Expert consensus on the structure and content of an enhanced care pathway for psychological changes after stroke in the UK: A modified Delphi survey

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Addressing current gaps in UK post-stroke cognitive care provision requires a pragmatic and scalable intervention that can be integrated in the existing stroke care pathway. This study aimed to develop consensus on core features of a UK-based monitoring and psychoeducational intervention for cognitive changes after stroke. Methods An expert panel of UK healthcare professionals and researchers participated in an online modified Delphi survey. Candidate intervention features were identified from clinical guidelines, existing literature, research team/collaborator expertise, and PPI group lived experience. Survey participants indicated whether they agreed/disagreed/had no opinion about including each candidate feature in the intervention and free-text responses were invited. We analysed responses for consensus (≥ 75% agreement) using descriptive statistics, with items not reaching consensus carried into subsequent rounds. Template analysis was used to identify similarities/differences in viewpoints for items that did not reach consensus. Results The survey rounds were completed by 36, 29 and 26 participants, respectively. Participants agreed reviews should include a stroke-specific cognitive screen (97% agree) and assessment of other psychological changes (low mood, anxiety, fatigue: 94%, 90%, 89% agree, respectively). They agreed stroke survivors should be offered at least one review, regardless of their psychological presentation in hospital. They agreed on the importance of various psychoeducation topics, and formal (100% agree) and informal (79% agree) training for those conducting reviews. Consensus was not reached on the review mode (in person/remote options: 67% agree), offering reviews one-year post-discharge to patients without impairments detected in hospital (68% disagree), or including a dementia screen (63% disagree) and/or neuropsychological assessment battery (58% disagree). However, there were similarities in participant viewpoints – for example, participants highlighted the importance of onwards referral where clinically indicated. Conclusions The UK-based post-stroke monitoring and psychoeducation intervention was originally conceptualised as a cognitive care pathway, but expert participants agreed on the importance of also addressing related psychological changes (eg low mood, anxiety). There was clear consensus on a minimum set of intervention features. Recommendations outlined here may usefully inform local service improvements. Future research will evaluate the impact of the intervention on patient outcomes. Figures Figure 1 Introduction Cognitive impairment affects 48–98% of patients in the first weeks after stroke ( 1 – 6 ). Although a proportion of patients recover from early impairments ( 7 , 8 ), prevalence of cognitive impairment in the months and years after stroke remains high ( 6 , 9 , 10 ), with post-stroke cognitive impairment having a substantial negative impact on quality of life, activity, and participation ( 11 , 12 ). National clinical guidelines recommend that post-stroke cognitive screening should be conducted as soon as possible ( 13 ) and the UK Sentinel Stroke National Audit Programme (SSNAP) confirmed that cognitive screening was conducted before discharge in the vast majority of cases in 2022–2023 ( 14 ). However, despite recommendations that “patients’ psychological needs should be considered throughout the rehabilitation process” (p.23) and that resources should be “in place to consider and support the psychological needs of stroke patients throughout their stroke care pathway” (p.36) ( 15 ), only 56% of UK stroke survivors needing support for psychological changes after discharge received it in 2022–2023 ( 14 ). Furthermore, recent systematic reviews have concluded that managing post-stroke cognitive impairment is one of the most frequently reported unmet needs over the long-term ( 16 – 18 ). The NHS Long Term Plan ( 19 ) and Demand Signalling Report ( 20 ) have called for improved long-term care after stroke in the UK, with psychological support being highlighted as an aspect of care requiring particular attention ( 20 , 21 ). Supporting post-stroke cognitive impairment over the longer term is a substantial challenge, as previous clinical trials have found no strong evidence for interventions to improve post-stroke cognitive functioning directly (see Cochrane reviews: 22–25). Whilst cognitive rehabilitation focusing on monitoring, psychoeducation, and signposting may be beneficial ( 26 – 28 ), there is a current lack of high-quality evidence evaluating the efficacy of such interventions after stroke ( 29 ). Furthermore, previously developed interventions may not be easily implementable and scalable within the existing UK stroke care pathway (e.g., 26), given the substantial clinical expertise and time required to administer them. This study aimed to develop consensus on the key features of a pragmatic and scalable UK-based monitoring and psychoeducational intervention to address cognitive changes after stroke. A modified Delphi survey was conducted to ensure the intervention would be grounded in evidence, theory, and stakeholder perspectives, in line with recommendations from the Medical Research Council (MRC) framework for complex intervention research ( 30 , 31 ). The intervention was initially conceptualised as comprising post-discharge reviews to monitor cognitive functioning over the longer term and psychoeducation about any identified cognitive impairments. In this study, we aimed to develop expert consensus on the following specific questions to clarify the intervention design: Who should receive cognitive reviews? Specifically, should cognitive reviews be offered to those with and without cognitive impairment detected in hospital and should review timepoints differ depending on in-hospital cognitive function? How should cognitive reviews be conducted? Given recent increases in remote healthcare provision ( 32 – 34 ) and the availability of cognitive screening tools validated for online use ( 35 ), should in person and/or online cognitive reviews be offered? What should cognitive reviews include? A wide variety of tools are used to assess post-stroke cognition in clinical practice ( 36 ), with approaches ranging from brief screens to comprehensive neuropsychological assessment batteries ( 37 ). Which approach(es) should be routinely incorporated within the intervention and should reviews assess psychological changes beyond cognitive impairment (e.g., low mood, anxiety)? What training might be required to support healthcare professionals to administer cognitive reviews? Healthcare professionals in community-based stroke teams have reported a lack of confidence when conducting post-stroke cognitive assessments and few opportunities for training ( 38 ). What type of training would best support skill development and confidence building? Methods Participants We recruited an expert panel of practice-based experts and research-based experts to participate in the online modified Delphi survey. Participants were included if they met the following criteria: (i) self-reported professional interest in and/or experience with cognition after stroke; and (ii) either an (allied) healthcare professional with at least five years’ experience working with stroke survivors in the UK, or a researcher with at least one published peer-reviewed stroke research article within the last ten years as first, second, or last author. We aimed to include participants with heterogeneous characteristics (e.g., different occupations and geographic locations). However, we did not define the precise composition or size of the panel a priori. Practice-based and research-based experts were recruited through a snow-balling approach after emailing initial professional contacts and publicising the study on social media (Twitter). Survey design We identified a set of candidate intervention features by drawing on existing literature ( 26 – 29 , 39 – 42 ), clinical guidelines and recommendations ( 13 , 43 ), expertise of the core study team and collaborators, as well as lived experience of our Patient and Public Involvement (PPI) Group. This ensured candidate intervention features were grounded in high-quality empirical evidence, robust psychological theory, and stakeholder perspectives, in line with MRC recommendations ( 30 , 31 ). Each candidate intervention feature was converted to a statement to be included as a survey item in the first modified Delphi survey round. For example, the candidate feature “Stroke-specific cognitive screen” was converted to the statement “Cognitive reviews should include a stroke-specific cognitive screen (15–20 minutes) (e.g., Oxford Cognitive Screen; OCS)”. Survey participants were asked to indicate whether they agreed, disagreed, or had no opinion about each statement. Categorical response options (i.e., agree, disagree, no opinion) were used to reduce participant burden, to make sure participants were clear about the consequences of their votes, and to ensure that the final results were actionable in terms of developing the intervention. Participants were encouraged to provide further free-text comments in response to each statement and at the end of each survey round. The survey was designed a priori to include two to four rounds, with the maximum set to account for likely participant attrition and fatigue ( 44 ). The survey was designed to end when all items reached consensus, four rounds had been completed, or there was little indication that consensus would be reached on the outstanding statements (a priori definition: <5% movement towards consensus from previous round for all statements that had not yet reached consensus). We aimed to achieve a 100% response rate for each survey round but accepted a round as valid if the response rate was at least 70%, recognising likely participant attrition ( 44 ). Survey procedure Participants completed initial consent and screening for eligibility online (Microsoft Forms). Eligible participants were contacted by email and invited to complete the first online survey round (Microsoft Forms) by following a hyperlink. Participants were given ten working days to complete each survey round and were encouraged to contact the research team if they had questions. A reminder was sent to participants to complete each round five working days after its opening. Participants who had not completed the round when it closed were excluded from subsequent round(s). Once each round was closed, the research team analysed results, developed the subsequent survey round by identifying and carrying forwards any items that had not reached consensus, and created personalised summary sheets of the results from the previous survey round (Supplementary Materials). Personalised summary sheets presented participants with each statement that had not reached consensus, their own response to the statement, the overall group response and all anonymised free-text comments provided in response to the statement ( 44 ). Data analysis R-Studio version 4.3.1 was used to calculate descriptive statistics from quantitative survey data. For each survey item, we calculated the number and percentage of participants who agreed/disagreed/had no opinion on including the candidate intervention feature within the cognitive care intervention. We defined consensus a priori as ≥ 75% agree/disagree after excluding responses of ‘no opinion’ ( 45 ). Free-text responses to the first and final survey rounds were analysed using template analysis ( 46 , 47 ). Free-text responses from the first survey round were coded inductively at a semantic level with the goal of identifying additional candidate intervention features that had not been identified by the research team when developing the survey. Free-text responses from the final round were also analysed inductively, with the goal of identifying any similarities and/or differences in participant viewpoints for statements that did not reach consensus by the end of the survey. Qualitative analyses were facilitated by Microsoft Word and Microsoft Excel. While template analysis is a flexible qualitative analytic approach devoid of any specific epistemological or ontological framework ( 47 ), this study was positioned within a critical realist framework, where we acknowledged the active role of research team members in coding and interpreting the data, but conceptualised this interpretive role an asset, rather than a confounder. The research team remained mindful during the qualitative analytic process of their own professional disciplines, values, and existing beliefs about the potential cognitive care intervention. Results Figure 1 shows the number of participants who completed each stage of the research. Table 1 presents participant demographic details. Table 2 presents statements that reached consensus in each survey round and Table 3 presents statements that had not reached consensus by the end of the survey. The following sections summarise quantitative results from each survey round in turn. Qualitative analysis results are briefly presented to highlight any overlapping viewpoints for those items that did not reach consensus by the end of the survey. Table 1 Demographic details of the participants included in each survey round. * Participants were given the option to select more than one professional occupation, as several participants had both clinical and academic roles. Demographics, N (%) Round 1 N = 36 Round 2 N = 29 Round 3 N = 26 Gender Male Female 7 29 5 24 5 21 Years of age 25–34 35–44 45–54 55–64 4 21 10 1 3 17 8 1 3 15 7 1 Professional occupation* Occupational Therapist Clinical Psychologist Clinical Neuropsychologist Speech and Language Therapist Stroke Specialist Nurse Physician Professor or Associate Professor Senior Lecturer or Lecturer Postdoctoral Researcher Doctoral Student 15 6 3 2 2 4 1 4 3 2 12 5 2 2 0 4 1 4 3 2 11 4 2 2 0 4 1 4 2 2 Region North East England North West England Yorkshire and the Humber West Midlands East of England London South East England South West England Scotland 2 6 3 6 2 4 7 2 4 2 5 2 4 2 3 6 2 3 2 4 2 3 2 3 5 2 3 Years of experience 0–5 6–10 > 10 3 9 24 3 6 20 3 6 17 Quantitative results Screening and consent The screening form and consent form were completed by 54 participants, 51 (94.44%) of whom met the inclusion and exclusion criteria. The 3 participants who did not meet the criteria were healthcare professionals, but they did not have at least five years of experience working with stroke survivors in the UK. Round 1 Of the 51 participants invited, 36 (70.59%) completed the first survey round, which included demographic questions and 30 survey items based on candidate intervention features. Of the 36 participants who completed Round 1, 29 (80.56%) were female and 21 (58.33%) were aged between 35–44 years. 