What factors affect clinical decision-making about access to stroke rehabilitation? A systematic review

Abstract

Objectives:To determine the factors affecting clinical decision-making about which patients should receive stroke rehabilitation.Methods:Data sources (MEDLINE, CINAHL, AMED and PsycINFO) were searched systematically from database inception to August 2018. Full-text English-language studies of data from stroke clinicians were included. Studies of patients were excluded. The included studies were any design focussed on clinical decision-making for referral or admission into stroke rehabilitation. Summary factors were compiled from each included study. The quality of the included studies was assessed using the Mixed Methods Appraisal Tool.Results:After removing duplicates, 1915 papers were identified, of which 13 met the inclusion criteria. Eight included studies were qualitative and one used mixed methods. A total of 292 clinicians were included in the studies. Quality of the included studies was mixed. Patient-level and organizational factors as well as characteristics of individual clinicians contributed to decisions about rehabilitation. The most often described factors were patients’ pre- and poststroke function (n = 6 studies), presence of dementia (n = 6), patients’ social/family support (n = 6), organizational service pressures (n = 7) and the decision-making clinician’s own knowledge (n = 5) and emotions (n = 5).Conclusion:The results highlight a lack of clinical guidance to aid decision-making and reveal that a subjective approach to rehabilitation decision-making influenced by patient-level and organizational factors alongside clinicians’ characteristics occurs across services and countries.

Rehabilitation referral process in acute stroke: decision-making of multidisciplinary teams and rehabilitation assessors

“…In a survey investigating 187 occupational therapists' clinical decision-making regarding management of sensory impairments post-stroke in the United States, clinical knowledge was found to influence occupational therapists' decisions to conduct assessments of post-stroke upper limb sensory impairment, while clinical knowledge, experience, and contextual factors influenced decisions about intervention (Doyle, Bennett, & Gustafsson, 2013). When considering access to post-stroke rehabilitation, a recent systematic review found that patient-related factors, organisational factors, and the characteristics of individual clinicians all influenced decision-making (Longley et al, 2019). These factors, and the studies from which they are drawn, will be discussed in the following sections.…”

“…This highlights the complexity of the decisions made by clinicians. As echoed in the recent systematic review by Longley et al (2019), research has been conducted to examine the patient, therapist and organisational factors that contribute to clinicians' decision-making around rehabilitation after stroke, but how these factors are integrated on the acute wards, and by rehabilitation assessors, has not been fully investigated within the stroke care context. Furthermore, given the variations between sites observed in audit data, and the importance of organisational factors in rehabilitation service referral and receipt, described in the sections above, it is expected that decision-making processes will vary between sites.…”

“…This study is the first to explore the processes and experiences of both acute clinicians and rehabilitation assessors around post-stroke rehabilitation referral decisions. As reported by Longley et al (2019), much of the previous literature in this area has focused on single disciplines, such as occupational therapists (Daniëls, Winding, & Borell, 2002;Lam Wai Shun et al, 2017), rehabilitation assessors (Hakkennes et al, 2011), and physicians (Kennedy et al, 2012;Putman et al, 2007). Others have considered decision-making by the acute stroke team (Luker et al, 2014;Lynch et al, 2015a) or the rehabilitation team only (Johnson et al, 2015).…”

“…Post-stroke rehabilitation decision-making has been described as a complex process, with significant variability in outcomes (Enderby et al, 2017;Longley, Peters, Swarbrick, & Bowen, 2019). Rehabilitation potential, which is an estimate of a patient's capacity to improve with rehabilitation, is an important factor considered in rehabilitation decisionmaking by acute and rehabilitation clinicians alike (Enderby et al, 2017); however, there is no clear consensus on which factors most accurately predict this potential (Enderby et al, 2017;Stroke Unit Trialists' Collaboration, 2013), therefore it has been recommended that all patients be offered rehabilitation with very few exceptions (Australian Stroke Coalition Rehabilitation Working Group, 2012).…”

“…The concepts of team and shared decision-making are discussed (Croker, Loftus, & Higgs, 2008;Trede & Higgs, 2008), in light of the literature around the recommended and observed decision-making practices in stroke care (Lynch, 2015;Stroke Foundation, 2017a). Rehabilitation potential is likely a key consideration in referral and acceptance decision-making (Enderby et al, 2017), and clinicians may consider the patient's pre-and post-stroke level of function, age, social supports, and motivation/tolerance for rehabilitation when assessing rehabilitation potential (Longley et al, 2019). In addition to these patient-related factors, decision-making is likely impacted by the organisational context in which the decisions are made, including assessment/referral processes, rehabilitation service availability, staffing of the acute stroke unit (ASU), relationships with the rehabilitation services, and the dynamics of the multidisciplinary team (Longley et al, 2019).…”