Interventions to promote the use of evidence-based practice in stroke rehabilitation

What is the aim of this review?

The aim of this Cochrane Review was to find out whether implementation strategies to encourage healthcare professionals to use evidence in stroke rehabilitation are effective. Examples of implementation strategies include education workshops, educational materials or providing feedback to healthcare professionals about their performance. The review authors collected and analysed all relevant studies to answer this question and found nine studies.

Key messages

We could not obtain a reliable estimate of the effect of implementation strategies in stroke rehabilitation on healthcare professional adherence to evidence-based practice at 12 months because the evidence is of very low quality.

What was studied in the review?

Patients who have a stroke and participate in rehabilitation do not always receive treatments based on evidence. Considerable research has been conducted in stroke rehabilitation but this information does not easily translate to clinical practice or it takes a long time to be used by healthcare professionals. Strategies are needed to help healthcare professionals use best evidence when working with stroke survivors.

We included studies that compared a group of healthcare professionals receiving support to use evidence in stroke rehabilitation with another group who did not. We were interested to see whether healthcare professionals used more evidence in practice, whether patients adhered to evidence-based recommendations from healthcare professionals, and whether patient health and well-being improved.

What are the main results of the review?

We found nine studies from five countries; Australia, Canada, Malaysia, the UK and the US. Four studies reported on whether healthcare professionals increased their use of evidence in their work with stroke survivors. Studies compared healthcare professionals who received support to use evidence in stroke rehabilitation with healthcare professionals who did not receive support or received a different type of support.

We are uncertain if implementation strategies to support healthcare professionals to use evidence in stroke rehabilitation improve their practice compared to no support as the quality of the evidence is very low. The review found that strategies to encourage healthcare professionals to use evidence in stroke rehabilitation may make little or no difference to patient adherence to recommended treatment and patient psychological well-being compared to no intervention (low-quality evidence). Additionally, we found these strategies probably lead to little or no difference in patient health-related quality of life and activities of daily living compared with no intervention (moderate certainty evidence).

We found no studies that reported healthcare professional intention to change their behaviour or satisfaction.

How up-to-date is this review?

The review authors searched for studies published up to 17 October 2019.

Authors' conclusions: 

We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence is very low.

Read the full abstract...
Background: 

Rehabilitation based upon research evidence gives stroke survivors the best chance of recovery. There is substantial research to guide practice in stroke rehabilitation, yet uptake of evidence by healthcare professionals is typically slow and patients often do not receive evidence-based care. Implementation interventions are an important means to translate knowledge from research to practice and thus optimise the care and outcomes for stroke survivors. A synthesis of research evidence is required to guide the selection and use of implementation interventions in stroke rehabilitation.

Objectives: 

To assess the effects of implementation interventions to promote the uptake of evidence-based practices (including clinical assessments and treatments recommended in evidence-based guidelines) in stroke rehabilitation and to assess the effects of implementation interventions tailored to address identified barriers to change compared to non-tailored interventions in stroke rehabilitation.

Search strategy: 

We searched CENTRAL, MEDLINE, Embase, and eight other databases to 17 October 2019. We searched OpenGrey, performed citation tracking and reference checking for included studies and contacted authors of included studies to obtain further information and identify potentially relevant studies.

Selection criteria: 

We included individual and cluster randomised trials, non-randomised trials, interrupted time series studies and controlled before-after studies comparing an implementation intervention to no intervention or to another implementation approach in stroke rehabilitation. Participants were qualified healthcare professionals working in stroke rehabilitation and the patients they cared for. Studies were considered for inclusion regardless of date, language or publication status. Main outcomes were healthcare professional adherence to recommended treatment, patient adherence to recommended treatment, patient health status and well-being, healthcare professional intention and satisfaction, resource use outcomes and adverse effects.

Data collection and analysis: 

Two review authors independently selected studies for inclusion, extracted data, and assessed risk of bias and certainty of evidence using GRADE. The primary comparison was any implementation intervention compared to no intervention.

Main results: 

Nine cluster randomised trials (12,428 patient participants) and three ongoing trials met our selection criteria. Five trials (8865 participants) compared an implementation intervention to no intervention, three trials (3150 participants) compared one implementation intervention to another implementation intervention, and one three-arm trial (413 participants) compared two different implementation interventions to no intervention. Eight trials investigated multifaceted interventions; educational meetings and educational materials were the most common components. Six trials described tailoring the intervention content to identified barriers to change. Two trials focused on evidence-based stroke rehabilitation in the acute setting, four focused on the subacute inpatient setting and three trials focused on stroke rehabilitation in the community setting.

We are uncertain if implementation interventions improve healthcare professional adherence to evidence-based practice in stroke rehabilitation compared with no intervention as the certainty of the evidence was very low (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.53 to 2.64; 2 trials, 39 clusters, 1455 patient participants; I2 = 0%). Low-certainty evidence indicates implementation interventions in stroke rehabilitation may lead to little or no difference in patient adherence to recommended treatment (number of recommended performed outdoor journeys adjusted mean difference (MD) 0.5, 95% CI –1.8 to 2.8; 1 trial, 21 clusters, 100 participants) and patient psychological well-being (standardised mean difference (SMD) –0.02, 95% CI –0.54 to 0.50; 2 trials, 65 clusters, 1273 participants; I2 = 0%) compared with no intervention. Moderate-certainty evidence indicates implementation interventions in stroke rehabilitation probably lead to little or no difference in patient health-related quality of life (MD 0.01, 95% CI –0.02 to 0.05; 2 trials, 65 clusters, 1242 participants; I2 = 0%) and activities of daily living (MD 0.29, 95% CI –0.16 to 0.73; 2 trials, 65 clusters, 1272 participants; I2 = 0%) compared with no intervention.

No studies reported the effects of implementation interventions in stroke rehabilitation on healthcare professional intention to change behaviour or satisfaction.

Five studies reported economic outcomes, with one study reporting cost-effectiveness of the implementation intervention. However, this was assessed at high risk of bias. The other four studies did not demonstrate the cost-effectiveness of interventions.

Tailoring interventions to identified barriers did not alter results.

We are uncertain of the effect of one implementation intervention versus another given the limited very low-certainty evidence.

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