25 (69.44%) participants occupied a clinical role only, 5 (13.89%) occupied an academic role only, and 5 occupied both a clinical and academic role (13.89%), with one participant choosing not to respond. Participants reached consensus on 25 of the items, with no consensus reached on 5 items. In summary, the expert panel agreed that stroke survivors with (100.00%) and without (88.24%) cognitive impairment detected during acute hospital admission should be offered at least one cognitive review. They agreed that those with cognitive impairment should receive a review in the first weeks (85.71%), three months (92.59%), six-months (95.45%) and one-year (95.00%) after discharge. Whilst they agreed that those without cognitive impairment detected should receive a review in the first weeks (82.14%) and six-months (80.00%) after discharge, participants did not reach consensus on whether they should receive reviews at three-months (72.00% agree) and one-year (55.00% agree) after discharge. Whilst the expert panel agreed that cognitive reviews should be conducted in person (86.67%), they failed to reach consensus on a separate item on whether stroke survivors should be given the choice of whether to attend a review in person or remotely (72.41% agree). Nevertheless, they agreed that a stroke specific cognitive screen (96.97%), a depression screen (93.75%), and an anxiety screen (90.32%) should be administered during reviews, highlighting the importance of screening for broader psychological changes alongside cognition. However, they did not agree on whether the cognitive review should also include a dementia screen (e.g. MoCA) (56.52% agree) and/or a neuropsychological assessment (e.g. RBANS) (62.50% agree). They also agreed that self-report questionnaires about cognition for stroke survivors (97.06%) and family members (96.55%) should be included. Participants agreed on the importance of information provision and psychoeducation during the cognitive reviews. Specifically, participants agreed that stroke survivors should be given information about their cognitive assessment results, (93.75%), how these results compare to earlier cognitive testing (90.32%), potential cognitive trajectories (78.79%), the impact of cognitive problems on ADLs (100.00%), and information about services and support available (100.00%). Participants also agreed that training for healthcare professionals administering cognitive reviews was important. They agreed healthcare professionals should be offered formal (100.00%) and informal (78.57%) training on administering cognitive assessments, as well as formal (97.06%) and informal (86.67%) training on discussing cognition with stroke survivors and their family members. Analysis of free-text responses from the first survey round resulted in the addition of three further survey items to the second round (see Table 2 starred items). These represented three further candidate intervention features: fatigue measure, online training, in person training. Table 2 Items that reached consensus within the modified Delphi survey. *Item introduced in Round 2 of the modified Delphi survey. Statement Consensus Round consensus reached Respondents (N) Agree N (%) Disagree N (%) Total Excluding no opinion Stroke survivors with a cognitive impairment detected during acute hospital admission should have a review of their cognition after discharge from an acute inpatient setting. Agree 1 36 36 36 (100.00) 0 (0.00) Stroke survivors with no cognitive impairment detected during acute hospital admission should have a review of their cognition after discharge from an acute inpatient setting. Agree 1 36 34 30 (88.24) 4 (11.76) For stroke survivors with a cognitive impairment detected during acute hospital admission, a review of their cognition should take place in the first few weeks after discharge. Agree 1 36 35 30 (85.71) 5 (14.29) For stroke survivors with a cognitive impairment detected during acute hospital admission, a review of their cognition should take place 3-months after discharge. Agree 1 31 27 25 (92.59) 2 (7.41) For stroke survivors with a cognitive impairment detected during acute hospital admission, a review of their cognition should take place 6-months after discharge. Agree 1 30 22 21 (95.45) 1 (4.55) For stroke survivors with a cognitive impairment detected during acute hospital admission, a review of their cognition should take place 1-year after discharge. Agree 1 29 20 19 (95.00) 1 (5.00) For stroke survivors with no cognitive impairment detected during acute hospital admission, a review of their cognition should take place in the first few weeks after discharge. Agree 1 32 28 23 (82.14) 5 (17.86) For stroke survivors with no cognitive impairment detected during acute hospital admission, a review of their cognition should take place 3-months after discharge . Agree 2 29 28 23 (82.14) 5 (17.86) For stroke survivors with no cognitive impairment detected during acute hospital admission, a review of their cognition should take place 6-months after discharge. Agree 1 29 20 16 (80.00) 4 (20.00) Cognitive reviews should take place in person . Agree 1 36 30 26 (86.67) 4 (13.33) Cognitive reviews should include a stroke-specific cognitive screen (15–20 minutes) (e.g., Oxford Cognitive Screen; OCS). Agree 1 36 33 32 (96.97) 1 (3.03) Cognitive reviews should include a questionnaire for the stroke survivor about their post-stroke cognition. Agree 1 36 34 33 (97.06) 1 (2.94) Cognitive reviews should include a questionnaire for a family member about the stroke survivor’s cognition. Agree 1 36 29 28 (96.55) 1 (3.45) Cognitive reviews should include a depression screen (e.g., Patient Health Questionnaire-9; PHQ-9). Agree 1 36 32 30 (93.75) 2 (6.25) Cognitive reviews should include an anxiety screen (e.g., Generalised Anxiety Disorder Assessment-7; GAD-7). Agree 1 36 31 28 (90.32) 3 (8.33) Cognitive reviews should include a general discussion with the stroke survivor about their overall cognitive functioning. Agree 1 36 34 34 (100.00) 0 (0.00) Cognitive reviews should include a general discussion with the stroke survivor about their domain-specific cognitive functioning. Agree 1 36 28 27 (96.43) 1 (3.57) Stroke survivors should be told the results of the cognitive assessment conducted during the review. Agree 1 36 32 30 (93.75) 2 (6.25) Stroke survivors should be told how their cognitive assessment result compares to earlier cognitive assessment results (e.g., in cognitive screen completed in acute inpatient setting). Agree 1 35 31 28 (90.32) 3 (9.68) Stroke survivors should be told about potential cognitive trajectories during the review. Agree 1 36 33 26 (78.79) 7 (21.21) Stroke survivors should be told about the potential impact of any cognitive impairments on activities of daily living during the review. Agree 1 36 34 34 (100.00) 0 (0.00) Stroke survivors should be signposted to available support and services during the review. Agree 1 36 36 36 (100.00) 0 (0.00) Healthcare professionals responsible for conducting cognitive reviews after stroke should receive formal training (e.g., training videos) on administering the cognitive assessment . Agree 1 36 35 35 (100.00) 0 (0.00) Healthcare professionals responsible for conducting cognitive reviews after stroke should receive informal training (e.g., training from colleague) on administering the cognitive assessment . Agree 1 35 28 22 (78.57) 6 (21.43) Healthcare professionals responsible for conducting cognitive reviews after stroke should receive formal training (e.g., training videos) on discussing cognition with stroke survivors and family members. Agree 1 36 34 33 (97.06) 1 (2.94) Healthcare professionals responsible for conducting cognitive reviews after stroke should receive informal training (e.g., training from colleague) on discussing cognition with stroke survivors and family members. Agree 1 35 30 26 (86.67) 4 (13.33) * Cognitive reviews should include a fatigue measure (e.g. Fatigue Severity Scale; FSS). Agree 2 29 28 25 (89.29) 3 (10.71) * Online training (e.g., training videos) should be offered to healthcare professionals administering cognitive reviews. Agree 2 29 27 26 (96.30) 1 (3.70) * In person training (e.g., training course) should be offered to healthcare professionals administering cognitive reviews. Agree 2 29 25 21 (84.00) 4 (16.00) Round 2 The second survey round was completed by 29 (80.56%) of the 36 participants invited. The second survey round included 8 items, 4 (50%) of which reached consensus. All three of the items developed from free-text responses to statements in the first survey round reached consensus: Participants agreed that the reviews should include a fatigue measure (89.29%), and that training for healthcare professionals should be offered online (96.30%) and in person (84.00%). However, only one of the five items rolled over from the first round reached consensus in the second round. Participants agreed that stroke survivors with no cognitive impairment detected during acute hospital admission should receive a review of their cognition three-months after discharge (82.14%), but they did not reach consensus on whether these stroke survivors should receive a review one-year after discharge (74.07% disagree). Participants failed to reach consensus on whether stroke survivors should be given the option to complete reviews in person or remotely (62.07% agree) and whether the review should include a dementia screen (65.38% disagree) and/or a neuropsychological assessment battery (58.33% disagree). Round 3 The third round of the survey was completed by 26 (89.66%) of the 29 participants invited. It included four items, none of which reached consensus. Compared to results of the second round, only one item moved closer to consensus (In person and remote review options: Agree − 62.07–66.67%). The level of consensus for one item remained the same in Round 3 compared to Round 2 (Inclusion of neuropsychological assessment battery: Disagree − 58.33%). Two items moved further from consensus (Reviews one-year after discharge for those without cognitive impairment acutely: Disagree − 74.07–68.00%; Inclusion of dementia screen: Disagree − 65.38–62.50%). Table 3 presents a summary of results for these items from each survey round. Table 3 Items that did not reach consensus in the modified Delphi survey. Statement Round Responses (N) Agree N (%) Disagree N (%) Total Excluding no opinion For stroke survivors with no cognitive impairment detected during acute hospital admission, a review of their cognition should take place 1-year after discharge. 1 2 3 26 29 25 20 27 25 11 (55.00) 7 (25.93) 8 (32.00) 9 (45.00) 20 (74.07) 17 (68.00) Individual stroke survivors should choose whether they would prefer cognitive reviews to take place either in person or remotely (i.e., telephone or videoconferencing). 1 2 3 36 29 26 29 29 24 21 (72.41) 18 (62.07) 16 (66.67) 8 (27.59) 11 (37.93) 8 (33.33) Cognitive reviews should include a dementia screen (10–15 minutes) (e.g., Montreal Cognitive Assessment; MoCA). 1 2 3 36 29 26 23 26 24 13 (56.52) 9 (34.62) 9 (37.50) 10 (43.48) 17 (65.38) 15 (62.50) Cognitive reviews should include a neuropsychological assessment battery (> 30 minutes) (e.g., Repeatable Battery for the Assessment of Neuropsychological Status; RBANS). 