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Objective To investigate stroke survivors’ perceptions of factors influencing their engagement in activity outside of dedicated therapy sessions during inpatient rehabilitation. Design Qualitative study. Setting Four metropolitan rehabilitation units in Australia. Participants People undertaking inpatient rehabilitation after stroke. Methods Semi-structured interviews conducted in person by a speech pathologist A stepped iterative process of inductive analysis was employed until data saturation was achieved with themes then applied against the three domains of the Theory of Planned Behaviour (perceived behavioural control, social norms and attitude). Results Interviews of 33 stroke survivors (60% female, median age of 73 years) revealed five themes (i) uncertainty about how to navigate and what was available for use in the rehabilitation unit restricts activity and (ii) post-stroke mobility, fatigue and pre- and post-stroke communication impairments restrict activity (perceived behavioural control); (iii) unit set up, rules (perceived and actual) and staff expectations influence activity and (iv) visiting family and friends are strong facilitators of activity (social norms), and (v) personal preferences and mood influence level of activity (attitude). Conclusion At the individual level, stroke survivors perceived that their ability to be active outside of dedicated therapy sessions was influenced by their impairments, including mood, and their attitude towards and preference for activity. At the ward level, stroke survivors perceived that their ability to be active was influenced by ward set-up, rules and staff expectations. Visitors were perceived to be important facilitators of activity outside of therapy sessions.

This study aimed to investigate rehabilitation staff perceptions of factors influencing stroke survivor activity outside of dedicated therapy time for the purpose of supporting successful translation of activity promoting interventions in a rehabilitation unit. Purposive sampling of multi-disciplinary teams from four rehabilitation units was performed, and semi-structured interviews were conducted by telephone, digitally audio-recorded and then transcribed verbatim. A stepped iterative process of thematic analysis was employed until data saturation was reached. All but one of the 22 participants were female, the majority were either physiotherapists or occupational therapists, with a median of 4 years (interquartile range, 2–10) working at their respective rehabilitation units. Analysis of the data revealed three themes: (i) stroke survivor characteristics influence their activity outside therapy, (ii) the rehabilitation environment influences physical, cognitive, and social activity, and (iii) institutional priorities, staff culture, and attitude can be barriers to activity. Rehabilitation units were perceived to be unstimulating, and visitors considered enablers of activity when resources were perceived to be scarce. Our results suggest careful consideration of the involvement of visitors, an individual’s needs and preferences, and the institution’s priorities and staff attitude may result in greater stroke survivor activity during rehabilitation.Implications for rehabilitationStaff should consider stroke survivor impairments and a rehabilitation unit’s institutional priorities and staff attitudes when aiming to enhance stroke survivor engagement in activity.The physical and social environment of a rehabilitation unit can be optimised by rehabilitation staff to promote activity.Utilisation of visitors of stroke survivors on a rehabilitation unit may be one way to enhance engagement in activity.Discussion within the rehabilitation team concerning “ownership” of the role of supporting stroke survivor activity outside of structured therapy time may support better engagement in same. Staff should consider stroke survivor impairments and a rehabilitation unit’s institutional priorities and staff attitudes when aiming to enhance stroke survivor engagement in activity. The physical and social environment of a rehabilitation unit can be optimised by rehabilitation staff to promote activity. Utilisation of visitors of stroke survivors on a rehabilitation unit may be one way to enhance engagement in activity. Discussion within the rehabilitation team concerning “ownership” of the role of supporting stroke survivor activity outside of structured therapy time may support better engagement in same.

BackgroundTo assess the effects of consumer engagement in health care policy, research and services.MethodsWe updated a review published in 2006 and 2009 and revised the previous search strategies for key databases (The Cochrane Central Register of Controlled Trials; MEDLINE; EMBASE; PsycINFO; CINAHL; Web of Science) up to February 2020. Selection criteria included randomised controlled trials assessing consumer engagement in developing health care policy, research, or health services. The International Association for Public Participation, Spectrum of Public Participation was used to identify, describe, compare and analyse consumer engagement. Outcome measures were effects on people; effects on the policy/research/health care services; or process outcomes.ResultsWe included 23 randomised controlled trials with a moderate or high risk of bias, involving 136,265 participants. Most consumer engagement strategies adopted a consultative approach during the development phase of interventions, targeted to health services. Based on four large cluster-randomised controlled trials, there is evidence that consumer engagement in the development and delivery of health services to enhance the care of pregnant women results in a reduction in neonatal, but not maternal, mortality. From other trials, there is evidence that involving consumers in developing patient information material results in material that is more relevant, readable and understandable for patients, and can improve knowledge. Mixed effects are reported of consumer-engagement on the development and/or implementation of health professional training. There is some evidence that using consumer interviewers instead of staff in satisfaction surveys can have a small influence on the results. There is some evidence that consumers may have a role in identifying broader range of health care priorities that are complementary to those from professionals. There is some evidence that consumer engagement in monitoring and evaluating health services may impact perceptions of patient safety or quality of life.ConclusionsThere is growing evidence from randomised controlled trials of the effects of consumer engagement on the relevance and positive outcomes of health policy, research and services. Health care consumers, providers, researchers and funders should continue to employ evidence-informed consumer engagement in their jurisdictions, with embedded evaluation. Systematic review registrationPROSPERO CRD42018102595.

Objective: To identify factors associated with receiving acute goal-directed treatment, being assessed for ongoing rehabilitation,and receiving post-acute rehabilitation after having a stroke. Design: Retrospective analysis of National Stroke Audit data for patients with acute stroke treated at Australian hospitals during 1 September 2014 – 28 February 2015. Setting, participants: 112 Australian hospitals that admit adults with acute stroke. Main outcomes: Associations between patient-related and organisational factors and the provision of rehabilitation interventions. Results: Data for 3462 patients were eligible for analysis; their median age was 74 years, 1962 (57%) were men, and 2470 (71%) had received care in a stroke unit. 2505 patients (72%) received goal-directed treatment during their acute admission; it was not provided to 364 patients (10.5%) who were responsive, had not fully recovered, and did not refuse treatment. Factors associated with higher odds of receiving goal-directed treatment included goal-setting with the patient and their family (odds ratio [OR], 6.75;95% CI, 5.07–8.90) and receiving care in a stroke unit (OR, 2.08;95% CI, 1.61–2.70). 1358 patients (39%) underwent further rehabilitation after discharge from acute care; factors associated with receiving post-acute rehabilitation included care in a stroke unit(OR, 1.73; 95% CI, 1.34–2.22) and having an arm or speech deficit.Dementia was associated with lower odds of receiving acute goal-directed treatment (OR, 0.49; 95%, 0.33–0.73) and post-acute rehabilitation (OR, 0.43; 95%, 0.30–0.61). Conclusions: Access to stroke units and to early and ongoing rehabilitation for patients after stroke can be improved in Australia,both to optimise outcomes and to reduce the burden of care on underresourced community and primary care providers. Refereed/Peer-reviewed

