Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Strangeways Research Laboratory, Worts' Causeway, Cambridge, CB1 8RN, UK.
Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Cambridge, CB2 0SR, UK.
BMC Fam Pract. 2020 Apr 18;21(1):66. doi: 10.1186/s12875-020-01139-4.
There is guidance in the United Kingdom about what long-term care stroke survivors should receive, but a lack of guidance about who should deliver it and where this care should take place. This is a key issue given the evidence that current needs are not well addressed. The purpose of this study was to explore when a referral from generalist to specialist services is appropriate in the long-term management of stroke survivors.
A modified RAND-Appropriateness method was used to gain consensus from a range of stroke specialist and generalist clinicians. Ten panelists rated fictional patient scenarios based on long-term post-stroke needs. Round 1 was an online survey in which panelists rated the scenarios for a) need for referral to specialist care and b) if referral was deemed necessary, need for this to be specifically to a stroke specialist. Round 2 was a face-to-face meeting in which panelists were presented with aggregate scores from round 1, and invited to discuss and then re-rate the scenarios.
Seventeen scenarios comprising 69 referral decisions were discussed. Consensus on whether the patient needed to be referred to a specialist was achieved for 59 (86%) decisions. Of the 44 deemed needing referral to specialists, 18 were judged to need referral to a stroke-specialist and 14 to a different specialist. However, for 12 decisions there was no consensus about which specialist the patient should be referred to. For some scenarios (spasticity; incontinence; physical disability; communication; cognition), referral was deemed to be indicated regardless of severity, whereas indications for referral for topics such as risk factor management and pain depended on complexity and/or severity.
There was broad agreement about when a stroke survivor requires referral to specialist care, but less agreement about destination of referral. Nevertheless, there was agreement that some of the longer-term issues facing stroke survivors are best addressed by stroke specialists, some by other specialists, and some by primary care. This has implications for models of longer-term stroke care, which need to reflect that optimal care requires access to, and better co-ordination between, both generalist and specialist healthcare.
英国有关于长期护理中风幸存者应接受哪些服务的指导意见，但对于应提供服务的人员以及应在何处提供服务缺乏指导。鉴于当前的需求未得到很好满足，这是一个关键问题。本研究旨在探讨在中风幸存者的长期管理中，何时应从全科医生转介至专科医生。
采用改良的 RAND 适宜性方法，从一系列中风专科和全科临床医生中获取共识。10 名小组成员根据中风后长期需求对虚构的患者情况进行评分。第 1 轮是在线调查，小组成员对以下情况进行评分：a）是否需要转介至专科护理，b）如果需要转介，是否需要专门转介至中风专科。第 2 轮是面对面会议，小组成员会看到第 1 轮的汇总分数，并邀请他们讨论，然后重新对情况进行评分。
讨论了 17 个包含 69 个转介决策的情景。对于 59 个（86%）决策，是否需要将患者转介至专科的问题达成了共识。在需要转介至专科的 44 个决策中，18 个被认为需要转介至中风专科，14 个需要转介至其他专科。然而，对于 12 个决策，对于患者应转介给哪个专科医生，没有达成共识。对于一些情况（痉挛、尿失禁、身体残疾、沟通、认知），无论严重程度如何，都认为需要转介，而对于一些情况（如危险因素管理和疼痛），转介的指征取决于复杂性和/或严重程度。
对于中风幸存者需要转介至专科护理的情况，有广泛的共识，但对于转介的目的地则没有达成共识。尽管如此，共识认为，一些中风幸存者面临的长期问题最好由中风专家、其他专家或初级保健医生来解决。这对长期中风护理模式有影响，这些模式需要反映出最佳护理需要同时获得全科医生和专家的医疗保健，并更好地协调两者。