1 2 3 35 29 26 24 24 24 15 (62.50) 10 (41.67) 10 (41.67) 9 (37.50) 14 (58.33) 14 (58.33) Qualitative results from final survey round Despite failing to reach consensus on four items, qualitative analysis of free-text responses indicated that many participants shared similar viewpoints about potential risks, benefits, and caveats of including these candidate intervention features in the intervention. Table 4 presents a summary of the final theme structure developed from free-text responses to items that did not reach consensus and example verbatim quotations. Further detail is provided in Supplementary Materials, where specific themes and subthemes are described in depth with example quotations. Table 4. Summary of theme structure developed to identify potential reasons for the lack of consensus on four statements in the modified Delphi survey. Survey item Theme Example quotation 1 For stroke survivors with no cognitive impairment detected during acute hospital admission, a review of their cognition should take place 1-year after discharge. Too late to be useful. “Should be earlier, as by a year post someone may have lost a job or relationships due to lack of support for cognitive changes by that point.” (P28, Speech and Language Therapist) Concerns about feasibility. “Given the evidence of the high prevalence of dementia post stroke, I think this would be a good opportunity to follow up on this. However, the resources needed would make it impossible and I do feel resources could be better allocated on those who really need the cognitive rehabilitation.” (P2, Occupational Therapist) It depends on earlier cognitive reviews. “I think if no cognitive deficits are indicated at 3 months there is no need to review again.” (P4, Occupational Therapist) 2 Individual stroke survivors should choose whether they would prefer cognitive reviews to take place either in person or remotely (i.e., telephone or videoconferencing). Downsides of remote assessments. “Building rapport is so much easier in person (assuming they'd not previously met the assessor) and this is important for the person to do their best during the assessment. I think it's probably also more likely that higher level difficulties would be picked up if seen in person. Not saying that remote options don't have a place, I just don't think patient preference is the right way to decide.” (P19, Doctoral Student) Importance of choice and person-centredness. “I do think choice and accessibility is important therefore both videoconferencing and face to face should be offered. Not telephone consult. However the pros and cons of each should be clearly explained to the patient to enable them making an informed choice. My personal preference would be face to face but remote is better than a DNA.” (P29, Occupational Therapist) 3 Cognitive reviews should include a dementia screen (10-15 minutes) (e.g., Montreal Cognitive Assessment; MoCA). Risk of misinterpretation in stroke populations. “Standard dementia screens can potentially be misleading because of all the confounds in a stroke population i.e. neglect, dysphasia, motor problems. Whatever training you put in place, there will still be some people who take the standard cut-off (e.g. 88/100 on ACE-III) and say, 'the score is below the cut-off and this suggests the person has dementia'.” (P1, Clinical Psychologist & Clinical Neuropsychologist) Preference for situation- and person-specific approach. “A dementia screen would be very useful in certain situations: evidence of longitudinal cognitive decline either before stroke or months/years after the stroke; or a cognitive profile that doesn't match the stroke eg dense amnestic picture with a posterior stroke. Stroke and neurodegenerative disorders often co-exist particularly in the older patients. [...] So Dementia screen is important in some patients but not routinely in ALL patients.” (P7, Physician & Lecturer) 4 Cognitive reviews should include a neuropsychological assessment battery (>30 minutes) (e.g., Repeatable Battery for the Assessment of Neuropsychological Status; RBANS). Concerns about feasibility. “I don't think there will ever be enough people in stroke services to administer something that requires a more sophisticated understanding of psychometric assessment to make this workable - a 'review' will end up being too long and unwieldy.” (P1, Clinical Psychologist & Clinical Neuropsychologist) Importance of onwards referral. “A two tiered approach with initial screening/triage to select those needing more detailed assessment seems a better use of resource.” (P33, Physician) Discussion Expert healthcare professionals and stroke researchers who participated in this modified Delphi survey reached consensus on the majority of design decisions for a monitoring and psychoeducational intervention addressing psychological changes to be implemented within the UK stroke care pathway. Participants agreed reviews should include a stroke-specific cognitive screen. While the intervention was originally conceptualised as a cognitive care pathway, participants also agreed the intervention should address post-stroke psychological changes, encompassing mood, anxiety, and fatigue. They agreed stroke survivors should be offered at least one review, regardless of their psychological presentation in hospital. They agreed on the importance of various psychoeducation topics, and formal and informal training for those conducting reviews. Consensus was not reached on the review mode (in person/remote options), offering reviews one-year post-discharge to patients without impairments detected in hospital, or including a dementia screen and/or neuropsychological assessment battery. Free-text responses highlighted a number of shared views, including the importance of onwards referral where clinically indicated. Alongside empirical evidence and psychological theory, stakeholder input from this study will inform the development of an intervention to address the ongoing and well-evidenced need for psychological support after stroke ( 16 – 18 , 48 ). Participants agreed that reviews of psychological changes after stroke should form a standard part of the UK stroke care pathway, with these reviews being offered to all stroke survivors, regardless of their presentation in hospital. The importance of reviewing psychological changes is indeed emphasised in UK clinical guidelines for stroke care ( 13 ) but audit and commissioning data indicate insufficient provision of longer term post-stroke psychological support across the UK ( 14 , 49 ). Furthermore, and perhaps most concerningly, evidence suggests provision of psychological support in the months after stroke has been declining over recent years ( 14 , 50 ), in spite of widespread calls to prioritise post-stroke psychological care provision ( 20 , 21 , 51 ). While interventions have been developed with the potential to address these gaps in post-stroke psychological care provision in the UK ( 26 – 28 ), they are generally limited by the substantial clinical expertise and time required to administer them. When identifying candidate intervention features to include in this modified Delphi survey, we held in mind the substantial constraints on community stroke services within the UK and expert stakeholder participants further reinforced the need to balance quality and efficiency of care provision. As a result, the monitoring and psychoeducational intervention that will be developed from this modified Delphi survey and other co-production activities ( 39 , 41 , 42 ) may have the potential to fill key gaps in post-stroke care provision, without overburdening services. As with post-stroke cognitive impairment, the high prevalence of low mood, anxiety, and fatigue after stroke is well-evidenced. A recent systematic review and meta-analysis of 97 studies found the pooled prevalence of anxiety between one-five months after stroke to be 21% in studies using interviews, and 24% in studies using self-report scales ( 52 ), while the pooled prevalence of depression any time up to five-years post-stroke across 61 studies has been estimated to be 31% ( 53 ). Recognising the high prevalence of cognitive impairment, low mood, and anxiety after stroke, a recent priority setting exercise by the James Lind Alliance identified psychological changes and cognitive changes as the top two research priorities needing to be addressed to improve post-stroke rehabilitation and long-term care ( 21 ). In particular, the Priority Setting Partnership ( 54 ) made explicit the following question “What is the best way to assess for, understand the impacts of and track progression in all areas of cognition – including using standardised measures - across the stroke pathway; what and how can interventions and services involving multidisciplinary teams and families be made accessible, and how can information on these problems be provided?” (p.12) By providing expert consensus on the optimal care delivery model for monitoring psychological changes after stroke, the results of this modified Delphi survey directly address this top stroke research priority. There was no consensus on whether reviews should include a dementia screen and/or neuropsychological assessment battery as a standard part of follow-up, which reflects an ongoing debate within the literature and clinical practice about the optimal approach for post-stroke cognitive screening and assessment ( 37 ). Proponents of post-stroke dementia screening have emphasised both within this survey and in previous research the increased risk of developing dementia after stroke and thus the urgent need to screen for it ( 55 ). Indeed, a recent meta-analysis reported that approximately 20% of stroke survivors experience clinically defined dementia one-year after stroke ( 56 ). However, as acknowledged by participants in this study, results on dementia screens like the Montreal Cognitive Assessment (MoCA: 57) and Mini-Mental State Examination (MMSE: 58) may be confounded by stroke-specific deficits and lack sensitivity ( 59 , 60 ), leading to potential misinterpretation and misdiagnoses when administered and interpreted by individuals with limited expertise. With regards to neuropsychology assessments, while proponents of neuropsychology assessments emphasised the advantage of understanding cognitive profiles in detail to support rehabilitation, participants highlighted the substantial constraints on clinical services in the UK and argued that it would not be feasible to implement extensive neuropsychological testing within a standardised and widespread post-stroke psychological care pathway. In both cases, participants emphasised the importance of onwards referral to specialist services, such as memory clinics and neuropsychology services. In terms of limitations, we note that the survey was designed and ethical approval was obtained prior to the publication of the latest revision of the National Clinical Guideline for Stroke in April 2023 ( 13 ), meaning that survey items were informed by the earlier 2016 guideline ( 61 ). Nevertheless, our results echo recommendations from the updated clinical guideline, as well as providing important clarification on some aspects of psychological care provision (e.g., importance of providing specific information about assessment results, potential trajectories, impact of psychological changes on activities of daily living, and signposting). A second limitation is that we only sought consensus on relatively broad intervention design decisions - for example, participants agreed that the intervention should include a stroke-specific cognitive screen, but we did not ask participants to advise on the optimal stroke-specific screening tool. We constrained the survey to broader design decisions to reduce participant burden and encourage participation. In conclusion, this study developed expert consensus on the overarching design of a ‘first-line’ monitoring and psychoeducation intervention addressing post-stroke psychological changes to be integrated in the existing UK stroke care pathway. Future research will evaluate the extent to which the intervention has a clinically meaningful impact on patient outcomes. In the meantime, the recommendations outlined here may prove beneficial for informing local service improvements. Declarations Ethics approval and consent to participate This study received ethical approval from University of Oxford’s Central University Research Ethics Committee (REC reference: R76686/RE001). Each participant provided consent via the online survey platform. Consent for publication Participants agreed to the publications of their research data. Availability of data and materials No further data will be made available. Competing interests ND is a developer of the Oxford Cognitive Screen but does not receive any financial remuneration from its use. Funding This study was supported by the National Institute for Health and Care Research (NIHR) through an Advanced Fellowship (NIHR302224). GH is supported by an Economic and Social Research Council (ESRC) award (ES/P000649/1). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care. Authors’ contributions GH and ND conceived the framework for this study. GH collected, analysed and interpreted the data. GH prepared the manuscript for submission. ET assisted with conceiving the framework for this study and edited the manuscript. ND assisted with data analysis, and critically reviewed and edited the manuscript. ND supervised the study and accepts full responsibility for this work. Acknowledgements We would like to thank those who kindly offered their time and expertise to support this study, including Dr Adam Bevins, Clara Buckle, Louisa Burton, Dr Verónica Cabreira, Alexandra Cantwell, Jennifer Crow, Dr Ruth Da Silva, Claudia Forrest, Nicola Jobson, Maria Mar Martin Saez, Dr Marco Mion, Kayleigh Pocrnic, Prof Terry Quinn, Rachel Teasdale-Smith, Nicola Tressler, Dr Grace Turner. References Demeyere N, Riddoch MJ, Slavkova ED, Jones K, Reckless I, Mathieson P, et al. Domain-specific versus generalized cognitive screening in acute stroke. J Neurol. 2016;263(2):306–15. Hurford R, Charidimou A, Fox Z, Cipolotti L, Werring DJ. Domain-specific trends in cognitive impairment after acute ischaemic stroke. J Neurol. 2013;260(1):237–41. Lesniak M, Bak T, Czepiel W, Seniow J, Czlonkowska A. Frequency and prognostic value of cognitive disorders in stroke patients. Dement Geriatr Cogn Disord. 2008;26(4):356–63. Milosevich E, Moore M, Pendlebury ST, Demeyere N. Domain-specific cognitive impairment 6 months after stroke: the value of early cognitive screening [Internet]. medRxiv; 2023 [cited 2023 Jul 27]. p. 2023.06.14.23291381. https://www.medrxiv.org/content/ 10.1101/2023.06.14.23291381v1 . Nijsse B, Visser-Meily JMA, van Mierlo ML, Post MWM, de Kort PLM, van Heugten CM. Temporal Evolution of Poststroke Cognitive Impairment Using the Montreal Cognitive Assessment. Stroke. 2017;48(1):98–104. Turunen KEA, Laari SPK, Kauranen TV, Uimonen J, Mustanoja S, Tatlisumak T, et al. Domain-Specific Cognitive Recovery after First-Ever Stroke: A 2-Year Follow-Up. J Int Neuropsychol Soc. 2018;24(2):117–27. Demeyere N, Sun S, Milosevich E, Vancleef K. Post-stroke cognition with the Oxford Cognitive Screen vs Montreal Cognitive Assessment: A multi-site randomized controlled study (OCS-CARE) [Internet]. Vol. 1. 