This research aims to identify the factors that influence caregivers’ decisions about the aged care providers they select for their elder relatives when caring from a distance and what they value once they have engaged a service. Adult long-distance carers for older relatives living within Australia were purposively sampled and they participated in audio-recorded interviews. A thematic analysis was employed to investigate the data. A sample of 13 participants enabled data saturation with no new major themes identified in the final three interviews. Participants were 50 to 65 years (Mean = 59.8) and mostly (77%) female. Four themes emerged relating to selection of care providers: (1) availability of care, (2) financial arrangements, (3) proximity and location, and (4) reputation of care provider. Five themes detailed valued qualities of care: (1) vigilant monitoring and responsivity, (2) communication with family, (3) flexibility and proactiveness of care, (4) staffing, and (5) access to appropriate and holistic care to maintain wellbeing. Long-distance caregivers face barriers in selecting and managing aged care services from afar within a complex Australian aged care system. They strongly value regular, proactive communication about the wellbeing of their relatives and may be particular beneficiaries of communication and assistive monitoring technologies Refereed/Peer-reviewed

It is of critical importance that findings from the wealth of clinical physical therapist research are transferred into clinical practice without unnecessary delays. There is a lack of knowledge about strategies that can be used to effectively implement physical therapist research findings and evidence-based practice (EBP) into everyday clinical practice in different national settings and contexts. The purpose of this article is to contribute to knowledge about effective strategies for implementing EBP that have been studied in different national physical therapy settings. The specific aims of this article are to share experiences and provide a current multinational perspective on different approaches and strategies for implementing EBP and to highlight important considerations and implications for both research and practice. Six research studies from various settings in 3 countries are described and synthesized. Key characteristics of the studies and intervention components are tabulated and mapped to the Cochrane Effective Practice and Organisation of Care taxonomy. Commonalities and differences are presented. The implementation strategies described were: a theory-based guideline implementation tailored to identified barriers and facilitators; a multifaceted EBP training package; journal clubs; a multifaceted strategy comprising contextualized procedures, protocols, and standardized resources; barrier identification, education, audit, feedback, and reminders; and contextualized guidelines. Commonalities were the use of a multifaceted approach, educational measures, and clinical guidelines. Key outcomes across the studies were improved attitudes and increased awareness, knowledge, skills, and confidence in EBP; better access to clinical practice guidelines and other EBP resources; identification of barriers that could be targeted in future implementation activities; earlier referrals; and use of recommended outcome measures. The article can serve as a template for other physical therapist researchers in designing implementation studies, as well as to inform policies and practice for health care managers and decision makers who are looking for ways to implement research findings in their organizations.

Objective: To explore the factors perceived to affect rehabilitation assessment and referral practices for patients with stroke. Design: Qualitative study using data from focus groups analysed thematically and then mapped to the Theoretical Domains Framework. Setting: Eight acute stroke units in two states of Australia. Subjects: Health professionals working in acute stroke units. Interventions: Health professionals at all sites had participated in interventions to improve rehabilitation assessment and referral practices, which included provision of copies of an evidence-based decision-making rehabilitation Assessment Tool and pathway. Results: Eight focus groups were conducted (32 total participants). Reported rehabilitation assessment and referral practices varied markedly between units. Continence and mood were not routinely assessed (4 units), and people with stroke symptoms were not consistently referred to rehabilitation (4 units). Key factors influencing practice were identified and included whether health professionals perceived that use of the Assessment Tool would improve rehabilitation assessment practices (theoretical domain ‘social and professional role’); beliefs about outcomes from changing practice such as increased equity for patients or conversely that changing rehabilitation referral patterns would not affect access to rehabilitation (‘belief about consequences’); the influence of the unit’s relationships with other groups including rehabilitation teams (‘social influences’ domain) and understanding within the acute stroke unit team of the purpose of changing assessment practices (‘knowledge’ domain). Conclusion: This study has identified that health professionals’ perceived roles, beliefs about consequences from changing practice and relationships with rehabilitation service providers were perceived to influence rehabilitation assessment and referral practices on Australian acute stroke units.

Background: The incidence of young stroke is increasing worldwide. However, young adults are inadequately supported in their recovery by a system of stroke care in which the older patient is the majority consumer. Purpose: To examine the unmet needs of younger stroke survivors in inpatient and outpatient healthcare settings and identify opportunities for improved service delivery. Materials and Methods: In-depth semi-structured interviews were undertaken with 19 participants aged 18–55 at the time of their first-ever stroke and inductively analysed using a rigorous qualitative descriptive approach. Results: Many unmet care needs were identified within three emergent themes: inadequately addressed psycho-emotional and cognitive needs after young stroke; isolation from lack of information and structured support; and failure to deliver age-relevant patient-centred care. These themes were further divided into sub-themes and the sub-themes were named in a manner to signpost the way forward for young stroke care. Conclusions: This study provides new insights into the experience of inpatient and outpatient stroke care by younger stroke survivors and outlines possible improvements for clinical practice. Future research should evaluate the effect of targeted strategies to support younger adults after stroke.Implications for rehabilitation Post-stroke rehabilitation might be improved by providing more support for the non-physical effects of stroke (e.g., psycho-emotional support, cognitive rehabilitation). Younger stroke survivors may also benefit from a long-term community care plan and longer-term rehabilitation. Patient-centered rehabilitation and education about self-management interventions appear to be important areas for further development. Future research is required to evaluate the effect of targeted strategies to support younger stroke survivors, as well as identify the needs of younger adults with post-stroke communication impairment Refereed/Peer-reviewed

ObjectivesTo examine the personal and social experiences of younger adults after stroke.DesignQualitative study design involving in-depth semi-structured interviews and rigorous qualitative descriptive analysis informed by social constructionism.ParticipantsNineteen younger stroke survivors aged 18 to 55 years at the time of their first-ever stroke.SettingParticipants were recruited from urban and rural settings across Australia. Interviews took place in a clinic room of the Florey Institute of Neuroscience and Mental Health (Melbourne, Australia), over an online conference platform or by telephone.ResultsFour main themes emerged from the discourses: (1) psycho-emotional experiences after young stroke; (2) losing pre-stroke life construct and relationships; (3) recovering and adapting after young stroke; and (4) invalidated by the old-age, physical concept of stroke. While these themes ran through the narratives of all participants, data analysis also drew out interesting variation between individual experiences.ConclusionsFor many younger adults, stroke is an unexpected and devastating life event that profoundly diverts their biography and presents complex and continued challenges to fulfilling age-normative roles. While adaptation, resilience and post-traumatic growth are common, this study suggests that more bespoke support is needed for younger adults after stroke. Increasing public awareness of young stroke is also important, as is increased research attention to this problem.

