A descriptive study on doctors' practices regarding different aspects of stroke rehabilitation in private acute-care hospitals situated in the Western Cape metropole

Thesis (MPhil)--Stellenbosch University, 2009.A research assignment submitted in partial fulfilment of the requirements of the degree Master of Philosophy (MPhil) in rehabilitation at Stellenbosch UniversityENGLISH ABSTRACT: Introduction: Stroke is a growing healthcare problem in South Africa. It contributes significantly to the burden of disease and is the largest cause of disability. Rehabilitation can significantly improve recovery and outcomes of stroke survivors particularly if implemented in the correct manner and through using certain approaches. The aim of this study was to examine the practice of doctors with regards to stroke rehabilitation in private acute-care hospitals in the Western Cape Metropole. In particular, attention has been given to the degree to which doctors in the private health care sector shared information with first time stroke patients. The study design was retrospective and descriptive in nature. Data collection was primarily of a quantitative nature although some qualitative data has been collected to elaborate on quantitative findings. Two self-designed questionnaires were used to collect data. Data from doctor-participants were collected to examine the use of care protocols. Data from both groups of participants were collected to determine which practices were prefered. In particular it was sought to ascertain what team work approach was favoured by doctors. To do this the method of communication among team members was examined. It was also sought to ascertain how information regarding diagnosis, prognosis, risk factors, post–acute rehabilitation options and discharge planning was shared. In total thirty-five doctors and forty-eight patients were interviewed. Quantitative data was captured on an excel spreadsheet and analysed with the help of a STATISTICA software package. A p value of less than 0.05 was deemed statistically significant. Results showed that none of the doctor participants had any formal rehabilitation qualification. It was found that stroke care protocols were used by 46% of doctor participants, while 89% acknowledged the advantages of a set protocol. The majority of doctors (57%) operated as part of a multidisciplinary team. Communication between team members regarding the patient’s management plan was done on a very informal basis with only 11% of doctors using ward rounds and none using team meetings for this purpose. Opinions differed between the two study groups on the frequency of information sessions (p = .00039). Only six % of doctors included the patient and family in the rehabilitation team. A large discrepancy was seen when it came to opinions on sharing information regarding diagnosis, prognosis, stroke risk factors, post-acute rehabilitation and discharge planning. P values ranging from 0.00013 to 0.0041 showed that the difference between the opinions of patients and doctors on these issues was statistically significant. Opinions also differed between the two groups when the frequency of information sessions was compared (p = 0.00039). Only 28% of patient participants were included in the decisionmaking process regarding further post-acute rehabilitation and in most cases the final decision was made by the doctor or the medical insurance company. Qualitative data highlighted some patients’ dissatisfaction regarding the post-acute rehabilitation process and indicated a problem with regard to the recognition of early stroke warning signs by general practitioners and the emergency treatment of these. The conclusion was that there is a great need for further motivation and education of doctors with respect to advanced research projects, further specialisation as well as the implementation of important rehabilitation modalities. It is also important that the patient himself acts as a fully-fledged team member. Recommendations were that administrators in both, the private and public health care sectors as well as non-government organisations and government welfare organisations identify the reasons for doctors’ hesitation to implement existing knowledge; that they make stroke rehabilitation training available and that they ensure that doctors implement the existing and new knowledge on all aspects of acute and post-acute stroke rehabilitation i.e. use of set care protocols, team work approach and sharing information on diagnosis, prognosis, risk factors, post–acute rehabilitation options and discharge planning when managing stroke patients. It was also recommended to promote more research projects which are implemented in the private health care sector.AFRIKAANSE OPSOMMING: Beroerte is reeds die grootste enkele oorsaak van gestremdheid in Suid Afrika en steeds aan die toeneem in insidensie. Navorsing het bewys dat rehabilitasie geskoei op wetenskaplik bewese metodes die uitkomste van beroerte lyers beduidend kan verbeter. Daarom was dit die doel van die studie om vas te stel tot watter mate dokters, werksaam in die privaat sektor in die Wes Kaapse Metropool, bewese rehabilitasie metodes implimenteer tydens behandeling van akute beroerte pasiënte. Spesifieke areas waaraan aandag geskenk is, was die gebruik van beroerte protokolle, die volg van die interdissiplinêre spanwerk benadering, kommunikasie metodes tussen spanlede en die deurgee van inligting met betrekking tot die diagnose, prognose, risiko faktore, opvolg rehabilitasie en ontslag beplanning aan pasiënte na `n eerste beroerte. Die studie was retrospektief en beskrywend van aard. Daar was primêr kwantitatiewe data ingesamel met behulp van twee self ontwerpde vraelyste. ‘n Klein hoeveelheid kwalitatiewe data is aanvullend ingesamel om kwantitatiewe bevindings toe te lig. 35 dokters en 48 pasiënte het aan die studie deelgeneem. ‘n STATISTICA sagteware pakket is gebruik vir die analise van kwalitatiewe data. ‘n P waarde van minder as 0.05 is as statisties beduidend beskou. Nie een van die dokters wat aan die studie deelgeneem het, het nagraadse opleiding in rehabilitasie gehad nie. 46% van dokters het beroerte protokolle gebruik in hulle praktyke, terwyl 89% gevoel het dat die gebruik van protokolle voordele inhou. Waar spanwerk gebruik was (57% van dokters), is die multidissiplinêre benadering gevolg. Kommunikasie tussen spanlede het meesal op `n informele basis geskied. Geen dokter het spanvergaderings gehou nie. 11% van dokters het saalrondtes gehou waartydens met spanlede gekommunikeer is. 6% van dokters het die pasiënt en familie ingesluit in die rehabilitasie span. Volgens dokters was daar beduidend meer inligting sessies met pasiënte gehou as volgens pasiënte (p = 0.00039). Die verskil in mening tussen die twee groepe is ook waargeneem met betrekking tot die hoeveelheid inligting wat verskaf is oor diagnose, prognose, risiko faktore, post akute rehabilitasie en onslag beplanning (P waardes het gewissel van 0.00013 tot 0.0041). 25% van pasiënte het deelgeneem aan die besluitnemings proses oor opvolg rehabilitasie. Die finale besluit hieroor was in die meerderheid van gevalle deur die dokter en die mediese versekeringsskema geneem. Dit het uit die kwalitatiewe data geblyk dat van die pasiënte ongelukkig was met die opvolg rehabilitasie wat hulle ontvang het. Voorts het pasiënte gevoel dat algemene praktisyns beter ingelig behoort te wees oor die vroeë waarskuwingstekens van beroerte sowel as die noodbehandling van die tekens. Die navorser het tot die gevolgtrekking gekom dat dokters oortuig moet word van die belang van verdere navorsing, spesialisasie in rehabilitasie en die implementasie van bewese beroerte rehabilitasie metodes. Sy beveel aan dat administrateurs van beide die privaat en staatssektor sowel as verteenwoordigers van nie regerings organisasies betrokke raak om bogenoemde te bewerkstellig. Daar moet vasgestel word waarom dokters huiwerig is om bestaande kennis te implemteer. Beroerte rehabilitasie opleiding moet beskikbaar gestel word aan dokters en dokters moet aangemoedig word om bewese kennis soos die gebruik van protokolle, interdissiplinêre spanwerk en verskaffing van inligting oor diagnose, prognose, risiko faktore, opvolg rehabilitasie en ontslag beplanning toe te pas in die praktyk. Die doen van meer navorsing in die privaat sektor word ook aangemoedig