2019 [cited 2022 Nov 8]. https://doi.org/10.12688/amrcopenres.12882.1 . Kusec A, Milosevich E, Williams OA, Chiu EG, Watson P, Carrick C et al. Long-term psychological outcomes following stroke: The OX-CHRONIC study [Internet]. medRxiv; 2023 [cited 2023 Jul 27]. p. 2023.03.27.23287789. https://www.medrxiv.org/content/ 10.1101/2023.03.27.23287789v2 . Lopes R, Bournonville C, Kuchcinski G, Dondaine T, Mendyk A, Viard R, et al. Prediction of Long-term Cognitive Functions after Minor Stroke, Using Functional Connectivity. Neurology. 2021;96(8):e1167–79. Williams OA, Demeyere N. Association of depression and anxiety with cognitive impairment 6 months after stroke. Neurology. 2021;96(15):e1966–74. Mole JA, Demeyere N. The relationship between early post-stroke cognition and longer term activities and participation: A systematic review. Neuropsychological Rehabilitation. 2018;30(2):346–70. Stolwyk RJ, Mihaljcic T, Wong DK, Chapman JE, Rogers JM. Poststroke Cognitive Impairment Negatively Impacts Activity and Participation Outcomes. Stroke. 2021;52(2):748–60. Intercollegiate Stroke Working Party. National Clinical Guideline for Stroke for the UK and Ireland. London: NICE; 2023. Intercollegiate Stroke Working Party. SSNAP Annual Results Portfolio: April 2022 to March 2023. [Internet]. London, United Kingdom: King’s College London. 2023. https://www.strokeaudit.org/Results2/Clinical-audit/National-Results.aspx . NHS. RightCare stroke toolkit. 2022. Lin Blei, Mei Y xia, Wang W, na, Wang Sshan, Li Y, shuang, Xu M et al. ya,. Unmet care needs of community-dwelling stroke survivors: a systematic review of quantitative studies. BMJ Open. 2021;11(4):e045560. Chen T, Zhang B, Deng Y, Fan JC, Zhang L, Song F. Long-term unmet needs after stroke: Systematic review of evidence from survey studies. BMJ Open. 2019;9(5):e028137. Guo Y, Zhang Z, Lin B, Mei Y, Liu Q, Zhang L, et al. The Unmet Needs of Community-Dwelling Stroke Survivors: A Systematic Review of Qualitative Studies. Int J Environ Res Public Health. 2021;18(4):2140. NHS. The NHS long term plan. 2019. NHS England. Research demand signalling: National Stroke Programme. 2022. Hill G, Regan S, Francis R. Research priorities to improve stroke outcomes. Lancet Neurol. 2022;21(4):312–3. Bowen A, Hazelton C, Pollock A, Lincoln N. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database of Systematic Reviews [Internet]. 2013 [cited 2023 Jul 6]; https://pubmed-ncbi-nlm-nih-gov.ezproxy-prd.bodleian.ox.ac.uk/23813503/ . Chung CSY, Pollock A, Campbell T, Durward BR, Hagen S. Cognitive rehabilitation for executive dysfunction in adults with stroke or other adult non-progressive acquired brain damage. Cochrane Database Syst Rev. 2013;2013(4):CD008391. das Nair R, Lincoln N. Cognitive rehabilitation for memory deficits following stroke. Cochrane Database of Systematic Reviews [Internet]. 2007 [cited 2023 Jul 6]; https://www-cochranelibrary-com.ezproxy-prd.bodleian.ox.ac.uk/cdsr/doi/10.1002/14651858.CD002293.pub2/abstract?cookiesEnabled . Loetscher T, Lincoln NB. Cognitive rehabilitation for attention deficits following stroke. Cochrane Database Syst Rev. 2013;2013(5):CD002842. Merriman NA, Gillan D, Pender N, Williams DJ, Horgan F, Sexton E, et al. The StrokeCog study: Development and description of a cognition-focused psychological intervention to address cognitive impairment following stroke. Psychol Health. 2021;36(7):792–809. Cheng HY, Chair SY, Chau JPC. The effectiveness of psychosocial interventions for stroke family caregivers and stroke survivors: A systematic review and meta-analysis. Patient Educ Couns. 2014;95(1):30–44. Mou H, Wong MS, Chien WT. Effectiveness of dyadic psychoeducational intervention for stroke survivors and family caregivers on functional and psychosocial health: A systematic review and meta-analysis. Int J Nurs Stud. 2021;120:103969. Kontou E, Kettlewell J, Condon L, Thomas S, Lee AR, Sprigg N, et al. A scoping review of psychoeducational interventions for people after transient ischemic attack and minor stroke. Top Stroke Rehabil. 2021;28(5):390–400. Skivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: Update of Medical Research Council guidance. BMJ. 2021;374:n2061. O’Cathain A, Croot L, Duncan E, Rousseau N, Sworn K, Turner KM, et al. Guidance on how to develop complex interventions to improve health and healthcare. BMJ Open. 2019;9(8):e029954. Chapman JE, Ponsford J, Bagot KL, Cadilhac DA, Gardner B, Stolwyk RJ. The use of videoconferencing in clinical neuropsychology practice: A mixed methods evaluation of neuropsychologists’ experiences and views. Australian Psychol. 2020;55(6):618–33. Fox-Fuller JT, Rizer S, Andersen SL, Sunderaraman P. Survey Findings About the Experiences, Challenges, and Practical Advice/Solutions Regarding Teleneuropsychological Assessment in Adults. Arch Clin Neuropsychol. 2022;37(2):274–91. Webb SS, Kontou E, Demeyere N. The COVID-19 pandemic altered the modality, but not the frequency, of formal cognitive assessment. Disabil Rehabil. 2022;44(21):6365–73. Webb SS, Carrick C, Kusec A, Demeyere N. Introducing the Tele-OCS: A validated remotely administered version of The Oxford Cognitive Screen. Health Open Research [Internet]. 2023 [cited 2023 Dec 21];5(8). https://healthopenresearch.org/articles/5-8/v1?src=rss . Lees RA, Broomfield NM, Quinn TJ. Questionnaire assessment of usual practice in mood and cognitive assessment in Scottish stroke units. Disabil Rehabil. 2014;36(4):339–43. Quinn TJ, Elliott E, Langhorne P. Cognitive and Mood Assessment Tools for Use in Stroke. Stroke. 2018;49(2):483–90. Ablewhite J, Geraghty J, das Nair R, Lincoln N, Drummond A. Cognitive Management Pathways in Stroke Services (COMPASS): A qualitative investigation of key issues in relation to community stroke teams undertaking cognitive assessments. Br J Occup Therapy. 2019;82(7):404–11. Hobden G, Tang E, Demeyere N. Cognitive assessment after stroke: A qualitative study of patients’ experiences. BMJ Open. 2023;13(6):e072501. Merriman N, Bruen C, Gorman A, Horgan F, Williams D, Pender N, et al. I’m just not a Sudoku person’: analysis of stroke survivor, carer, and healthcare professional perspectives for the design of a cognitive rehabilitation intervention. Disabil Rehabil. 2019;42(23):3359–69. Hobden G, Tang EYH, Demeyere N. A qualitative study investigating the views of stroke survivors and their family members on discussing post-stroke cognitive trajectories. Neuropsychological Rehabilitation. 2024;0(0):1–18. Hobden G, Tabone F, Demeyere N. Cognition after stroke: A scoping review to investigate the information needs of stroke survivors and their family members. In review. NHS Improvement. Psychological care after stroke: Improving stroke services for people with cognitive and mood disorders [Internet]. Leicester, UK. 2011. https://www.nice.org.uk/media/default/sharedlearning/531_strokepsychologicalsupportfinal.pdf . Hasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32(4):1008–15. Keeney S, Hasson F, McKenna H. Consulting the oracle: ten lessons from using the Delphi technique in nursing research. J Adv Nurs. 2006;53(2):205–12. King N. Template analysis. Qualitative methods and analysis in organizational research: A practical guide. Thousand Oaks, CA: Sage Publications Ltd; 1998. pp. 118–34. King N, University H. 2024 [cited 2024 Mar 6]. What is Template Analysis? https://research.hud.ac.uk/research-subjects/human-health/template-analysis/what-is-template-analysis/ . McKevitt C, Fudge N, Redfern J, Sheldenkar A, Crichton S, Rudd AR, et al. Self-reported long-term needs after stroke. Stroke. 2011;42(5):1398–403. Care Quality Commission. Supporting life after stroke: A review of services for people who have had a stroke and their carers. 2011. Intercollegiate Stroke Working Party. Sentinel Stroke National Audit Programme (SSNAP). SSNAP Annual Portfolio for April 2017-March 2018 admissions and discharges [Internet]. 2018 [cited 2023 Dec 21]. https://www.strokeaudit.org/BackupV1/results/Clinical-audit/National-Results.aspx . Division of Neuropsychology. Recommendations for Integrated Community Stroke Services: Service design, workforce planning & clinical governance requirements for a high-quality service and rehabilitation outcomes [Internet]. The British Psychological Society; 2023 [cited 2024 Apr 26]. https://cms.bps.org.uk/sites/default/files/2023-04/BRE56%20Recommendations%20for%20Integrated%20Community%20Stroke%20Services_April.pdf . Knapp P, Dunn-Roberts A, Sahib N, Cook L, Astin F, Kontou E, et al. Frequency of anxiety after stroke: An updated systematic review and meta-analysis of observational studies. Int J Stroke. 2020;15(3):244–55. Hackett ML, Pickles K, Part I. Frequency of Depression after Stroke: An Updated Systematic Review and Meta-Analysis of Observational Studies. Int J Stroke. 2014;9(8):1017–25. Stroke Association. Shaping stroke research to rebuild lives: The Stroke Priority Setting Partnership results for investment [Internet]. 2021. https://www.stroke.org.uk/research/stroke-priority-setting-partnership . Mijajlović MD, Pavlović A, Brainin M, Heiss WD, Quinn TJ, Ihle-Hansen HB, et al. Post-stroke dementia – a comprehensive review. BMC Med. 2017;15(1):11. Craig L, Hoo ZL, Yan TZ, Wardlaw J, Quinn TJ. Prevalence of dementia in ischaemic or mixed stroke populations: Systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2022;93(2):180–7. Nasreddine ZS, Phillips NA, Bédirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695–9. Folstein M, Folstein S, McHugh P. Mini-Mental State’ A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189–98. Mancuso M, Demeyere N, Abbruzzese L, Damora A, Varalta V, Pirrotta F, et al. Using the Oxford Cognitive Screen to detect cognitive impairment in stroke patients: A comparison with the Mini-Mental State Examination. Front Neurol. 2018;9:101. Pendlebury ST, Mariz J, Bull L, Mehta Z, Rothwell PM, MoCA ACE-R. Versus the National Institute of Neurological Disorders and Stroke–Canadian Stroke Network Vascular Cognitive Impairment Harmonization Standards Neuropsychological Battery After TIA and Stroke. Stroke. 2012;43(2):464–9. Bowen A, James M, Young G. Royal College of Physicians 2016 National clinical guideline for stroke [Internet]. RCP; 2016 Jan [cited 2022 Jul 20]. https://pearl.plymouth.ac.uk/handle/10026.1/10488 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4638082","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321222349,"identity":"3379e8b7-9951-43fe-a73d-788bc6494aeb","order_by":0,"name":"Georgina Hobden","email":"data:image/png;base64,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","orcid":"","institution":"University of Oxford","correspondingAuthor":true,"prefix":"","firstName":"Georgina","middleName":"","lastName":"Hobden","suffix":""},{"id":321222351,"identity":"f6e3138b-4664-4fe1-9843-15d64f82e210","order_by":1,"name":"Eugene Yee Hing Tang","email":"","orcid":"","institution":"Newcastle University","correspondingAuthor":false,"prefix":"","firstName":"Eugene","middleName":"Yee Hing","lastName":"Tang","suffix":""},{"id":321222353,"identity":"44298c84-f370-4b82-8db3-53e6a1f6f6a2","order_by":2,"name":"Nele Demeyere","email":"","orcid":"","institution":"University of Oxford","correspondingAuthor":false,"prefix":"","firstName":"Nele","middleName":"","lastName":"Demeyere","suffix":""}],"badges":[],"createdAt":"2024-06-25 17:29:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4638082/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4638082/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-024-11551-6","type":"published","date":"2024-10-01T15:57:45+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60811870,"identity":"438693a8-8ccc-4331-ac02-c3678b2bc338","added_by":"auto","created_at":"2024-07-22 11:00:01","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":225381,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram showing the number of participants included at each stage of the research.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4638082/v1/d77bdc05e4afac405b390545.jpeg"},{"id":66097894,"identity":"2c77977e-e562-4d06-8c3a-37c28b9b190c","added_by":"auto","created_at":"2024-10-07 16:15:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1446125,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4638082/v1/17caa308-6822-414c-a897-6f2f5a35c0a6.pdf"},{"id":60811868,"identity":"6cde99de-65db-4992-b3c7-bc902197b7eb","added_by":"auto","created_at":"2024-07-22 11:00:01","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":39360,"visible":true,"origin":"","legend":"","description":"","filename":"DelphiSupMatBMC.HSR20240425docx.docx","url":"https://assets-eu.researchsquare.com/files/rs-4638082/v1/0ee0f3c4bc8a852773462c01.