Background Interventions that enable people to remain in their own home as they age are of interest to stakeholders, yet detailed information on effective interventions is scarce. Our objective was to systematically search and synthesise evidence for the effectiveness of community-based, aged care interventions in delaying or avoiding admission to residential aged care. Method Nine databases were searched from January 2000 to February 2018 for English publications. Reference lists of relevant publications were searched. The databases yielded 55,221 citations and 50 citations were gleaned from other sources. Where there was sufficient homogeneity of study design, population, intervention and measures, meta-analyses were performed. Studies were grouped by the type of intervention: complex multifactorial interventions, minimal/single focus interventions, restorative programs, or by the target population (e.g. participants with dementia). Results Data from 31 randomised controlled trials (32 articles) that met our inclusion criteria were extracted and analysed. Compared to controls, complex multifactorial interventions in community aged care significantly improved older adults’ ability to remain living at home (risk difference − 0.02; 95% CI -0.03, − 0.00; p = 0.04). Commonalities in the 13 studies with complex interventions were the use of comprehensive assessment, regular reviews, case management, care planning, referrals to additional services, individualised interventions, frequent client contact if required, and liaison with General Practitioners. Complex interventions did not have a significantly different effect on mortality. Single focus interventions did not show a significant effect in reducing residential aged care admissions (risk difference 0, 95% CI -0.01, 0.01; p = 0.71), nor for mortality or quality of life. Subgroup analysis of complex interventions for people with dementia showed significant risk reduction for residential aged care admissions (RD -0.05; 95% CI -0.09, -0.01; p = 0.02). Compared to controls, only interventions targeting participants with dementia had a significant effect on improving quality of life (SMD 3.38, 95% CI 3.02, 3.74; p

Purpose: Less than half of the patients with stroke in Australian hospitals are assessed by rehabilitation specialists. We sought to explore how clinicians working in acute stroke units (ASUs) determine which patients to refer to rehabilitation services. Method: Qualitative descriptive study. Team meetings were observed and medical records were reviewed over four weeks at two ASUs. Focus groups were conducted with staff from eight ASUs in two states of Australia. Results: Rehabilitation was mentioned in team meetings for 50/64 patients (78%) during the observation period. Rehabilitation referrals were organised for 47 patients (94%) for whom rehabilitation was discussed (74% of the sample); and for no patients when rehabilitation was not discussed. Factors identified that influenced whether referrals were organised included the anticipated discharge destination; severity of stroke; staff expectations of the patient’s recovery; and if there was advocacy by families about rehabilitation. Clinicians tended to refer the patients they considered would be accepted by the rehabilitation service. Staff at two ASUs expressed concern that referring all patients with stroke-related deficits to rehabilitation would be unfavourable with rehabilitation providers. Conclusions: Decisions made by ASU staff regarding who to refer to stroke rehabilitation are often not solely based on patients’ rehabilitation requirements.Implications for Rehabilitation Not all patients on acute stroke units (ASUs) who may have benefited from rehabilitation were offered rehabilitation referrals.Criteria for rehabilitation referrals need to be made explicit and discussed openly with consumers, ASU clinicians and rehabilitation specialists.A change in rehabilitation assessment practices is required to provide data regarding the unmet rehabilitation needs of patients with stroke.New models of rehabilitation service delivery or increased rehabilitation services may be required to meet the rehabilitation needs of all patients with stroke. Refereed/Peer-reviewed

Background: Inequities in accessing inpatient rehabilitation after stroke have been reported in many countries and impact on patient outcomes. Objective: To explore variation in international recommendations regarding which patients should receive inpatient rehabilitation after stroke and to describe reported access to rehabilitation. Conclusion: Recommendations regarding which patients with moderate and severe strokes should access ongoing rehabilitation are inconsistent. Clinical practice guidelines from different countries regarding post-stroke rehabilitation do not always reflect the evidence regarding the likely benefits to people with stroke. Inequity in access to rehabilitation after stroke is an international issue. Methods: A scoping review was conducted to identify clinical guidelines with recommendations regarding which patients should access inpatient rehabilitation after stroke, and data regarding the proportion of patients accessing stroke rehabilitation. Four bibliographic databases and grey literature were searched. Results: Twenty-eight documents were included. Selection criteria for post-acute inpatient rehabilitation were identified for 14 countries or regions and summary data on the proportion of patients receiving inpatient rehabilitation were identified for 14 countries. In Australia, New Zealand, and theUnited Kingdom, it is recommended that all patients with stroke symptoms should access rehabilitation, whereas guidelines from the United States, Canada, and Europe did not consistently recommend rehabilitation for people with severe stroke. Access to inpatient rehabilitation ranged from 13% in Sweden to 57% in Israel. Differences in availability of early supported discharge/home rehabilitation programs and variations in reporting methods may influence the ability to reliably compare access to rehabilitation between regions. Conclusion: Recommendations regarding which patients with moderate and severe strokes should access ongoing rehabilitation are inconsistent. Clinical practice guidelines from different countries regarding post-stroke rehabilitation do not always reflect the evidence regarding the likely benefits to people with stroke. Inequity in access to rehabilitation after stroke is an international issue. Refereed/Peer-reviewed

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: To assess the effects of implementation interventions for promoting the uptake of evidence-based recommendations in acute stroke unit environments. Secondary objectives are to describe any factors that may modify the effect of implementation interventions; determine factors that may influence the uptake of recommendations in acute stroke units; and determine if single or multifaceted intervention strategies (two or more interventions) are more effective in improving uptake of evidence, patient outcomes, system outcomes or professionals' knowledge, attitudes or intentions in this setting. Refereed/Peer-reviewed

