Centre for Health Services Studies, University of Kent, Canterbury, UK.
Health Soc Care Community. 2019 Jan;27(1):249-259. doi: 10.1111/hsc.12677. Epub 2018 Oct 30.
Stroke is the UK's fourth highest cause of death and an estimated 300,000 people in England are living with related disability. This paper explores the six-month review (6MR), a policy initiative that aimed to ameliorate unmet need. A multiple case study approach underpinned by critical realism was used to elicit the views of patients, carers, providers and commissioners across three sites using interviews, observations and documentation. Forty-six patients (age range 28-91 years), 30 carers and 28 professionals were interviewed between December 2015 and October 2016. Twenty-nine reviews were observed. Data was analysed thematically across sites. 6MRs carried out by stroke nurse specialists (SNSs) were found to be more medically orientated than those completed by a Stroke Association (SA) co-ordinator who focused on social issues. Reviewers regarded reviews primarily as an opportunity to address unmet need and signpost to further services. Patients responded in three different ways: proactive and engaged, reflected an active orientation to recovery and self-management; proactive and self-managing on their own terms, encompassed patients who were striving for independence but took their own approach sometimes at odds with that of clinicians; and passive orientation, whereby patients did not engage in rehabilitation or self-management. Patients identified different priorities to those of reviewers, particularly those with other long-term conditions and this appeared to contribute to the dissatisfaction that some expressed. In conclusion, there was little evidence that the 6MR played a key role in recovery. Locally defined outcomes for the 6MR reflecting national policy were not substantiated by the findings. Our findings suggest that the 6MR should review therapy goals and facilitate patient-led goals. Reviewers should be allowed the freedom to individualise the process rather than adhering to a rigid framework dictated by national policy and local protocols.
中风是英国第四大死因，据估计，英格兰有 30 万人因此残疾。本文探讨了六个月审查（6MR），这是一项旨在改善未满足需求的政策举措。本研究采用以批判现实主义为基础的多案例研究方法，在三个地点通过访谈、观察和文件记录，收集了患者、护理人员、提供者和决策者的观点。2015 年 12 月至 2016 年 10 月期间，对 46 名患者（年龄 28-91 岁）、30 名护理人员和 28 名专业人员进行了访谈。共观察了 29 次审查。在各个地点对数据进行了主题分析。研究发现，由中风护士专家（SNS）进行的 6MR 比由中风协会（SA）协调员进行的更具医学导向，后者更关注社会问题。审查员认为审查主要是解决未满足需求和转介到进一步服务的机会。患者的反应有三种不同方式：积极参与，表现出积极的康复和自我管理取向；积极主动地按照自己的方式管理自己，包括那些努力争取独立但采取自己的方法的患者，有时与临床医生的方法不一致；以及被动的态度，即患者不参与康复或自我管理。患者确定的优先级与审查员的不同，特别是那些患有其他长期疾病的患者，这似乎导致了一些患者的不满。总之，几乎没有证据表明 6MR 在恢复中发挥了关键作用。发现与国家政策一致的 6MR 的地方定义结果没有得到证实。我们的研究结果表明，6MR 应审查治疗目标并促进以患者为主导的目标。审查员应被允许自由地个性化审查过程，而不是遵循国家政策和地方协议规定的僵化框架。