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Expert consensus on the structure and content of an enhanced care pathway for psychological changes after stroke in the UK: A modified Delphi survey","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCognitive impairment affects 48\u0026ndash;98% of patients in the first weeks after stroke (\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Although a proportion of patients recover from early impairments (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e), prevalence of cognitive impairment in the months and years after stroke remains high (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e), with post-stroke cognitive impairment having a substantial negative impact on quality of life, activity, and participation (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eNational clinical guidelines recommend that post-stroke cognitive screening should be conducted as soon as possible (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) and the UK Sentinel Stroke National Audit Programme (SSNAP) confirmed that cognitive screening was conducted before discharge in the vast majority of cases in 2022\u0026ndash;2023 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). However, despite recommendations that \u0026ldquo;patients\u0026rsquo; psychological needs should be considered throughout the rehabilitation process\u0026rdquo; (p.23) and that resources should be \u0026ldquo;in place to consider and support the psychological needs of stroke patients throughout their stroke care pathway\u0026rdquo; (p.36) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), only 56% of UK stroke survivors needing support for psychological changes after discharge received it in 2022\u0026ndash;2023 (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Furthermore, recent systematic reviews have concluded that managing post-stroke cognitive impairment is one of the most frequently reported unmet needs over the long-term (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe NHS Long Term Plan (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) and Demand Signalling Report (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) have called for improved long-term care after stroke in the UK, with psychological support being highlighted as an aspect of care requiring particular attention (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Supporting post-stroke cognitive impairment over the longer term is a substantial challenge, as previous clinical trials have found no strong evidence for interventions to improve post-stroke cognitive functioning directly (see Cochrane reviews: 22\u0026ndash;25). Whilst cognitive rehabilitation focusing on monitoring, psychoeducation, and signposting may be beneficial (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), there is a current lack of high-quality evidence evaluating the efficacy of such interventions after stroke (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Furthermore, previously developed interventions may not be easily implementable and scalable within the existing UK stroke care pathway (e.g., 26), given the substantial clinical expertise and time required to administer them.\u003c/p\u003e \u003cp\u003eThis study aimed to develop consensus on the key features of a pragmatic and scalable UK-based monitoring and psychoeducational intervention to address cognitive changes after stroke. A modified Delphi survey was conducted to ensure the intervention would be grounded in evidence, theory, and stakeholder perspectives, in line with recommendations from the Medical Research Council (MRC) framework for complex intervention research (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). The intervention was initially conceptualised as comprising post-discharge reviews to monitor cognitive functioning over the longer term and psychoeducation about any identified cognitive impairments. In this study, we aimed to develop expert consensus on the following specific questions to clarify the intervention design:\u003c/p\u003e \u003cp\u003e \u003col\u003e\u003col style=\"list-style-type:lower-alpha;\"\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWho should receive cognitive reviews? Specifically, should cognitive reviews be offered to those with and without cognitive impairment detected in hospital and should review timepoints differ depending on in-hospital cognitive function?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow should cognitive reviews be conducted? Given recent increases in remote healthcare provision (\u003cspan additionalcitationids=\"CR33\" citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) and the availability of cognitive screening tools validated for online use (\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e), should in person and/or online cognitive reviews be offered?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat should cognitive reviews include? A wide variety of tools are used to assess post-stroke cognition in clinical practice (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e), with approaches ranging from brief screens to comprehensive neuropsychological assessment batteries (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Which approach(es) should be routinely incorporated within the intervention and should reviews assess psychological changes beyond cognitive impairment (e.g., low mood, anxiety)?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat training might be required to support healthcare professionals to administer cognitive reviews? Healthcare professionals in community-based stroke teams have reported a lack of confidence when conducting post-stroke cognitive assessments and few opportunities for training (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). What type of training would best support skill development and confidence building?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eWe recruited an expert panel of practice-based experts and research-based experts to participate in the online modified Delphi survey. Participants were included if they met the following criteria: (i) self-reported professional interest in and/or experience with cognition after stroke; and (ii) either an (allied) healthcare professional with at least five years\u0026rsquo; experience working with stroke survivors in the UK, or a researcher with at least one published peer-reviewed stroke research article within the last ten years as first, second, or last author. We aimed to include participants with heterogeneous characteristics (e.g., different occupations and geographic locations). However, we did not define the precise composition or size of the panel a priori. Practice-based and research-based experts were recruited through a snow-balling approach after emailing initial professional contacts and publicising the study on social media (Twitter).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurvey design\u003c/h2\u003e \u003cp\u003eWe identified a set of candidate intervention features by drawing on existing literature (\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan additionalcitationids=\"CR40 CR41\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e), clinical guidelines and recommendations (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), expertise of the core study team and collaborators, as well as lived experience of our Patient and Public Involvement (PPI) Group. This ensured candidate intervention features were grounded in high-quality empirical evidence, robust psychological theory, and stakeholder perspectives, in line with MRC recommendations (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEach candidate intervention feature was converted to a statement to be included as a survey item in the first modified Delphi survey round. For example, the candidate feature \u0026ldquo;Stroke-specific cognitive screen\u0026rdquo; was converted to the statement \u0026ldquo;Cognitive reviews should include a stroke-specific cognitive screen (15\u0026ndash;20 minutes) (e.g., Oxford Cognitive Screen; OCS)\u0026rdquo;. Survey participants were asked to indicate whether they agreed, disagreed, or had no opinion about each statement. Categorical response options (i.e., agree, disagree, no opinion) were used to reduce participant burden, to make sure participants were clear about the consequences of their votes, and to ensure that the final results were actionable in terms of developing the intervention. Participants were encouraged to provide further free-text comments in response to each statement and at the end of each survey round.\u003c/p\u003e \u003cp\u003eThe survey was designed a priori to include two to four rounds, with the maximum set to account for likely participant attrition and fatigue (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). The survey was designed to end when all items reached consensus, four rounds had been completed, or there was little indication that consensus would be reached on the outstanding statements (a priori definition: \u0026lt;5% movement towards consensus from previous round for all statements that had not yet reached consensus). We aimed to achieve a 100% response rate for each survey round but accepted a round as valid if the response rate was at least 70%, recognising likely participant attrition (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSurvey procedure\u003c/h2\u003e \u003cp\u003eParticipants completed initial consent and screening for eligibility online (Microsoft Forms). Eligible participants were contacted by email and invited to complete the first online survey round (Microsoft Forms) by following a hyperlink. Participants were given ten working days to complete each survey round and were encouraged to contact the research team if they had questions. A reminder was sent to participants to complete each round five working days after its opening. Participants who had not completed the round when it closed were excluded from subsequent round(s). Once each round was closed, the research team analysed results, developed the subsequent survey round by identifying and carrying forwards any items that had not reached consensus, and created personalised summary sheets of the results from the previous survey round (Supplementary Materials). Personalised summary sheets presented participants with each statement that had not reached consensus, their own response to the statement, the overall group response and all anonymised free-text comments provided in response to the statement (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eR-Studio version 4.3.1 was used to calculate descriptive statistics from quantitative survey data. For each survey item, we calculated the number and percentage of participants who agreed/disagreed/had no opinion on including the candidate intervention feature within the cognitive care intervention. We defined consensus a priori as \u0026ge;\u0026thinsp;75% agree/disagree after excluding responses of \u0026lsquo;no opinion\u0026rsquo; (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFree-text responses to the first and final survey rounds were analysed using template analysis (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Free-text responses from the first survey round were coded inductively at a semantic level with the goal of identifying additional candidate intervention features that had not been identified by the research team when developing the survey. Free-text responses from the final round were also analysed inductively, with the goal of identifying any similarities and/or differences in participant viewpoints for statements that did not reach consensus by the end of the survey. Qualitative analyses were facilitated by Microsoft Word and Microsoft Excel.\u003c/p\u003e \u003cp\u003eWhile template analysis is a flexible qualitative analytic approach devoid of any specific epistemological or ontological framework (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), this study was positioned within a critical realist framework, where we acknowledged the active role of research team members in coding and interpreting the data, but conceptualised this interpretive role an asset, rather than a confounder. The research team remained mindful during the qualitative analytic process of their own professional disciplines, values, and existing beliefs about the potential cognitive care intervention.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e shows the number of participants who completed each stage of the research. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents participant demographic details. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents statements that reached consensus in each survey round and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents statements that had not reached consensus by the end of the survey. The following sections summarise quantitative results from each survey round in turn. Qualitative analysis results are briefly presented to highlight any overlapping viewpoints for those items that did not reach consensus by the end of the survey.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic details of the participants included in each survey round. \u003cb\u003e*\u003c/b\u003eParticipants were given the option to select more than one professional occupation, as several participants had both clinical and academic roles.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographics, \u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRound 1\u003c/p\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;36\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRound 2\u003c/p\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;29\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRound 3\u003c/p\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;26\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003cp\u003eMale\u003c/p\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of age\u003c/p\u003e \u003cp\u003e25\u0026ndash;34\u003c/p\u003e \u003cp\u003e35\u0026ndash;44\u003c/p\u003e \u003cp\u003e45\u0026ndash;54\u003c/p\u003e \u003cp\u003e55\u0026ndash;64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e21\u003c/p\u003e \u003cp\u003e10\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e17\u003c/p\u003e \u003cp\u003e8\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional occupation*\u003c/p\u003e \u003cp\u003eOccupational Therapist\u003c/p\u003e \u003cp\u003eClinical Psychologist\u003c/p\u003e \u003cp\u003eClinical Neuropsychologist\u003c/p\u003e \u003cp\u003eSpeech and Language Therapist\u003c/p\u003e \u003cp\u003eStroke Specialist Nurse\u003c/p\u003e \u003cp\u003ePhysician\u003c/p\u003e \u003cp\u003eProfessor or Associate Professor\u003c/p\u003e \u003cp\u003eSenior Lecturer or Lecturer\u003c/p\u003e \u003cp\u003ePostdoctoral Researcher\u003c/p\u003e \u003cp\u003eDoctoral Student\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e12\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRegion\u003c/p\u003e \u003cp\u003eNorth East England\u003c/p\u003e \u003cp\u003eNorth West England\u003c/p\u003e \u003cp\u003eYorkshire and the Humber\u003c/p\u003e \u003cp\u003eWest Midlands\u003c/p\u003e \u003cp\u003eEast of England\u003c/p\u003e \u003cp\u003eLondon\u003c/p\u003e \u003cp\u003eSouth East England\u003c/p\u003e \u003cp\u003eSouth West England\u003c/p\u003e \u003cp\u003eScotland\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYears of experience\u003c/p\u003e \u003cp\u003e0\u0026ndash;5\u003c/p\u003e \u003cp\u003e6\u0026ndash;10\u003c/p\u003e \u003cp\u003e\u0026gt;\u0026thinsp;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e9\u003c/p\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative results\u003c/h2\u003e \u003cdiv id=\"Sec9\" class=\"Section3\"\u003e \u003ch2\u003eScreening and consent\u003c/h2\u003e \u003cp\u003eThe screening form and consent form were completed by 54 participants, 51 (94.44%) of whom met the inclusion and exclusion criteria. The 3 participants who did not meet the criteria were healthcare professionals, but they did not have at least five years of experience working with stroke survivors in the UK.