in tPA rates between the two groups post-intervention. The secondary outcome is the proportion of tPA treated patients in both groups with good functional outcomes (modified Rankin Score (mRS <2) and the proportion with intracranial haemorrhage (mRS ≥2), compared to international benchmarks.

Discussion: TIPS will trial a comprehensive, multi-component and multidisciplinary collaborative approach to improving thrombolysis rates at multiple sites. The trial has the potential to identify methods for optimal care which can be implemented for stroke patients during the acute phase. Study findings will include barriers and solutions to effective thrombolysis implementation and trial outcomes will be published whether significant or not.

Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12613000939796.
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March 2014

Australian public's awareness of stroke warning signs improves after national multimedia campaigns.

Stroke 2013 Dec 17;44(12):3540-3. Epub 2013 Oct 17.

From the Monash University, Clayton, VIC, Australia (J.E.B., D.C.); National Stroke Foundation, Melbourne, VIC, Australia (R.J., K.T., E.L.); and Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia (I.M., D.C.).

Background And Purpose: The aim of this study was to examine the reach and impact of the National Stroke Foundation (NSF) multimedia stroke warning sign campaigns across Australia.

Methods: A total of 12 439 surveys were performed across 6 states during 6 years on random state-weighted samples of Australians≥40 years old.

Results: Awareness of stroke advertising increased 31% to 50% between 2004 and 2010 (P<0.001), as did the unprompted recall of ≥2 most common stroke warning signs 20% to 53% (P<0.001). Awareness of stroke advertising was independently associated with recalling ≥2 common signs (adjusted odds ratio=1.88, 95% confidence interval [1.74-2.04]; P<0.001). Awareness was not greater in respondents with previous stroke or risk factors, except atrial fibrillation.

Conclusions: The Australian public's awareness of stroke warning signs has improved since commencement of the NSF campaigns commensurate with greater awareness of stroke advertising. Public education efforts are worthwhile, and future efforts should focus on groups identified with low awareness or those at high risk of stroke.
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December 2013

The Know Your Numbers (KYN) program 2008 to 2010: impact on knowledge and health promotion behavior among participants.

Int J Stroke 2015 Jan 12;10(1):110-6. Epub 2013 Mar 12.

Department of Medicine, Monash University, Stroke and Ageing Research Centre, Clayton, Vic., Australia; Stroke Division, Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic., Australia; The University of Melbourne, Heidelberg, Vic., Australia.

Background: Since 2007, the National Stroke Foundation in Australia has undertaken a community-based 'Know Your Numbers' program on blood pressure and other stroke risk factors.

Aims: The aims of this study are to assess, in a sample of registrants participating in a three-month follow-up survey, retention of knowledge of risk factors and health conditions associated with hypertension, and whether those who were advised to see their doctor sought treatment or performed other health promotion actions.

Methods: Various organizations (mainly pharmacies) were recruited to offer a 'free' standardized blood pressure check and educational resources for one-week/year between 2008 and 2010. Data collection was done thru registration log and detailed questionnaires for a sample of registrants at baseline and three-months. Descriptive statistics were used for comparison of baseline and three-month data.

Results: There were 59 817 registrants over three-years. A total of 2044/2283 (90%) registrants completed a baseline survey (66% female, 50% aged >55 years); 43% had blood pressure ≥140/90 mmHg whereby 32% were unaware of their blood pressure status. Follow-up surveys were obtained from 510/805 (63%) baseline participants who provided consent. At three-months, improved knowledge was found for 9 of 11 risk factors for hypertension (e.g. lack of exercise baseline 73%; three-months 85%, P < 0·001). Knowledge for all the health conditions assessed that are associated with hypertension improved (e.g. stroke baseline 72%; three-months 87%, P < 0·001, heart attack baseline 69%; three-months 84%, P < 0·001). All respondents reported at least one health promotion action. Among 141/510 advised to visit their doctor, 114 (81%) did.

Conclusion: Know Your Numbers is a successful health promotion program and encourages people to be reviewed by their doctor.
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January 2015

Is there evidence that performance measurement in stroke has influenced health policy and changes to health systems?

Stroke 2012 Dec;43(12):3413-20

National Stroke Research Institute, Florey Institute of Neuroscience and Mental Health, Heidelberg, Victoria, Australia.

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December 2012

Comparison of stroke warning sign campaigns in Australia, England, and Canada.

Int J Stroke 2013 Oct 27;8 Suppl A100:28-31. Epub 2012 Sep 27.

National Stroke Foundation, Melbourne, Vic., Australia.

Background: Public awareness of the signs of stroke is essential to ensure that those affected by stroke arrive at the hospital in time for lifesaving therapies. It is unclear how well stroke awareness campaigns improve awareness of stroke signs and whether people translate this into action.

