Of 121 respondents targeted, only 59 returned the questionnaire, making the response rate 48.8%.
Background of the respondents
The mean age of the respondents was 40.5 (SD 7.5) years. The mean number of years in public service was 15.3 (SD 7.23) years, with an average of 7.55 (SD 4.16) years after postgraduate qualification i.e. MMed (Family Medicine). The majority of respondents were females (83.0%, 49/59) and ethnic Malays (72.9%).
The practice details are shown in Table
1. The calculated stroke care burden was 2 out of every 100 patients seen in the healthcentres.
Table 1
Practice details of FMS at Malaysian public healthcentres
Clinic sessions/week | 4.60 (2.97) |
Number of primary care patients seen per session | 19.32 (9.51) |
Number of stroke patients seen per month | 7.17 (7.15) |
Median 5 (IQR 2-10) |
Burden of stroke patients in primary care | 0.02 |
Geographical location of practice in Malaysia |
Peninsular
| |
East Malaysia
| |
North | 13 | Sabah | 1 |
South | 5 | Sarawak | 2 |
East | 5 | Unspecified | 3 |
Central | 30 | | |
Place of practice | Rural | 17 | 28.8% |
Urban | 35 | 59.3% |
Rural & urban | 7 | 11.9% |
Estimated stroke patients seen at healthcentres/year | <20 | | 32.2% | |
21-40 | | 25.4% | |
41-60 | | 6.8% | |
61-80 | | 1.7% | |
81-100 | 3.4% | |
101-120 | 6.8% | |
Unsure | 23.7% | |
In terms of having a standard care plan for managing post stroke patients at primary care level, 72.4% (42/58) did not have one at their clinic, 19% (11/58) had a specific care plan while the remainder (8.6%, 5/58) were not sure if one existed. However, the majority 96.6% agreed that it was necessary to have a standardised care plan and this would improve quality of care for this group of patients.
Further analysis was done to determine if the location of practice would influence the current post stroke care provision was not statistically significant (Table
2).
Table 2
FMS opinion regarding post stroke care service provision based on practice/healthcentre location
Does your clinic/health centre have a standard care plan specifically for managing stroke patients? | | | | |
• Yes | 2 | 9 | 0 | 2.282 | 0.272 |
• No | 15 | 26 | 6 | | |
Do you think it is necessary to have a standard care plan for you and your team for managing stroke patients? | | | | |
• Yes | 16 | 34 | 6 | 1.053 | 1.00 |
• No | 1 | 1 | 0 | | |
In your opinion, do you think a standard care plan for stroke patients will help improve the quality of care for stroke patients in your health center? | | | | |
• Yes | 16 | 34 | 6 | 1.053 | 1.00 |
• No | 1 | 1 | 0 | | |
Have you ever managed a patient who had features of acute stroke during a consultation? | | | | |
• Yes | 12 | 30 | 4 | 2.594 | 0.293 |
• No | 5 | 5 | 2 | | |
Have you ever been consulted by your subordinates/staff on the management of patients who have had a stroke? | | | | |
• Yes | 14 | 29 | 6 | 0.802 | 0.751 |
• No | 3 | 6 | 0 | | |
Overall, do you feel comfortable managing patients with stroke? | | | | |
• Yes | 14 | 32 | 6 | 1.375 | 0.424 |
• No | 3 | 3 | 1 | | |
Table
3 lists the problems encountered by FMS in provision of care for post stroke patients at primary care level. The top 3 problems in general are related with transfer of care issues i.e. when the patient is discharged from the hospital and back to their own homes. On the other hand, it is encouraging to note that whilst reactive consultations to the primary care team does occur it is not highly ranked by the respondents.
