Not one thing discussed here will do a damn bit of good until you finally CREATE EXACT 100% RECOVERY PROTOCOLS! It's that simple! Does no one in stroke have two functioning neurons to rub together? 'Care' does NOTHING! Survivors want recovery, or are you THAT BLITHERINGLY STUPID? Well, the answer? Are you stupid or not?
Transforming Posthospital Stroke Care, Outcomes, and Use of New Innovations Through Implementation Science
Life after an acute stroke hospitalization requires an intentional focus toward ensuring optimal daily functioning, behaviors, support, and well‐being. This could be achieved with an array of posthospital services and supports. Although the availability and use of services after a stroke vary widely by individual and geographic region, posthospital stroke care could include additional inpatient stays, outpatient clinic or home‐based care, and remote monitoring. Services can offer rehabilitation, secondary prevention, behavioral health management, and community programs to support return to work, school or family roles, spiritual and social connections, medication management, and healthy lifestyles.1 Because the global stroke burden remains high, and financial landscape supporting service delivery gets further constrained, there is a need for leaders of poststroke services to incorporate new approaches for addressing quality of care and equity in services offered. Bringing the methods from implementation research to poststroke care can help service leaders optimize resource use, ensure evidence‐based guidelines and new best practices are integrated and routinely used, and design interventions tailored to meet the needs of stroke survivors.
Few poststroke services provide guideline‐recommended, evidence‐based treatments to 100% of their stroke survivor patient population. Implementation science, which systematically aims to improve the uptake of research findings and what we know works into practice or policy,2 focuses on this know–do gap. Implementation research is used to explore factors and develop and test strategies or approaches that better promote the adoption and integration of evidence into clinical and community settings to improve population health for all.3 The methods used in implementation research are useful for several purposes.4, 5 There are frameworks to help identify contextual factors that are preventing full use of effective interventions. There are tools to identify how to address barriers to implementation. There are also models and study designs to guide processes for improved implementation and sustainability. Fully and systematically integrating these methods into poststroke services could help address treatments, programs, and policies so current rates of stroke recurrence and years lived with disability do not persist for another decade unchanged.6, 7 It should not be considered acceptable that, for example, a third of stroke survivors live with untreated or uncontrolled hypertension globally; a third of stroke survivors in the United States do not receive any rehabilitation therapy in the year after their stroke, and significant racial and ethnic disparities in care and outcomes persist.8, 9, 10 This article describes 3 opportunities for applying implementation science in posthospital stroke service settings to improve what is delivered, to whom, how well, and with what resources to achieve better outcomes and equity.
EVALUATING IMPLEMENTATION IN ROUTINE CARE AND POSTSTROKE SERVICE DELIVERY
Poststroke service administrators and community program leaders likely monitor the number of people treated or served and what services are provided for those individuals. These interventions may span a range of specific procedures, include different products, stem from different practices or policies, or come together as a multicomponent program. For any of these interventions with an established evidence base, there is a known expectation for who should receive them and the outcomes that should be achieved as a result. These are foundational measures of implementation and effectiveness, respectively. Implementation can be further evaluated in several ways.
Even specific interventions have multiple levels of implementation. When considering a practice of interest that has evidence demonstrating significant population benefit with widespread implementation (eg, addressing poststroke hypertension and falls risk), service leaders can ask high‐level questions of their data to determine the biggest opportunities for improving uptake (Figure).11 Some degree of this evaluation is common in health departments, government agencies with surveillance functions, and organizations with stroke learning health systems that include an operations staff team and robust data infrastructure.12 The data can help identify at which level of implementation within an organization the voltage drop affecting potential benefit is occurring.13 Depending on resources available, priorities, and timing, further exploration may be needed before working toward an action plan for 1 or more levels.
*Initial evaluation with these and other related questions can establish baseline measures of implementation. From an established baseline, evaluations of representativeness can begin to explore equity. Evaluations of context may follow.
In some organizations, the processes for evaluating practices that address hypertension, falls risk, tobacco use, and other areas with long‐standing evidence may be well established. However, a deeper dive into these data could help identify inequities. Reading the Figure from the bottom up, and focusing on stroke survivors who are not served (or representativeness of those served), service leaders can identify if differences by race, ethnicity, social need, ability, sex, age, ability, and other characteristics are systematic. Even when adoption at the provider level, for example, appears to be 80% within an organization, there is likely to be variation across stroke survivors that would warrant further attention and action.