Methods: We evaluated stroke awareness campaigns conducted in England, Australia, and Canada using pre- and post-campaign surveys. We assessed the proportion of people who could name the main signs of stroke, and compared the proportion naming these correctly between locations. We also assessed whether people would call emergency services in the event of a stroke. Proportion responding correctly was compared using chi-square analysis.

Results: The amount spent on the campaigns was different in each country. The post-campaign survey was conducted among 400 people in Australia, 1921 in England, and 2703 in Canada. Sixty-eight per cent of people in Australia and 57% in Canada could name two or more signs of stroke (P < 0.001). After the campaign, knowledge of each of the elements of the campaign (face, arm, speech, time) was significantly greater in England than in Australia (P < 0.001 for each item). A high proportion of participants reported that they would call emergency services in the event of a stroke (97% in England, 90% in Australia, and 67% in Canada).

Conclusion: Knowledge of stroke signs and the action to be taken can be improved with awareness campaigns. The effectiveness of these campaigns may be enhanced by spend on media, media mix, and key messages. It is critical to ensure that campaigns provide the clear and bold message that prompt action is an essential ingredient to reduce death and disability following stroke.
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October 2013

No evidence for an epidemic of stroke with the ageing of the population.

Neuroepidemiology 2012 5;38(4):268-73. Epub 2012 Jun 5.

Department of Medicine, Southern Clinical School, Monash Medical Centre, Monash University, Melbourne, Vic., Australia.

Background/aim: The ageing population in Australia may contribute to an epidemic of stroke in coming years. We aimed to assess whether deaths and hospitalisations from stroke in Australia are increasing.

Methods: Nationwide age- and sex-specific hospitalisation episode data from 1996 to 1997 were used to predict future hospitalisations from stroke. Age- and sex-specific mortality data from 1997 were used to predict future mortality from stroke. These predictions were based on an expected increase in the population's age and population growth. We compared these estimates to those observed in national figures for the following 9 years.

Results: Based on 1996-1997 hospitalisation rates, we calculated that hospitalisations for stroke would be expected to rise from 27,399 to 35,041 in 2005-2006. Using 1997 mortality rates, deaths from stroke would be expected to rise from 9,126 to 12,726 in 2007. Observed hospitalisations (2005-2006) were 6,380 fewer than expected, while deaths (2007) were 4,103 fewer than expected. This represents a 2.21% annual reduction in hospitalisation rate, and a 4.0% annual reduction in mortality rate.

Conclusion: Encouragingly, hospitalisation and mortality rates for stroke appear to be declining. If these figures reflect actual occurrences of stroke then it may be that primary and secondary prevention strategies are working.
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October 2012

Very early poststroke aphasia therapy: a pilot randomized controlled efficacy trial.

Int J Stroke 2012 Dec 6;7(8):635-44. Epub 2011 Oct 6.

School of Psychology and Social Science, Edith Cowan University, Joondalup, Western Australia, Australia.

Background And Purpose: Early stroke rehabilitation has shown benefits over spontaneous recovery. Insufficient evidence exists to determine the benefits of early aphasia intervention. We hypothesized that daily aphasia therapy would show better communication outcomes than usual care (UC) in early poststroke recovery.

Method: This prospective, randomized, single-blinded, controlled trial was conducted in three acute-care hospitals in Perth, Australia, each with over 200 stroke admissions annually. Patients with acute stroke causing moderate to severe aphasia were recruited at a median of three-days (range: 0-10 days) to receive daily aphasia therapy or usual care therapy. Individually tailored, impairment-based intervention was provided for the acute hospital stay or intervention phase (median: 19 days; range: 5-76). Primary outcome measures were the aphasia quotient and functional communication profile at acute hospital discharge or four-weeks poststroke, whichever came first. A random-number generator and sealed envelopes were used to randomize participants. Assessments were completed by a blinded assessor.

Results: Fifty-nine participants were recruited, with six withdrawals (10%) and seven deaths (12%) at six-months. Ninety percent had ischemic strokes, with 56·5% experiencing a total anterior circulation stroke. The group mean (± SD) age was 69·1 (± 13·9) years. Six participants (18·75%) in the daily aphasia therapy group did not complete the minimum (150 min) therapy required for this study. The daily aphasia therapy intervention phase mean therapy session time was 45 min (range: 30-80) and the total mean amount of therapy for the daily aphasia therapy participants was 331 min (range: 30-1415). Four (15%) participants in the usual care group received therapy. The collective total therapy provided to these participants was 295 min over seven sessions. Usual care participants received an average of 10·5 min of therapy per week during the intervention phase. At the primary end point, a generalized estimating equations model demonstrated that after controlling for initial aphasia severity, participants receiving daily aphasia therapy scored 15·1 more points (P = 0·010) on the aphasia quotient and 11·3 more points (P = 0·004) on the functional communication profile than those receiving usual care therapy.