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eRound 1\u003c/h2\u003e \u003cp\u003eOf the 51 participants invited, 36 (70.59%) completed the first survey round, which included demographic questions and 30 survey items based on candidate intervention features. Of the 36 participants who completed Round 1, 29 (80.56%) were female and 21 (58.33%) were aged between 35\u0026ndash;44 years. 25 (69.44%) participants occupied a clinical role only, 5 (13.89%) occupied an academic role only, and 5 occupied both a clinical and academic role (13.89%), with one participant choosing not to respond. Participants reached consensus on 25 of the items, with no consensus reached on 5 items.\u003c/p\u003e \u003cp\u003eIn summary, the expert panel agreed that stroke survivors with (100.00%) and without (88.24%) cognitive impairment detected during acute hospital admission should be offered at least one cognitive review. They agreed that those with cognitive impairment should receive a review in the first weeks (85.71%), three months (92.59%), six-months (95.45%) and one-year (95.00%) after discharge. Whilst they agreed that those without cognitive impairment detected should receive a review in the first weeks (82.14%) and six-months (80.00%) after discharge, participants did not reach consensus on whether they should receive reviews at three-months (72.00% agree) and one-year (55.00% agree) after discharge.\u003c/p\u003e \u003cp\u003eWhilst the expert panel agreed that cognitive reviews should be conducted in person (86.67%), they failed to reach consensus on a separate item on whether stroke survivors should be given the choice of whether to attend a review in person or remotely (72.41% agree). Nevertheless, they agreed that a stroke specific cognitive screen (96.97%), a depression screen (93.75%), and an anxiety screen (90.32%) should be administered during reviews, highlighting the importance of screening for broader psychological changes alongside cognition. However, they did not agree on whether the cognitive review should also include a dementia screen (e.g. MoCA) (56.52% agree) and/or a neuropsychological assessment (e.g. RBANS) (62.50% agree). They also agreed that self-report questionnaires about cognition for stroke survivors (97.06%) and family members (96.55%) should be included.\u003c/p\u003e \u003cp\u003eParticipants agreed on the importance of information provision and psychoeducation during the cognitive reviews. Specifically, participants agreed that stroke survivors should be given information about their cognitive assessment results, (93.75%), how these results compare to earlier cognitive testing (90.32%), potential cognitive trajectories (78.79%), the impact of cognitive problems on ADLs (100.00%), and information about services and support available (100.00%).\u003c/p\u003e \u003cp\u003eParticipants also agreed that training for healthcare professionals administering cognitive reviews was important. They agreed healthcare professionals should be offered formal (100.00%) and informal (78.57%) training on administering cognitive assessments, as well as formal (97.06%) and informal (86.67%) training on discussing cognition with stroke survivors and their family members.\u003c/p\u003e \u003cp\u003eAnalysis of free-text responses from the first survey round resulted in the addition of three further survey items to the second round (see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e starred items). These represented three further candidate intervention features: fatigue measure, online training, in person training.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eItems that reached consensus within the modified Delphi survey. *Item introduced in Round 2 of the modified Delphi survey.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eConsensus\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRound consensus reached\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eRespondents \u003cem\u003e(N)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExcluding no opinion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke survivors\u0026nbsp;\u003cb\u003ewith\u0026nbsp;a cognitive impairment\u003c/b\u003e\u0026nbsp;detected during acute hospital admission should have a\u0026nbsp;\u003cb\u003ereview\u003c/b\u003e\u0026nbsp;of their cognition\u0026nbsp;\u003cb\u003eafter discharge\u003c/b\u003e\u0026nbsp;from an acute inpatient setting.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e36\u003c/p\u003e \u003cp\u003e(100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke survivors\u0026nbsp;\u003cb\u003ewith no\u0026nbsp;cognitive impairment\u003c/b\u003e\u0026nbsp;detected during acute hospital admission should have a\u0026nbsp;\u003cb\u003ereview\u003c/b\u003e\u0026nbsp;of their cognition\u0026nbsp;\u003cb\u003eafter discharge\u003c/b\u003e\u0026nbsp;from an acute inpatient setting.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e(88.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(11.76)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor stroke survivors\u0026nbsp;\u003cb\u003ewith\u0026nbsp;a cognitive impairment\u003c/b\u003e\u0026nbsp;detected during acute hospital admission, a review of their cognition should take place in the\u0026nbsp;\u003cb\u003efirst few weeks\u003c/b\u003e after discharge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e(85.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(14.29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor stroke survivors\u0026nbsp;\u003cb\u003ewith\u0026nbsp;a cognitive impairment\u003c/b\u003e\u0026nbsp;detected during acute hospital admission, a review of their cognition should take place \u003cb\u003e3-months\u003c/b\u003e after discharge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003cp\u003e(92.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(7.41)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor stroke survivors\u0026nbsp;\u003cb\u003ewith\u0026nbsp;a cognitive impairment\u003c/b\u003e\u0026nbsp;detected during acute hospital admission, a review of their cognition should take place \u003cb\u003e6-months\u003c/b\u003e after discharge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e21\u003c/p\u003e \u003cp\u003e(95.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(4.55)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor stroke survivors\u0026nbsp;\u003cb\u003ewith\u0026nbsp;a cognitive impairment\u003c/b\u003e\u0026nbsp;detected during acute hospital admission, a review of their cognition should take place \u003cb\u003e1-year\u003c/b\u003e after discharge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e19\u003c/p\u003e \u003cp\u003e(95.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(5.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor stroke survivors\u0026nbsp;\u003cb\u003ewith no\u0026nbsp;cognitive impairment\u003c/b\u003e\u0026nbsp;detected during acute hospital admission, a\u0026nbsp;review of their cognition should take place in the\u0026nbsp;\u003cb\u003efirst few weeks\u003c/b\u003e after discharge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003cp\u003e(82.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(17.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor stroke survivors\u0026nbsp;\u003cb\u003ewith no\u0026nbsp;cognitive impairment\u003c/b\u003e\u0026nbsp;detected during acute hospital admission, a\u0026nbsp;review of their cognition should take place\u0026nbsp;\u003cb\u003e3-months after discharge\u003c/b\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e23\u003c/p\u003e \u003cp\u003e(82.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u003c/p\u003e \u003cp\u003e(17.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor stroke survivors\u0026nbsp;\u003cb\u003ewith no\u0026nbsp;cognitive impairment\u003c/b\u003e\u0026nbsp;detected during acute hospital admission, a\u0026nbsp;review of their cognition should take place \u003cb\u003e6-months\u003c/b\u003e after discharge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e16\u003c/p\u003e \u003cp\u003e(80.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(20.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive reviews should take place\u0026nbsp;\u003cb\u003ein person\u003c/b\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e(86.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(13.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive reviews should include\u0026nbsp;a\u0026nbsp;\u003cb\u003estroke-specific cognitive screen\u003c/b\u003e\u0026nbsp;(15\u0026ndash;20 minutes) (e.g., Oxford Cognitive Screen; OCS).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e32\u003c/p\u003e \u003cp\u003e(96.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(3.03)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive reviews should include\u0026nbsp;a\u0026nbsp;\u003cb\u003equestionnaire\u003c/b\u003e\u0026nbsp;for the\u0026nbsp;\u003cb\u003estroke survivor\u003c/b\u003e\u0026nbsp;about their post-stroke cognition.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e33\u003c/p\u003e \u003cp\u003e(97.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(2.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive reviews should include a\u0026nbsp;\u003cb\u003equestionnaire\u003c/b\u003e\u0026nbsp;for a\u0026nbsp;\u003cb\u003efamily member\u003c/b\u003e\u0026nbsp;about the stroke survivor\u0026rsquo;s cognition.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003cp\u003e(96.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(3.45)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive reviews should include a\u0026nbsp;\u003cb\u003edepression screen\u003c/b\u003e\u0026nbsp;(e.g., Patient Health Questionnaire-9; PHQ-9).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e(93.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(6.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive reviews should include an\u0026nbsp;\u003cb\u003eanxiety screen\u003c/b\u003e\u0026nbsp;(e.g., Generalised Anxiety Disorder Assessment-7; GAD-7).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003cp\u003e(90.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(8.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive reviews should include a\u0026nbsp;\u003cb\u003egeneral\u0026nbsp;discussion\u003c/b\u003e\u0026nbsp;with the stroke survivor about their\u0026nbsp;\u003cb\u003eoverall cognitive functioning.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e34\u003c/p\u003e \u003cp\u003e(100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive reviews should include a\u0026nbsp;\u003cb\u003egeneral\u0026nbsp;discussion\u003c/b\u003e\u0026nbsp;with the stroke survivor about their\u0026nbsp;\u003cb\u003edomain-specific cognitive functioning.\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e27\u003c/p\u003e \u003cp\u003e(96.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(3.57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke survivors should be told the\u0026nbsp;\u003cb\u003eresults of the cognitive assessment\u003c/b\u003e\u0026nbsp;conducted during the review.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e30\u003c/p\u003e \u003cp\u003e(93.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e(6.25)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke survivors should be told how their\u0026nbsp;\u003cb\u003ecognitive assessment result compares to earlier cognitive assessment results\u003c/b\u003e\u0026nbsp;(e.g., in cognitive screen completed in acute inpatient setting).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e28\u003c/p\u003e \u003cp\u003e(90.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(9.68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke survivors should be told about\u0026nbsp;\u003cb\u003epotential cognitive trajectories\u003c/b\u003e\u0026nbsp;during the review.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e(78.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003cp\u003e(21.21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke survivors should be told about the potential\u0026nbsp;\u003cb\u003eimpact\u003c/b\u003e\u0026nbsp;of any cognitive impairments on\u0026nbsp;\u003cb\u003eactivities of daily living\u003c/b\u003e\u0026nbsp;during the review.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e34\u003c/p\u003e \u003cp\u003e(100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStroke survivors should be\u0026nbsp;\u003cb\u003esignposted\u003c/b\u003e\u0026nbsp;to available\u0026nbsp;\u003cb\u003esupport and services\u003c/b\u003e\u0026nbsp;during the review.