Purpose: Boredom may impede engagement in inpatient rehabilitation following an acquired brain injury. This review aimed to: (1) describe the experience and (2) quantify the incidence of boredom; (3) identify measurement tools used to quantify boredom; (4) summarize factors contributing to boredom, and (5) outline evidence-based interventions shown to reduce boredom during inpatient rehabilitation. Methods: Two researchers independently screened publications retrieved from electronic database searches. Publications presenting patient, carer or staff data relating to boredom in inpatients with acquired brain injuries were included. Results: Two thousand four hundred and ninety-nine references were retrieved, 88 full texts were reviewed, with 24 studies included. The majority of studies reported qualitative data indicating boredom to be a common experience of patients with acquired brain injuries (n = 14 studies +1 review). The incidence of boredom post acquired brain injury is unknown. Personal and organizational factors and the physical environment may contribute to boredom (n = 11 studies +2 reviews). Qualitative work (n = 9 studies) indicates that use of the creative-arts or exposure to environmental enrichment may help alleviate boredom in patients with acquired brain injuries during inpatient rehabilitation. Conclusion: Further mixed-methods research is required to establish the incidence of and contributing factors to boredom in patients with acquired brain injuries undergoing rehabilitation. Understanding this will help inform future research aimed at improving patient engagement in inpatient rehabilitation.Implications for rehabilitationBoredom is commonly reported by hospitalised patients with ABI to negatively affect their rehabilitation yet the scope of the problem has not been measured.Boredom is a complex phenomenon, likely influenced by a number of personal and environmental factors that are not fully understood in this population.Through a better understanding of boredom, interventions may be developed to improve patient engagement in inpatient rehabilitation programs. Boredom is commonly reported by hospitalised patients with ABI to negatively affect their rehabilitation yet the scope of the problem has not been measured. Boredom is a complex phenomenon, likely influenced by a number of personal and environmental factors that are not fully understood in this population. Through a better understanding of boredom, interventions may be developed to improve patient engagement in inpatient rehabilitation programs.

Background: Stroke results from an acute lack of blood supply to the brain and becomes a chronic health condition for millions of survivors around the world. Self management can offer stroke survivors a pathway to promote their recovery. Self management programmes for people with stroke can include specific education about the stroke and likely effects but essentially, also focusses on skills training to encourage people to take an active part in their management. Such skills training can include problem-solving, goal-setting, decision-making, and coping skills. Objectives: To assess the effects of self management interventions on the quality of life of adults with stroke who are living in the community, compared with inactive or active (usual care) control interventions. Search methods: We searched the following databases from inception to April 2016: the Cochrane Stroke Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, PsycINFO, SCOPUS, Web of Science, OTSeeker, OT Search, PEDro, REHABDATA, and DARE. We also searched the following trial registries: ClinicalTrials.gov, Stroke Trials Registry, Current Controlled Trials, World Health Organization, and Australian New Zealand Clinical Trials Registry. Selection criteria: We included randomised controlled trials of adults with stroke living in the community who received self management interventions. These interventions included more than one component of self management or targeted more than a single domain of change, or both. Interventions were compared with either an inactive control (waiting list or usual care) or active control (alternate intervention such as education only). Measured outcomes included changes in quality of life, self efficacy, activity or participation levels, impairments, health service usage, health behaviours (such as medication adherence or lifestyle behaviours), cost, participant satisfaction, or adverse events. Data collection and analysis: Two review authors independently extracted prespecified data from all included studies and assessed trial quality and risk of bias. We performed meta-analyses where possible to pool results. Main results: We included 14 trials with 1863 participants. Evidence from six studies showed that self management programmes improved quality of life in people with stroke (standardised mean difference (SMD) random effects 0.34, 95% confidence interval (CI) 0.05 to 0.62, P = 0.02; moderate quality evidence) and improved self efficacy (SMD, random effects 0.33, 95% CI 0.04 to 0.61, P = 0.03; low quality evidence) compared with usual care. Individual studies reported benefits for health-related behaviours such as reduced use of health services, smoking, and alcohol intake, as well as improved diet and attitude. However, there was no superior effect for such programmes in the domains of locus of control, activities of daily living, medication adherence, participation, or mood. Statistical heterogeneity was mostly low; however, there was much variation in the types and delivery of programmes. Risk of bias was relatively low for complex intervention clinical trials where participants and personnel could not be blinded. Authors' conclusions: The current evidence indicates that self management programmes may benefit people with stroke who are living in the community. The benefits of such programmes lie in improved quality of life and self efficacy. These are all well-recognised goals for people after stroke. There is evidence for many modes of delivery and examples of tailoring content to the target group. Leaders were usually professionals but peers (stroke survivors and carers) were also reported - the commonality is being trained and expert in stroke and its consequences. It would be beneficial for further research to be focused on identifying key features of effective self management programmes and assessing their cost-effectiveness. Refereed/Peer-reviewed

Purpose: To explore stroke survivors’ perspectives of two novel models of inpatient physiotherapy, which provide an increased amount of therapy: five days a week circuit class therapy and seven days a week individual therapy. Method: This is a qualitative descriptive study using semi-structured interviews and thematic analysis. The participants were 10 purposively sampled stroke survivors in the post-acute phase of recovery, who had experienced seven days a week individual therapy or five days a week circuit group therapy during inpatient rehabilitation. Results: Three main themes emerged from the data: Too much, too little or just right; My experience – alone and together; and Meeting my needs. Findings revealed considerable variety in participants’ beliefs, priorities and preferences regarding how intensely they could work; their experience of success and challenge individually and collectively; and their need to have their own unique individual needs met. Lack of choice seemed to be a linking concept between the themes. Conclusion: In order to provide patient-centred services, novel methods of increased therapy must take into consideration the individual needs and preferences of the people accessing them. One model may not meet all these needs, hence a “menu” of options for therapy sessions (different timing, frequency, duration, content, rest and supervision) may be required to accommodate the diversity of patient needs, preferences and capacities.Implications for Rehabilitation People with stroke have diverse needs and preferences regarding the modes of delivering more therapy during rehabilitation.These diverse needs may not be met by one rigid service model.Therapists and service providers could engage their clients in a dialogue about the need for more therapy and how it can be delivered.This dialogue could include options of the various ways to increase their therapy.Therapists need to provide clear reasons and education around therapy components, including rest time and practice schedules. Refereed/Peer-reviewed

The purpose of this study was to evaluate whether the implementation of interdisciplinary circuit class therapy is a feasible and sustainable means of increasing activity-based therapy time for patients in an acute stroke unit. Thirty participants (15 with stroke as a primary diagnosis) participated in twice weekly circuit class therapy for 3 weeks. Measures included therapy time, attendance rate and patient levels. Circuit class therapy signifi cantly increased the time spent engaged in activity-based therapy (circuit class therapy days: 86 ± 28; non-circuit class therapy days: 32 ± 26, P < 0.001). Circuit class therapy was feasible; operating within existing staffi ng levels with an attendance rate of 78%. It was sustainable over a 12-month period and it was also associated with high patient satisfaction. Circuit class therapy is a feasible and sustainable way of increasing activity-based therapy time for patients in an acute care setting. Further research should examine the impact of circuit class therapy provided in an acute care setting on recovery of functional abilities and length of hospital stay.