Conclusions: Daily aphasia therapy in very early stroke recovery improved communication outcomes in people with moderate to severe aphasia.
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December 2012

Social marketing and the FAST campaign.

Int J Stroke 2011 Aug;6(4):370; author reply 371

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August 2011

A phase II multicentered, single-blind, randomized, controlled trial of the stroke self-management program.

Stroke 2011 Jun 14;42(6):1673-9. Epub 2011 Apr 14.

National Stroke Research Institute, Florey Neuroscience Institutes, Heidelberg Heights 3081, Victoria, Australia.

Background And Purpose: The benefits of chronic disease self-management programs for stroke survivors are uncertain because individuals with severe impairments have been excluded from previous research. We undertook a phase II randomized controlled trial to determine whether a self-management program designed for survivors (SSMP; 8 weeks) was safe and feasible compared to standard care (control) or a generic self-management program (generic; 6 weeks).

Methods: Stroke survivors were recruited from 7 South Australian hospitals via a letter or indirectly (eg, newspapers). Eligible participants were randomized at a 1:1:1 ratio of 50 per group. Primary outcomes were recruitment, participation, and participant safety. Secondary outcomes were positive and active engagement in life using the Health Education Impact Questionnaire and characteristics of quality of life and mood at 6 months from program completion.

Results: Of 315 people screened, 149 were eligible and 143 were randomized (48 SSMP, 47 generic, 48 control); mean age was 69 years (SD, 11) and 59% were female. Demographic features were similar between groups and 41% had severe cognitive impairment; 57% accessed the interventions, with 52% SSMP and 38% generic completing >50% of sessions (P=0.18). Thirty-two participants reported adverse events (7 control, 12 generic, 13 SSMP; P=0.3; 34% severe); however, none was attributable to the interventions. Potential benefits for improved mood were found.

Conclusions: SSMP was safe and feasible. Benefits of the stroke-specific program over the generic program included greater participation and completion rates. An efficacy trial is warranted given the forecast growth in the stroke population and improved survival trends.
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June 2011

Setting stroke research priorities: The consumer perspective.

J Vasc Nurs 2010 Dec;28(4):121-31

Nursing Research Institute, St Vincent's Hospital, Darlinghurst, NSW 2010.

Objectives: To test a method of engaging consumers in research priority-setting using a quantitative approach and to determine consumer views on stroke research priorities for clinical practice recommendations with lower levels of evidence (Level III and Level IV) and expert consensus opinion as published in the Australian stroke clinical practice guidelines.

Design: Survey

Setting: Urban community

Subjects: Eighteen stroke survivors (n = 12) and carers (n = 6) who were members of the "Working Aged Group - Stroke" (WAGS) consumer support group.

Main Outcome Measures: Phase I: Participants were asked whether recommendations were "worth" researching ("yes" or "no"); and, if researched, what potential impact they likely would have on patient outcomes. Phase II: Participants were asked to rank recommendations rated by more than 75% of participants in Phase I as "worth" researching and "highly likely" or "likely" to generate research with a significant effect on patient outcomes (n = 13) in order of priority for future stroke research.

Results: All recommendations were rated by at least half (n = 9, 50%) of participants as "worth" researching. The majority (67% to 100%) rated all recommendations as "highly likely" or "likely" that research would have a significant effect on patient outcomes. Thirteen out of 20 recommendations were ranked for their research priorities. Recommendations under the topic heading Getting to hospital were ranked highest and Organization of care and Living with stroke were ranked as a lower priority for research.

Discussion/conclusion: This study provided an example of how to involve consumers in research priority setting successfully using a quantitative approach. Stroke research priorities from the consumer perspective were different from those of health professionals, as published in the literature; thus, consumer opinion should be considered when setting research priorities.
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December 2010

Clinical guidelines for stroke care: why the fuss and is there opportunity for collaboration?

Int J Stroke 2008 Aug;3(3):173-4

Guidelines Program, National Stroke Foundation of Australia, Australia.

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August 2008

Improving access to evidence-based acute stroke services: development and evaluation of a health systems model to address equity of access issues.

Aust Health Rev 2006 Feb;30(1):109-18

National Stroke Research Institute, Level 1 Neurosciences Building, Repatriation Hospital, 300 Waterdale Road, Melbourne, and The University of Melbourne, VIC, Australia.

Level 1 evidence for management of patients with stroke in a dedicated Stroke Care Unit (SCU) demonstrates improved outcomes by about 20%. It has been estimated that 21% of Australian hospitals provide an SCU and that these SCUs are mainly located in either metropolitan sites and/or in hospitals with more than 300 beds. To address equity issues related to access to SCUs, the National Stroke Foundation and the Australian Government undertook the National Stroke Units Program. One program outcome was the development of a conceptual model of acute stroke service delivery. The development process and initial evaluation of the model are described. Use of the model to increase capacity within the health care system to treat stroke is discussed.
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February 2006