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e36\u003c/p\u003e \u003cp\u003e(100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare professionals responsible for conducting cognitive reviews after stroke should receive\u0026nbsp;\u003cb\u003eformal training\u003c/b\u003e\u0026nbsp;(e.g., training videos) on\u0026nbsp;\u003cb\u003eadministering the cognitive assessment\u003c/b\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e35\u003c/p\u003e \u003cp\u003e(100.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0\u003c/p\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare professionals responsible for conducting cognitive reviews after stroke should receive\u0026nbsp;\u003cb\u003einformal training\u003c/b\u003e\u0026nbsp;(e.g., training from colleague) on\u0026nbsp;\u003cb\u003eadministering the cognitive assessment\u003c/b\u003e.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e22\u003c/p\u003e \u003cp\u003e(78.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e6\u003c/p\u003e \u003cp\u003e(21.43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare professionals responsible for conducting cognitive reviews after stroke should receive\u0026nbsp;\u003cb\u003eformal training\u003c/b\u003e\u0026nbsp;(e.g., training videos) on\u0026nbsp;\u003cb\u003ediscussing cognition\u003c/b\u003e\u0026nbsp;with stroke survivors and family members.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e33\u003c/p\u003e \u003cp\u003e(97.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(2.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHealthcare professionals responsible for conducting cognitive reviews after stroke should receive\u0026nbsp;\u003cb\u003einformal training\u003c/b\u003e\u0026nbsp;(e.g., training from colleague) on\u0026nbsp;\u003cb\u003ediscussing cognition\u003c/b\u003e\u0026nbsp;with stroke survivors and family members.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e(86.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(13.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e* Cognitive reviews should include\u0026nbsp;a\u0026nbsp;\u003cb\u003efatigue measure\u003c/b\u003e\u0026nbsp;(e.g. Fatigue Severity Scale; FSS).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e25\u003c/p\u003e \u003cp\u003e(89.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u003c/p\u003e \u003cp\u003e(10.71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e* Online training\u003c/b\u003e\u0026nbsp;(e.g., training videos) should be offered to\u0026nbsp;healthcare professionals administering cognitive reviews.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e(96.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e(3.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e* In person training\u003c/b\u003e\u0026nbsp;(e.g., training course) should be offered to\u0026nbsp;healthcare professionals administering cognitive reviews.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e21\u003c/p\u003e \u003cp\u003e(84.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4\u003c/p\u003e \u003cp\u003e(16.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRound 2\u003c/h2\u003e \u003cp\u003eThe second survey round was completed by 29 (80.56%) of the 36 participants invited. The second survey round included 8 items, 4 (50%) of which reached consensus.\u003c/p\u003e \u003cp\u003eAll three of the items developed from free-text responses to statements in the first survey round reached consensus: Participants agreed that the reviews should include a fatigue measure (89.29%), and that training for healthcare professionals should be offered online (96.30%) and in person (84.00%).\u003c/p\u003e \u003cp\u003eHowever, only one of the five items rolled over from the first round reached consensus in the second round. Participants agreed that stroke survivors with no cognitive impairment detected during acute hospital admission should receive a review of their cognition three-months after discharge (82.14%), but they did not reach consensus on whether these stroke survivors should receive a review one-year after discharge (74.07% disagree). Participants failed to reach consensus on whether stroke survivors should be given the option to complete reviews in person or remotely (62.07% agree) and whether the review should include a dementia screen (65.38% disagree) and/or a neuropsychological assessment battery (58.33% disagree).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eRound 3\u003c/h2\u003e \u003cp\u003eThe third round of the survey was completed by 26 (89.66%) of the 29 participants invited. It included four items, none of which reached consensus. Compared to results of the second round, only one item moved closer to consensus (In person and remote review options: Agree \u0026minus;\u0026thinsp;62.07\u0026ndash;66.67%). The level of consensus for one item remained the same in Round 3 compared to Round 2 (Inclusion of neuropsychological assessment battery: Disagree \u0026minus;\u0026thinsp;58.33%). Two items moved further from consensus (Reviews one-year after discharge for those without cognitive impairment acutely: Disagree \u0026minus;\u0026thinsp;74.07\u0026ndash;68.00%; Inclusion of dementia screen: Disagree \u0026minus;\u0026thinsp;65.38\u0026ndash;62.50%). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e presents a summary of results for these items from each survey round.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eItems that did not reach consensus in the modified Delphi survey.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eStatement\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eRound\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eResponses\u003c/p\u003e \u003cp\u003e\u003cem\u003e(N)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003cp\u003e\u003cem\u003eN (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExcluding no opinion\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFor stroke survivors\u0026nbsp;\u003cb\u003ewith no\u0026nbsp;cognitive impairment\u003c/b\u003e\u0026nbsp;detected during acute hospital admission, a\u0026nbsp;review of their cognition should take place \u003cb\u003e1-year\u003c/b\u003e\u0026nbsp;after discharge.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e29\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003cp\u003e27\u003c/p\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e11 (55.00)\u003c/p\u003e \u003cp\u003e7 (25.93)\u003c/p\u003e \u003cp\u003e8 (32.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9 (45.00)\u003c/p\u003e \u003cp\u003e20 (74.07)\u003c/p\u003e \u003cp\u003e17 (68.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIndividual stroke survivors should\u0026nbsp;\u003cb\u003echoose\u003c/b\u003e\u0026nbsp;whether they would prefer cognitive reviews to take place either\u0026nbsp;\u003cb\u003ein person or remotely\u003c/b\u003e\u0026nbsp;(i.e., telephone or videoconferencing).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003cp\u003e29\u003c/p\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e29\u003c/p\u003e \u003cp\u003e29\u003c/p\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21 (72.41)\u003c/p\u003e \u003cp\u003e18 (62.07)\u003c/p\u003e \u003cp\u003e16 (66.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e8 (27.59)\u003c/p\u003e \u003cp\u003e11 (37.93)\u003c/p\u003e \u003cp\u003e8 (33.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive reviews should include\u0026nbsp;a\u0026nbsp;\u003cb\u003edementia\u0026nbsp;screen\u003c/b\u003e\u0026nbsp;(10\u0026ndash;15 minutes) (e.g., Montreal Cognitive Assessment; MoCA).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36\u003c/p\u003e \u003cp\u003e29\u003c/p\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23\u003c/p\u003e \u003cp\u003e26\u003c/p\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e13 (56.52)\u003c/p\u003e \u003cp\u003e9 (34.62)\u003c/p\u003e \u003cp\u003e9 (37.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e10 (43.48)\u003c/p\u003e \u003cp\u003e17 (65.38)\u003c/p\u003e \u003cp\u003e15 (62.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCognitive reviews should include\u0026nbsp;a\u0026nbsp;\u003cb\u003eneuropsychological assessment battery\u003c/b\u003e\u0026nbsp;(\u0026gt;\u0026thinsp;30 minutes) (e.g., Repeatable Battery for the Assessment of Neuropsychological Status; RBANS).\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003cp\u003e29\u003c/p\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24\u003c/p\u003e \u003cp\u003e24\u003c/p\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15 (62.50)\u003c/p\u003e \u003cp\u003e10 (41.67)\u003c/p\u003e \u003cp\u003e10 (41.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e9 (37.50)\u003c/p\u003e \u003cp\u003e14 (58.33)\u003c/p\u003e \u003cp\u003e14 (58.33)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eQualitative results from final survey round\u003c/h2\u003e \u003cp\u003eDespite failing to reach consensus on four items, qualitative analysis of free-text responses indicated that many participants shared similar viewpoints about potential risks, benefits, and caveats of including these candidate intervention features in the intervention. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e presents a summary of the final theme structure developed from free-text responses to items that did not reach consensus and example verbatim quotations. Further detail is provided in Supplementary Materials, where specific themes and subthemes are described in depth with example quotations.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable 4.\u003c/strong\u003e Summary of theme structure developed to identify potential reasons for the lack of consensus on four statements in the modified Delphi survey.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"718\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.16155988857939%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurvey item\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.030640668523677%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.807799442896936%\"\u003e\n \u003cp\u003e\u003cstrong\u003eExample quotation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8997214484679668%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.26183844011142%\" rowspan=\"3\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eFor stroke survivors \u003cstrong\u003ewith no\u0026nbsp;cognitive impairment\u003c/strong\u003e detected during acute hospital admission, a review of their cognition should take place \u003cstrong\u003e1-year\u003c/strong\u003e after discharge.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.030640668523677%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eToo late to be useful.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.807799442896936%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Should be earlier, as by a year post someone may have lost a job or relationships due to lack of support for cognitive changes by that point.\u0026rdquo;\u003c/em\u003e (P28, Speech and Language Therapist)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.009009009009006%\" valign=\"top\"\u003e\n \u003cp\u003eConcerns about feasibility.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Given the evidence of the high prevalence of dementia post stroke, I think this would be a good opportunity to follow up on this. However, the resources needed would make it impossible and I do feel resources could be better allocated on those who really need the cognitive rehabilitation.\u0026rdquo;\u003c/em\u003e (P2, Occupational Therapist)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.009009009009006%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8997214484679668%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.26183844011142%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.030640668523677%\" valign=\"top\"\u003e\n \u003cp\u003eIt depends on earlier cognitive reviews.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.807799442896936%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I think if no cognitive deficits are indicated at 3 months there is no need to review again.\u0026rdquo;\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;(P4, Occupational Therapist)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8997214484679668%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.26183844011142%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eIndividual stroke survivors should \u003cstrong\u003echoose\u003c/strong\u003e whether they would prefer cognitive reviews to take place either \u003cstrong\u003ein person or remotely\u003c/strong\u003e (i.e., telephone or videoconferencing).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.030640668523677%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDownsides of remote assessments.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.807799442896936%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Building rapport is so much easier in person (assuming they\u0026apos;d not previously met the assessor) and this is important for the person to do their best during the assessment. \u0026nbsp;I think it\u0026apos;s probably also more likely that higher level difficulties would be picked up if seen in person. Not saying that remote options don\u0026apos;t have a place, I just don\u0026apos;t think patient preference is the right way to decide.\u0026rdquo;\u003c/em\u003e (P19, Doctoral Student)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.009009009009006%\" valign=\"top\"\u003e\n \u003cp\u003eImportance of choice and person-centredness.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I do think choice and accessibility is important therefore both videoconferencing and face to face should be offered. Not telephone consult. However the pros and cons of each should be clearly explained to the patient to enable them making an informed choice. My personal preference would be face to face but remote is better than a DNA.