Objectives To examine the frequency and factors associated with patients with stroke in Australian hospitals receiving documented rehabilitation assessments; to examine the criteria used when rehabilitation was not recommended; and to examine whether being assessed for rehabilitation affected access to rehabilitation. Design Retrospective medical record audit of patients with a diagnosis of stroke who were discharged consecutively between 2013 and 2014. Setting Acute care public hospitals. Participants Adults with stroke (N=333) receiving care in participating hospitals. Interventions Not applicable. Main Outcome Measure Documented assessment regarding patient suitability for rehabilitation during acute hospitalization. Results Data from 292 patients were included for analysis (60% men; mean age, 72y). Of the patients, 42% were assessed for rehabilitation by a health professional providing care in the hospital, 43% were assessed for rehabilitation by a representative from a rehabilitation service, and 37% did not receive any documented rehabilitation assessment. In multivariable analysis, patients were significantly more likely to be assessed for rehabilitation if they lived in the community before their stroke, had moderate severity strokes, or received occupational therapy during hospital admission. Rehabilitation was not recommended in 9% of assessments despite the presence of stroke-related symptoms. Patients not assessed for rehabilitation were significantly less likely to access rehabilitation than patients who were assessed. Conclusions More than one third of patients were not assessed for rehabilitation. When assessed, rehabilitation was not consistently recommended for patients with stroke-related symptoms. This study highlights factors that increase the likelihood of being assessed for rehabilitation.

Background Large numbers of people provide carer roles for survivors of stroke. Person-centred stroke rehabilitation must consider the perspectives of carers, as stroke affects not only the stroke survivor but also the quality of life and health of the carers. There is little collective knowledge about stroke carers’ experiences, needs and preferences during the inpatient stroke rehabilitation process to then inform person-centred service improvements. Our objective is to report and synthesise experiences, needs and preferences of the carers of stroke survivors undergoing rehabilitation in inpatient settings. Methods/design We will conduct a systematic review of qualitative studies using a thematic synthesis methodology. We will follow the Enhancing Transparency in Reporting the Synthesis of Qualitative Research Guidelines (ENTREQ) and search the following databases for relevant articles: MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Embase, and Web of Science. No language or publication date constraints will be applied. Eligible studies will have to use qualitative methods of data collection and analysis and reported data from the carers of stroke survivors who underwent inpatient stroke rehabilitation. Studies will be eligible for inclusion if they report the experiences, needs and preferences of carers regarding inpatient rehabilitation environments, organisation, care systems, therapeutic interventions, information exchange, carer training, discharge and community service planning and other issues of relevance to their roles as carers. Study selection and assessment of quality will be performed independently by two reviewers. Any disagreement will be resolved by a third reviewer. Data will be extracted by one reviewer, tabled, and checked for accuracy by another reviewer. All text reported in studies’ results, discussion and conclusion sections will be entered into the NVivo software for analysis. Extracted texts will be inductively coded independently by two reviewers and analysed in three phases using thematic synthesis. Descriptive and analytical themes will be developed. Discussion This study is expected to provide new insights into the perspectives of stroke survivors’ carers. Increased knowledge about carer perspectives and preferences will inform person-centred improvements in stroke rehabilitation. Study registration PROSPERO registration number: CRD42015017315. Electronic supplementary material The online version of this article (doi:10.1186/s13643-015-0097-0) contains supplementary material, which is available to authorized users.

Objective To report and synthesize the experiences, needs, and preferences of carers of stroke survivors undergoing inpatient rehabilitation. Data Sources MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science were searched to March 2016. Reference lists of relevant publications were searched. No language restrictions were applied. Study Selection Eligible qualitative studies reported the experiences of carers of stroke survivors who underwent inpatient rehabilitation. The search yielded 3532 records; 93 full-text publications were assessed for eligibility, and 34 documents (33 studies) were included. Comprehensiveness of reporting was assessed using the Consolidated Criteria for Reporting Qualitative Health Research framework. Data Extraction Data on the characteristics of included studies were independently extracted by 2 authors. Differences in data extraction between authors were resolved through discussion or by a third author. All text in studies' results and discussion sections were extracted for analysis. Data Synthesis Extracted texts were analyzed inductively using thematic synthesis. Seven analytical themes were developed that related to the carers' experiences, needs, and preferences: (1) overwhelmed with emotions; (2) recognition as a stakeholder in recovery; (3) desire to be heard and informed; (4) persisting for action and outcomes; (5) being legitimate clients; (6) navigating an alien culture and environment; and (7) managing the transition home. Conclusions This systematic review provides new insights into the experiences, needs, and preferences of carers of stroke survivors undergoing inpatient rehabilitation. Carers experienced distress as they navigated a foreign culture and environment without adequate communication and processes in place for their inclusion. We recommend deliberate efforts to provide a more inclusive environment that better supports and prepares carers for their new role.