Table 3
Obstacles encountered in provision of stroke care at primary level (1-most common, 10-less common)
1 | 17/45 | 37.8 | Lack of written information during transfer of care after discharge from hospital |
2 | 14/52 | 26.9 | Lack of information regarding rehabilitation therapy services |
3 | 10/50 | 20.0 | Lack of caregiver involvement |
4 | 8/42 | 19.0 | Most consultations are reactive |
5 | 8/43 | 18.6 | Delay in obtaining aids e.g. wheelchair |
6 | 9/49 | 18.4 | Unclear of available resources in the community & confusion regarding purpose of therapies |
7/38 | 18.4 |
7 | 10/55 | 18.2 | Poor overall/general care |
8 | 7/44 | 15.9 | Lack of self-interest and knowledge on stroke care management |
9 | 8/51 | 15.7 | Dealing with patient's emotional problems i.e. post stroke depression |
10 | 6/42 | 14.3 | Re-employment of patients with minimal neurological deficit |
Table
4 demonstrates the type of referrals received and the type of services used by the Family Medicine Specialists in managing post stroke patients. Most of the services accessed are within Ministry of Health facilities. The three most common types of referrals being transfer of care type with no further follow-up by tertiary care team (88.1%), shared care between tertiary and primary care team (67.8%) followed by ‘in-house’ primary care patients developing stroke while under primary care management for NCD or other problems (64.4%). The top three ranking of services utilised in the management of post stroke patients while at primary care are Physiotherapy, Dietitian and followed by Speech & Language Pathologist.
Table 4
Types of referrals for post stroke management seen at primary care
Patients referred for transfer of care from tertiary hospital to health centre (No further follow-up at Neurology or Physician Clinic) | 52/59 | 88.1% |
Patients referred for further monitoring in a shared care approach (i.e. with simultaneous follow-up at Neurology/Physician Clinic) | 40/59 | 67.8% |
Patients under FMS* care diagnosed as stroke | 38/59 | 64.4% |
Patients referred for further management by health care team (incl. nurses, Medical Assistants, Physiotherapist, Occupational Therapists etc.) | 33/59 | 55.9% |
Patients and/or carers requested for FMS intervention for stroke care | 26/59 | 44.1% |
Table
5 lists the expectations of the FMS in improving the quality of care to post stroke patients. The findings, in order of importance reiterate the problems identified by the respondents in Table
3, which highlight the areas of inadequate instructions to primary care on care provision after discharge.
Table 5
Expectations for improvement of stroke care provision at primary care level (1-most common, 5-less common)
1st | 37/55 | 67.3 | Referral with adequate instructions and goals from discharging physician at tertiary or secondary hospital |
2nd | 27/54 | 50.0 | Specific guidelines on management of long term stroke patients at community level |
3rd | 25/52 | 48.1 | A web based system which prompts you on measures to be taken during follow-up of stroke patients at your centre |
4th | 23/56 | 41.1 | Training programme or attachment at centres with expertise on community stroke care |
5th | 17/54 | 31.5 | Regular meetings with Neurologists/Physician/Rehabilitation team to discuss specific problems of stroke patients managed at your centre |
Qualitative data
Altogether 53 respondents wrote their opinions with regard to aspects of stroke management which they perceive as being critical/important in primary care. Five themes emerged from the transcripts of the FMS response. The themes in priority list were; the need for multidisciplinary team approach, access to rehabilitation services, patient and carer empowerment, the need for standardised care plan and availability of social support services.
The need for multidisciplinary team approach: Majority of the respondents were of opinion that the management of post stroke patients in the community requires a multidisciplinary team approach (n = 20/53, 37.7%)
“(There should be a..) Shared care (plan) with other teams e.g. physio (physiotherapy), occupational therapy, NGO, kebajikan (welfare) etc. (R40)
“Multidisciplinary/ team (MDT) management that can hasten the treatment as in primary care with many patient(s) and long waiting hours, care which is integrated on the system will compromised stroke patient (waiting time). MDT comprises of doctors, paramedics/community nurse for home visit, physiotherapist, dietician and welfare at least to serve stroke patient in a designated stroke clinic…” (R46)
The respondents also emphasised the need for coordination of care between the tertiary centres and primary care, adopting a shared care approach.