IMPROVING ADOPTION AND IMPLEMENTATION IN POSTSTROKE SERVICE DELIVERY
Context: Understanding the context for implementation and improvement is critical to successfully advance any plan of action. Implementation science has dozens of frameworks that can be used to specify barriers and enablers of adoption and implementation.4 The purpose of contextual inquiry is to begin to document and explain things that influence the process and ultimately the outcomes. Three commonly used comprehensive determinant frameworks include the Consolidated Framework for Implementation Research, Theoretical Domains Framework, and Promoting Action on Research Implementation in Health Services. Applying these or other frameworks in the exploration of context in poststroke service delivery can identify specific characteristics of the providers and stroke survivors, internal and external environment, the intervention or evidence‐based practice itself, and the processes used for implementing it. Often several barriers are operating simultaneously, such as discordance between a policy and strength of the evidence, lack of a clinical champion, or fractured communication channels. Mixed and multiple methods are recommended for studying context14; the scientific rigor that is applied may be dependent on resources and methodological expertise.
A pragmatic effectiveness trial example of exploring context in postacute stroke care leveraged a process that integrated data from surveys, group calls, interviews, and field notes.15 This evaluation of the COMPASS (Comprehensive Post‐Acute Stroke Services) cluster‐randomized pragmatic trial of transitional care used the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework to identify individual, organizational and community factors that facilitated system‐level intervention adoption, patient reach, and intervention implementation. Organizational readiness, a shared commitment and belief in the capacity for change, was the factor most highly correlated with successful implementation.
Adaptation: A comprehensive assessment of context can signal that the intervention or program itself needs to be adapted. This is especially common when expanding to be more inclusive or culturally relevant. A scoping review of frameworks for adapting evidence‐based interventions documented more than a dozen frameworks from the past 2 decades16; none originated in stroke research or service delivery, but several have since been applied for the benefit of stroke survivors. The synthesis suggests that adaptation involves input and feedback from topical and front‐line experts, engagement with end users, which could include both stroke survivors and their care partners, iterative refinement, training with expected implementers, and small tests of change. In the literature on posthospital stroke care, codesign has been applied as an approach for active engagement of a broad range of people as partners in the process of refinement. Engaging experts and end‐users can also identify how things are implemented.
Implementation Strategies: How clinical and community providers put evidence‐based interventions into routine practice is specified in implementation science as strategies. Strategies already exist when the intervention is already being used; however, if inequities, voltage drops, or persistent gaps in uptake are identified, the existing strategies need to be revisited, and perhaps others should be explored for use. A 2023 scientific statement for strategies to improve blood pressure control recognized that depending on where the gap lies, multiple levels of interventions will be needed.17
Many methodologies exist for identifying strategies. With data from the exploration of context or process of intervention refinement, teams can select from strategies that were reported as enablers. Strategies can also be matched to specifically target barriers. Teams can use other approaches to vet options available in preexisting lists of strategies categorized to facilitate application.18 An approach for identifying strategies that stems from improvement science and studies of organizations is to understand those with better outcomes (or top performers).19 Although this approach has been applied in the stroke community, results from its use have not yet been disseminated for evidence‐based interventions in posthospital stroke care or community‐based services.
Implementation Intervention Research: Testing the strategies that were identified for implementing an evidence‐based intervention while simultaneously measuring clinical, health service, and person‐centered outcomes can generate new knowledge for larger population health benefit. This is a key distinction from quality improvement, which aims to improve care locally and may not include a comprehensive evaluation of context or factors enabling sustainability.20 Study designs for implementation science examine application and can compare the effectiveness of the strategies hypothesized to facilitate change in an implementation outcome such as greater adoption and uptake of the intervention.21 Protocols for hybrid effectiveness‐implementation study designs that prioritize implementation outcomes (hybrid type III) in posthospital stroke services are available, but these studies are underway with no published findings yet available.
NEW INNOVATIONS
It is not uncommon for a new device, technology, or intervention to be brought directly to the posthospital clinical or community setting for use with stroke survivors. Innovators are eager to work directly in the real world. If efficacy is not yet established, or no real‐world study has been conducted to determine effectiveness among a more heterogeneous population of service providers and stroke survivors, it can be useful to include implementation research questions as part of the efficacy or effectiveness study design. Implementation questions in this phase of research or introduction of new innovations into practice include gathering contextual data, documenting where intervention adaptations are needed, and processes or pathways for its use.22 Designing for implementation as part of a randomized controlled trial for efficacy, or planning an effectiveness‐implementation hybrid study design, can expedite research translation.
CONCLUSIONS
There is a strong evidence base and clear guidelines for stroke secondary prevention, rehabilitation, and recovery. However, an estimated 101 million stroke survivors are alive today globally, living longer with disability and earlier onset of comorbid chronic conditions than in past decades. Although clinical and community‐based organizations may need to establish partnerships to acquire the necessary expertise, it is imperative that service leaders become familiar with and begin integrating implementation science to accelerate uptake of emerging evidence into routine practice and improve use of effective interventions with all eligible stroke survivors.
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