Conclusions:The thematic synthesis provides new insights into stroke survivors' experiences of inpatient rehabilitation. Negative experiences were reported in all studies and include disempowerment, boredom, and frustration. Rehabilitation could be improved by increasing activity within formal therapy and in free time, fostering patients' autonomy through genuinely patient-centered care, and more effective communication and information. Future stroke rehabilitation research should take into account the experiences and preferences of stroke survivors. Data Extraction: Data regarding characteristics of the included studies were extracted by 1 reviewer, tabled, and checked for accuracy by another reviewer. All text reported in studies' results sections were entered into qualitative data management software for analysis. Data Sources: MEDLINE, CINAHL, Embase, and PsycINFO were searched from database inception to February 2014. Reference lists of relevant publications were searched. All languages were included. Data Synthesis: Extracted texts were inductively coded and analyzed in 3 phases using thematic synthesis. Nine interrelated analytical themes, with descriptive subthemes, were identified that related to issues of importance to stroke survivors: (1) physical activity is valued; (2) bored and alone; (3) patient-centered therapy; (4) recreation is also rehabilitation; (5) dependency and lack of control; (6) fostering autonomy; (7) power of communication and information; (8) motivation needs nurturing; and (9) fatigue can overwhelm. Objective: To report and synthesize the perspectives, experiences, and preferences of stroke survivors undertaking inpatient physical rehabilitation through a systematic review of qualitative studies. Study Selection Qualitative studies reporting stroke survivors' experiences of inpatient stroke rehabilitation were selected independently by 2 reviewers. The search yielded 3039 records; 95 full-text publications were assessed for eligibility, and 32 documents (31 studies) were finally included. Comprehensiveness and explicit reporting were assessed independently by 2 reviewers using the consolidated criteria for reporting qualitative research framework. Discrepancies were resolved by consensus. Refereed/Peer-reviewed

Background: Evaluating the methodological quality of clinical practice guidelines is essential before deciding which ones which could best inform policy or practice. One current method of evaluating clinical guideline quality is the research-focused AGREE II instrument. This uses 23 questions scored 1-7, arranged in six domains, which requires at least two independent testers, and uses a formulaic weighted domain scoring system. Following feedback from time-poor clinicians, policy-makers and managers that this instrument did not suit clinical need, we developed and tested a simpler, shorter, binary scored instrument (the iCAHE Guideline Quality Checklist) designed for single users. Conclusion: The iCAHE Guideline Quality Checklist has promising psychometric properties and clinical utility. Methods: Content and construct validity, inter-tester reliability and clinical utility were tested by comparing the new iCAHE Guideline Quality Checklist with the AGREE II instrument. Firstly the questions and domains in both instruments were compared. Six randomly-selected guidelines on a similar theme were then assessed by three independent testers with different experience in guideline quality assessment, using both instruments. Per guideline, weighted domain and total AGREE II scores were calculated, using the scoring rubric for three testers. Total iCAHE scores were calculated per guideline, per tester. The linear relationship between iCAHE and AGREE II scores was assessed using Pearson r correlation coefficients. Score differences between testers were assessed for the iCAHE Guideline Quality Checklist. Results: There were congruent questions in each instrument in four domains (Scope & Purpose, Stakeholder involvement, Underlying evidence/Rigour, Clarity). The iCAHE and AGREE II scores were moderate to strongly correlated for the six guidelines. There was generally good agreement between testers for iCAHE scores, irrespective of their experience. The iCAHE instrument was preferred by all testers, and took significantly less time to administer than the AGREE II instrument. However, the use of only three testers and six guidelines compromised study power, rendering this research as pilot investigations of the psychometric properties of the iCAHE instrument. Refereed/Peer-reviewed

Julie A Luker1, Julie Bernhardt2,3, Karen A Grimmer-Somers11International Centre for Allied Health Evidence, University of South Australia, Adelaide, South Australia; 2School of Physiotherapy, La Trobe University, Melbourne, Victoria, Australia; 3Stroke Division, Florey Neurosciences Institute, Heidelberg Heights, Victoria, AustraliaBackground: We recently indicated that patient age on its own is not a determinant of quality of allied health care received after an acute stroke. It has not been tested whether other non-age variables influence care decisions made by allied health professionals. This paper explores demographic and stroke-related variables that are putatively associated with the quality of care provided to acute stroke patients by allied health professionals.Methods: Data were retrospectively audited from 300 acute stroke patient records regarding allied health care. Compliance with each of 20 indicators of allied health care quality was established. The influence of various demographic and stroke-related variables on each performance indicator was examined. We undertook a series of analyses using univariate logistic regression models to establish the influence of these variables on care quality.Results: Patient age had a significant correlation with only one process indicator (early mobilization). Seven variables, including stroke severity and level of dependence, were associated with patient age. The majority of these age proxies had significant associations with process indicator compliance. Correlations between non-age variables, in particular stroke severity and comorbidity, suggest the potential for complex confounding relationships between non-age variables and quality of allied health care.Conclusion: Compliance with individual indicators of allied health care was significantly associated with variables other than patient age, and included stroke severity, previous independence, comorbidities, day of admission, stroke unit admission, and length of stay. The inter-relationships between these non-age variables suggest that their influence on quality of care is complex.Keywords: predictor variables, stroke severity, allied health care, comorbidity levels

Objective: A small percentage of Australians frequently attend hospital emergency departments (ED) with potentially avoidable health crises. These individuals are termed ‘vulnerable’ due to their complex health and social needs. When these needs are unmanaged, unnecessary ED and hospital‐admission costs are incurred. A holistic community‐based program was developed to engage a cohort of vulnerable individuals in strategies to improve their health and health behaviours, and health service use. Methods: A purposive sample of frequent ED attendees was identified in one Australian metropolitan health region. Core program elements included working with clients within their environment, problem solving, empowerment, education, goal setting and mentoring. Evaluation data included services provided for, and time spent with, clients; hospital admission and emergency department attendances and related costs; client engagement data; mental health measures; client stories and participant interviews. Results: Data was analysed from 37 clients. On average, staff spent 34 hours with each client, costing approximately $1,700 each. Significant improvements resulted in client health and health behaviours. Crisis emergency department and inpatient admissions decreased, and planned outpatient clinic use increased. Conclusion: Low‐cost community‐based intervention for frequent ED attendees has the potential for significant tertiary hospital savings. Refereed/Peer-reviewed

Adherence to recommended clinical practices improves stroke outcomes. As a result, stroke clinicians are increasingly expected to evaluate the quality of the care they provide so that areas for improvement can be targeted. Finding the best method to evaluate the quality of dysphagia management can be challenging. Aim To systematically review process indicators used to assess the quality of care provided to patients with dysphagia following acute stroke and examine the level of evidence underpinning these indicators. Methods Databases were systematically searched to identify publications (January 2006–April 2009) that describe process indicators relating to the clinical management of acute stroke-related dysphagia. Relevant process indicators were extracted from the reviewed publications for detailed post hoc analysis including supporting evidence and alignment to the current Australian and English stroke guidelines. Results Title and abstract review found 150 potential studies. Full-text review resulted in 25 publications that met the study's inclusion criteria. Thirteen process indicators were identified in the literature that related to the initial assessment, clinical management, rehabilitation and discharge planning for patients with acute stroke-related dysphagia. These processes were supported by levels of evidence ranging from high ‘level 1’ (8%) down to ‘expert opinion’ evidence (46%). Two process indicators did not align to recommendations in the clinical guidelines. This systematic review underpins informed selection of process indicators for evaluating the quality of dysphagia management following stroke. The selection of quality indicators is complicated by equivocal supporting evidence; however, indicators should reflect expected local practices, align with national stroke guidelines and be feasible for clinical auditing.