“…(The) Referral (should come) with adequate instruction(s) from tertiary hospital regarding long term goals (which have been planned) for the patient (to achieve at community level)…” (R9)
“..(There should be better) Support (given) by tertiary centres (in providing expert advise on long-term-care goals and..) (not dumping patient to the clinic) (to manage as the primary care team chooses) ….” (R34)
Access to rehabilitation services: The respondents highlighted the need for availability of rehabilitation facilities to be based at primary care, i.e. healthcentres (n = 21/53, 39.6%).
Not all healthcentres in Malaysia have facilities for rehabilitation services [
9], although there has been a recent move by the MOH to provide this facility at selected healthcentres with either physiotherapy alone or together with occupational therapy services. In some healthcentres, a visiting physiotherapist or occupational therapist provide services on rotational basis for healthcentres. However, the rehabilitation service at healthcentres is not solely for stroke rehabilitation. Therapists also have to cater for other services such as acute pain service, rehabilitation for amputees for example [
1].
“(There is) Problem of rehabilitation care as our patient mostly having difficulty to go to rehab centre which is at the tertiary hospital. (There is a …) Need of physiotherapist & occupational therapist (to be based) in health centre (as rehabilitation) is most critical in stroke care.” (R23)
“(There should be) More (accessible secondary care) service –physiotherapy, OT (Occupational Therapist) (to be based) in primary care clinic” (R38)
The above findings are similarly highlighted in the ranked list of rehabilitation services used by the FMS in provision of post stroke care in Table
6.
Table 6
Rehabilitation services used in management of post stroke patients in last one year
1st | 23/59 | 39.98 | Physiotherapy (MOH*) |
2nd | 7/59 | 11.86 | Dietitian |
3rd | 4/59 | 6.78 | Occupational therapy (MOH) |
4th | 7/59 | 11.86 | Social welfare |
5th | 7/59 | 11/86 | Speech & Language Therapy (MOH) |
6th | 5/59 | 8.47 | Prosthetics & Orthotics (MOH) |
7th | 4/59 | 6.78 | NGO |
8th | 8/59 | 13.56 | Occupational therapy (Private) |
Patient and carer empowerment: Apart from type of care and service-related issues, the FMS acknowledged the impact of patients and their caregivers’ efforts and motivation to obtain optimal post discharge care for stroke. Another apparent theme observed was the impact of the patients’ and caregivers’ effort after discharge to the patient’s overall well-being. The level of commitment from both patients and caregivers was singled out as an important feature to ensure successful post stroke care delivery (n = 17/53, 13.2%).
“To educate and empower patient and carer regarding home management of stroke; short and long term outcome of stroke and risk of recurrent stroke.” (R1)
“(The most important aspect for post stroke management at primary care is the..) Commitment from patients & relatives/family.” (R34)
The need for standardised care plan: The respondents indicated there was a need for a standard care plan or guideline that addressed components of stroke management at community level (i.e. further rehabilitation, management of stroke risk factors and re-integration into community) (n = 7/53, 13.2%)
“(There should be a) Well-written (care) plan (to guide the primary care team)” (R11)
“Should have (a) standard care plan for stroke management at health clinic level.” (R16)
“Knowledge among the health care provider and the community (regarding post stroke monitoring and rehabilitation) needs to be strengthened.” (R29)
Respondents were familiar with the management of stroke risk factors. However, these conditions were generally managed as NCD patients per se, at the expense of other post stroke complications such as need for further rehabilitation, screening for depression and/or vascular dementia for example. Specifically, management of these complications was difficult particularly for the FMS who have not had training in rehabilitation or elderly care for instance.
The availability of social support services: The importance of social support services is included as a vital aspect of managing post stroke patients. Social welfare workers should be included in the multidisciplinary team caring for post stroke patients in the community (7/53, 13.2%).
“(The) Social worker need to be actively involved in the care of not only the patient but also (the) carers (caregivers)/involved family members.” (R29)