Rationale, aim and objective: The use of stroke clinical guidelines is widely encouraged yet variably operationalized. The factors which support, or hinder guideline compliance are poorly understood, and there is little research which pertains to the unique roles of Allied Health (AH) staff when operationalizing stroke clinical guidelines. This study identifies factors influencing AH staff compliance with guideline recommendations in an acute stokeunit. Method: A retrospective audit was conducted of hospital records of stroke patients admitted to an Australian tertiary metropolitan hospital in 2005. The recorded clinical care provided by an AH team was audited against the 38 recommendations in the Australian acute stroke guidelines relevant to allied health. Results: Compliance with guideline recommendations was variable, with better care compliance found for younger patients, patients admitted on weekdays, and patients with poorer functional ability on admission, longer lengths of stay and better functional improvements during admission. Compliance also reflected the congruence of guideline recommendations with ‘usual practice’. Conclusions: A number of factors influenced AH staff compliance with acute stroke guidelines. These findings are a platform upon which further implementation research can be launched for AH professionals. Refereed/Peer-reviewed

Purpose: To investigate staff compliance with discharge planning clinical guideline recommendations in an acute stroke unit, and its relationship with post-discharge experiences of stroke patients and their carers. Subjects: Fifty acute stroke patients were systematically recruited for a retrospective patient record audit of staff compliance with clinical guideline recommendations related to discharge planning. Methods: Semi-structured interviews were conducted over six months post-discharge on patients’ actual community support needs and experiences. Audit and patient experience data were integrated to seek evidence of 1) characteristics of patients receiving guideline-compliant care, 2) relationships between staff compliance with discharge planning recommendations and patient’s post-discharge experiences, and 3) whether patient’s post-discharge experiences of shortfalls in support related to hospital discharge planning. Results: Not all patients received guideline-based care. There was a trend that patients with more complex strokes received guideline-compliant care than other patients. Compliance with providing an occupational therapy (OT) home assessment was significantly related to discharge directly home from hospital. There was a shortfall with 40% of patients between community supports predicted by hospital staff and actual post-discharge support requirements. Community support requirements increased over time for 32% of patients, whose six-month post-discharge needs were actually greater than their needs at six weeks. Conclusions: Staff compliance with discharge planning recommendations was variable and did not always relate to improved post-discharge patient experiences. The post-discharge experiences of many stroke patients could not have been predicted whilst they were in hospital. Discharge planning and support systems thus need to be flexible and responsive to short and long-term needs.

Background: The need for chronic disease self-management (CDS-M) is increasing worldwide. CDS-M programs are variably effective for vulnerable and disadvantaged individuals. Objectives: The objects of this study were 1) To explore experiences of health workers leading CDS-M programs for vulnerable and disadvantaged populations, and 2) To develop guiding principles for the delivery of more effective CDS-M programs for vulnerable and disadvantaged populations. Methods: Two focus groups were undertaken, with all primary health workers, and allied health (AH) staff in a large community centre in an Australian city, who worked with vulnerable and disadvantaged individuals with chronic disease. Results: Consistent messages were identified, producing nine guiding principles. Self-management programs / messages should be tailored to cultural groups, learning styles and available supports, cultural sensitivities, group leadership requirements, language, literacy levels, belief systems and social circumstances and supports, past experiences, and individuals’ ability to motivate change. Implications: The draft guiding principles may assist others to deliver more effective CDS-M programs for disadvantaged and vulnerable populations. BACKGROUND Chronic disease (CD) poses an enormous challenge to Australian health and social systems. 1 CD in Australia now contributes to over 70% of the burden of disease, and is expected to increase to 80% by 2020.2 In response, the Australian Government has initiated a major focus on CD prevention and management through three complementary policies: the National Chronic Disease Strategy, National Service Improvement Framework, and the Blueprint for Chronic Disease Surveillance.3 This has been supported by increased government funding for CD self-manageme nt (S-M) programs delivered by primary health services across Australia.4 The priority CDs outlined under the National Service Improvement Framework are asthma, cancer, diabetes, heart disease, stroke and vascular disease, osteoarthritis, rheumatoid arthritis, and osteoporosis. 3

Background: Many patients with acute stroke do not receive recommended care in tertiary hospital settings. Allied health professionals have important roles within multidisciplinary stroke teams and influence the quality of care patients receive. Studies examining the role of allied health professionals in acute stroke management are scarce, and very little is known about the clinical decision making of these stroke clinicians. In this study we aimed to describe factors that influence the complex clinical decision making of these professionals as they prioritise acute stroke patients for recommended care. This qualitative study was part of a larger mixed methods study. Conclusions: Our qualitative enquiry provided new insights into the way allied health professionals make important clinical decisions for patients with acute stroke. This is the first known study to demonstrate that the subjective prediction of discharge destination made early in an acute admission by allied health professionals, has a powerful influence over the care and rehabilitation provided, and the ultimate outcomes for stroke patients. Methods: The qualitative methodology applied was a constructivist grounded theory approach. Fifteen allied health professionals working with acute stroke patients at three metropolitan tertiary care hospitals in South Australia were purposively sampled. Semi-structured interviews were conducted face to face using a question guide, and digital recording. Interviews were transcribed and analysed by two researchers using rigorous grounded theory processes. Results: Our analysis highlighted 'predicted discharge destination' as a powerful driver of care decisions and clinical prioritisation for this professional group. We found that complex clinical decision making to predict discharge destination required professionals to concurrently consider patient's pre-stroke status, the nature and severity of their stroke, the course of their recovery and multiple factors from within the healthcare system. The consequences of these decisions had potentially profound consequences for patients and sometimes led to professionals experiencing considerable uncertainty and stress. Refereed/Peer-reviewed

Background Functional decline (FD) is a largely preventable feature of aging, characterized as gradual erosion of functional autonomy. This reduces an older person’s capacity for safe, independent community living. The healthcare needs of an unprecedented aging population places pressure on health systems to develop innovative approaches to ensuring older people live healthy and independent lives for as long as possible. TRIIFL aims to demonstrate that: Incipient FD in older people can be identified using a simple telephone-screening process within four weeks of discharge from an emergency department presentation for a minor health event; and Early engagement into a person-centered individualized intervention arrests or reduces the rate of FD over the next 12 months. Methods/Design A randomized controlled trial (RCT) nested within a 13-month longitudinal cohort study. The RCT (conducted over 12 months) tests the effectiveness of a novel, early, home-based, personalized program (compared with no intervention) in arresting or slowing FD. TRIIFL focuses on older adults living independently in the community, who have not yet had a serious health event, yet are potentially on the cusp of FD. Participants in the longitudinal cohort study will be recruited as they present to one large tertiary hospital Emergency Department, providing they are not subsequently admitted to a ward. Sample size calculations indicate that 570 participants need to be recruited into the longitudinal study, with 100 participants randomized into the trial arms. Measures from all subjects will be taken face-to-face at baseline (recruitment), then subsequently by telephone at one, four, seven and thirteen months later. Measures include functional abilities, quality of life, recent falls, mobility dependence, community supports and health service usage. Specific to the nested RCT, the quality of life tool (SF12) applied at one month, will identify individuals with low mental component quality of life scores, who will be invited to enter the RCT. Assessors will be blinded to RCT arm allocation, and subjects in the RCT will be blinded to the intervention being received by other subjects. Trials Registration Australian & New Zealand Clinical Trials Registry: ACTRN12613000234718

Julie A Luker1, Julie Bernhardt2, Karen A Grimmer-Somers11International Centre for Allied Health Evidence, University of South Australia Adelaide, South Australia, Australia; 2School of Physiotherapy, La Trobe University Melbourne, Victoria, Australia and Stroke Division, Florey Neurosciences Institutes Heidelberg Heights, Melbourne, Victoria, AustraliaBackground: Improvement in acute stroke care requires the identification of variables which may influence care quality. The nature and impact of demographic and stroke-related variables on care quality provided by allied health (AH) professionals is unknown.Aims: Our research explores the association of age and gender on an index of acute stroke care quality provided by AH professionals.Methods: A retrospective clinical audit of 300 acute stroke patients extracted data on AH care, patients' age and gender. AH care quality was determined by the summed compliance with 20 predetermined process indicators. Our analysis explored relationships between this index of quality, age, and gender. Age was considered in different ways (as a continuous variable, and in different categories). It was correlated with care quality, using gender-specific linear and logistic regression models. Gender was then considered as a confounder in an overall model.Results: No significant association was found for any treatment of age and the index of AH care quality. There were no differences in gender-specific models, and gender did not significantly adjust the age association with care quality.Conclusion: Age and gender were not predictors of the quality of care provided to acute stroke patients by AH professionals.Keywords: acute stroke, allied health, quality of care, age, gender

Background The implementation of multidisciplinary stroke rehabilitation interventions is challenging, even when the intervention is evidence-based. Very little is known about the implementation of complex interventions in rehabilitation clinical trials. The aim of study was to better understand how the implementation of a rehabilitation intervention in a clinical trial within acute stroke units is experienced by the staff involved. This qualitative process evaluation was part of a large Phase III stroke rehabilitation trial (AVERT). Methods A descriptive qualitative approach was used. We purposively sampled 53 allied health and nursing staff from 19 acute stroke units in Australia, New Zealand and Scotland. Semi-structured interviews were conducted by phone, voice-internet, or face to face. Digitally recorded interviews were transcribed and analysed by two researchers using rigorous thematic analysis. Results Our analysis uncovered ten important themes that provide insight into the challenges of implementing complex new rehabilitation practices within complex care settings, plus factors and strategies that assisted implementation. Themes were grouped into three main categories: staff experience of implementing the trial intervention, barriers to implementation, and overcoming the barriers. Participation in the trial was challenging but had personal rewards and improved teamwork at some sites. Over the years that the trial ran some staff perceived a change in usual care. Barriers to trial implementation at some sites included poor teamwork, inadequate staffing, various organisational barriers, staff attitudes and beliefs, and patient-related barriers. Participants described successful implementation strategies that were built on interdisciplinary teamwork, education and strong leadership to ‘get staff on board’, and developing different ways of working. Conclusions The AVERT stroke rehabilitation trial required commitment to deliver an intervention that needed strong collaboration between nurses and physiotherapists and was different to current care models. This qualitative process evaluation contributes unique insights into factors that may be critical to successful trials teams, and as AVERT was a pragmatic trial, success factors to delivering complex intervention in clinical practice. Trial registration AVERT registered with Australian New Zealand Clinical Trials Registry ACTRN12606000185561. Electronic supplementary material The online version of this article (doi:10.1186/s12874-016-0156-9) contains supplementary material, which is available to authorized users.

Background Evidence-based care should improve acute stroke outcomes with the same magnitude of effect for stroke patients of all ages. However, there is evidence to suggest that, in some instances, older stroke patients may receive poorer quality care than younger patients. Our aim was to systematically review evidence of the quality of care provided to patients with acute stroke related to their age. Quality of care was determined by compliance with recommended care processes. Methods We systematically searched MEDLINE, CINAHL, ISI Web of Knowledge, Ageline and the Cochrane Library databases to identify publications (1995-2009) that reported data on acute stroke care process indicators by patient age. Data extracted included patient demographics and process indicator compliance. Included publications were critically appraised by two independent reviewers using the Critical Appraisal Skills Programme tool, and a comparison was made of the risk of bias according to studies' findings. The evidence base for reported process indicators was determined, and meta-analysis was undertaken for studies with sufficient similarity. Results Nine from 163 potential studies met the inclusion criteria. Of the 56 process indicators reported, eleven indicators were evidence-based. Seven of these indicators (64%) showed significantly poorer care for older patients compared to younger ones, while younger patients received comparatively inferior care for only antihypertensive therapy at discharge. Our findings are limited by the variable methodological quality of included studies. Conclusion Patients' age may be a factor in the care they receive after an acute stroke. However, the possible influence of patients' age on clinicians' decision-making must be considered in terms of the many complex issues that surround the provision of optimal care for older patients with acute stroke.