\u0026rdquo;\u003c/em\u003e (P29, Occupational Therapist)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8997214484679668%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.26183844011142%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCognitive reviews should include a \u003cstrong\u003edementia\u0026nbsp;screen\u003c/strong\u003e (10-15 minutes) (e.g., Montreal Cognitive Assessment; MoCA).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.030640668523677%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eRisk of misinterpretation in stroke populations.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.807799442896936%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;Standard dementia screens can potentially be misleading because of all the confounds in a stroke population i.e. neglect, dysphasia, motor problems. \u0026nbsp;Whatever training you put in place, there will still be some people who take the standard cut-off (e.g. 88/100 on ACE-III) and say, \u0026apos;the score is below the cut-off and this suggests the person has dementia\u0026apos;.\u0026rdquo;\u003c/em\u003e (P1, Clinical Psychologist \u0026amp; Clinical Neuropsychologist)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.009009009009006%\" valign=\"top\"\u003e\n \u003cp\u003ePreference for situation- and person-specific approach.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;A dementia screen would be very useful in certain situations: evidence of longitudinal cognitive decline either before stroke or months/years after the stroke; or a cognitive profile that doesn\u0026apos;t match the stroke eg dense amnestic picture with a posterior stroke. Stroke and neurodegenerative disorders often co-exist particularly in the older patients. [...] So Dementia screen is important in some patients but not routinely in ALL patients.\u0026rdquo;\u003c/em\u003e (P7, Physician \u0026amp; Lecturer)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"3.8997214484679668%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"34.26183844011142%\" rowspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eCognitive reviews should include a \u003cstrong\u003eneuropsychological assessment battery\u003c/strong\u003e (\u0026gt;30 minutes) (e.g., Repeatable Battery for the Assessment of Neuropsychological Status; RBANS).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"21.030640668523677%\" valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eConcerns about feasibility.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.807799442896936%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;I don\u0026apos;t think there will ever be enough people in stroke services to administer something that requires a more sophisticated understanding of psychometric assessment to make this workable - a \u0026apos;review\u0026apos; will end up being too long and unwieldy.\u0026rdquo;\u003c/em\u003e (P1, Clinical Psychologist \u0026amp; Clinical Neuropsychologist)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"34.009009009009006%\" valign=\"top\"\u003e\n \u003cp\u003eImportance of onwards referral.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"65.990990990991%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cem\u003e\u0026ldquo;A two tiered approach with initial screening/triage to select those needing more detailed assessment seems a better use of resource.\u0026rdquo;\u003c/em\u003e (P33, Physician)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Discussion","content":"\u003cp\u003eExpert healthcare professionals and stroke researchers who participated in this modified Delphi survey reached consensus on the majority of design decisions for a monitoring and psychoeducational intervention addressing psychological changes to be implemented within the UK stroke care pathway. Participants agreed reviews should include a stroke-specific cognitive screen. While the intervention was originally conceptualised as a \u003cem\u003ecognitive\u003c/em\u003e care pathway, participants also agreed the intervention should address post-stroke \u003cem\u003epsychological\u003c/em\u003e changes, encompassing mood, anxiety, and fatigue. They agreed stroke survivors should be offered at least one review, regardless of their psychological presentation in hospital. They agreed on the importance of various psychoeducation topics, and formal and informal training for those conducting reviews. Consensus was not reached on the review mode (in person/remote options), offering reviews one-year post-discharge to patients without impairments detected in hospital, or including a dementia screen and/or neuropsychological assessment battery. Free-text responses highlighted a number of shared views, including the importance of onwards referral where clinically indicated. Alongside empirical evidence and psychological theory, stakeholder input from this study will inform the development of an intervention to address the ongoing and well-evidenced need for psychological support after stroke (\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipants agreed that reviews of psychological changes after stroke should form a standard part of the UK stroke care pathway, with these reviews being offered to all stroke survivors, regardless of their presentation in hospital. The importance of reviewing psychological changes is indeed emphasised in UK clinical guidelines for stroke care (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) but audit and commissioning data indicate insufficient provision of longer term post-stroke psychological support across the UK (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Furthermore, and perhaps most concerningly, evidence suggests provision of psychological support in the months after stroke has been declining over recent years (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), in spite of widespread calls to prioritise post-stroke psychological care provision (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). While interventions have been developed with the potential to address these gaps in post-stroke psychological care provision in the UK (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), they are generally limited by the substantial clinical expertise and time required to administer them. When identifying candidate intervention features to include in this modified Delphi survey, we held in mind the substantial constraints on community stroke services within the UK and expert stakeholder participants further reinforced the need to balance quality and efficiency of care provision. As a result, the monitoring and psychoeducational intervention that will be developed from this modified Delphi survey and other co-production activities (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e) may have the potential to fill key gaps in post-stroke care provision, without overburdening services.\u003c/p\u003e \u003cp\u003eAs with post-stroke cognitive impairment, the high prevalence of low mood, anxiety, and fatigue after stroke is well-evidenced. A recent systematic review and meta-analysis of 97 studies found the pooled prevalence of anxiety between one-five months after stroke to be 21% in studies using interviews, and 24% in studies using self-report scales (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), while the pooled prevalence of depression any time up to five-years post-stroke across 61 studies has been estimated to be 31% (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Recognising the high prevalence of cognitive impairment, low mood, and anxiety after stroke, a recent priority setting exercise by the James Lind Alliance identified psychological changes and cognitive changes as the top two research priorities needing to be addressed to improve post-stroke rehabilitation and long-term care (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). In particular, the Priority Setting Partnership (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e) made explicit the following question \u0026ldquo;What is the best way to assess for, understand the impacts of and track progression in all areas of cognition \u0026ndash; including using standardised measures - across the stroke pathway; what and how can interventions and services involving multidisciplinary teams and families be made accessible, and how can information on these problems be provided?\u0026rdquo; (p.12) By providing expert consensus on the optimal care delivery model for monitoring psychological changes after stroke, the results of this modified Delphi survey directly address this top stroke research priority.\u003c/p\u003e \u003cp\u003eThere was no consensus on whether reviews should include a dementia screen and/or neuropsychological assessment battery as a standard part of follow-up, which reflects an ongoing debate within the literature and clinical practice about the optimal approach for post-stroke cognitive screening and assessment (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e). Proponents of post-stroke dementia screening have emphasised both within this survey and in previous research the increased risk of developing dementia after stroke and thus the urgent need to screen for it (\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Indeed, a recent meta-analysis reported that approximately 20% of stroke survivors experience clinically defined dementia one-year after stroke (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). However, as acknowledged by participants in this study, results on dementia screens like the Montreal Cognitive Assessment (MoCA: 57) and Mini-Mental State Examination (MMSE: 58) may be confounded by stroke-specific deficits and lack sensitivity (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e, \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e), leading to potential misinterpretation and misdiagnoses when administered and interpreted by individuals with limited expertise. With regards to neuropsychology assessments, while proponents of neuropsychology assessments emphasised the advantage of understanding cognitive profiles in detail to support rehabilitation, participants highlighted the substantial constraints on clinical services in the UK and argued that it would not be feasible to implement extensive neuropsychological testing within a standardised and widespread post-stroke psychological care pathway. In both cases, participants emphasised the importance of onwards referral to specialist services, such as memory clinics and neuropsychology services.\u003c/p\u003e \u003cp\u003eIn terms of limitations, we note that the survey was designed and ethical approval was obtained prior to the publication of the latest revision of the National Clinical Guideline for Stroke in April 2023 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e), meaning that survey items were informed by the earlier 2016 guideline (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e). Nevertheless, our results echo recommendations from the updated clinical guideline, as well as providing important clarification on some aspects of psychological care provision (e.g., importance of providing specific information about assessment results, potential trajectories, impact of psychological changes on activities of daily living, and signposting). A second limitation is that we only sought consensus on relatively broad intervention design decisions - for example, participants agreed that the intervention should include a stroke-specific cognitive screen, but we did not ask participants to advise on the optimal stroke-specific screening tool. We constrained the survey to broader design decisions to reduce participant burden and encourage participation.\u003c/p\u003e \u003cp\u003eIn conclusion, this study developed expert consensus on the overarching design of a \u0026lsquo;first-line\u0026rsquo; monitoring and psychoeducation intervention addressing post-stroke psychological changes to be integrated in the existing UK stroke care pathway. Future research will evaluate the extent to which the intervention has a clinically meaningful impact on patient outcomes. In the meantime, the recommendations outlined here may prove beneficial for informing local service improvements.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received ethical approval from University of Oxford\u0026rsquo;s Central University Research Ethics Committee (REC reference: R76686/RE001). Each participant provided consent via the online survey platform.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants agreed to the publications of their research data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo further data will be made available.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eND is a developer of the Oxford Cognitive Screen but does not receive any financial remuneration from its use.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported by the National Institute for Health and Care Research (NIHR) through an Advanced Fellowship (NIHR302224). GH is supported by an Economic and Social Research Council (ESRC) award (ES/P000649/1). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGH and ND conceived the framework for this study. GH collected, analysed and interpreted the data. GH prepared the manuscript for submission. ET assisted with conceiving the framework for this study and edited the manuscript. ND assisted with data analysis, and critically reviewed and edited the manuscript. ND supervised the study and accepts full responsibility for this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank those who kindly offered their time and expertise to support this study, including Dr Adam Bevins, Clara Buckle, Louisa Burton, Dr Ver\u0026oacute;nica Cabreira, Alexandra Cantwell, Jennifer Crow, Dr Ruth Da Silva, Claudia Forrest, Nicola Jobson, Maria Mar Martin Saez, Dr Marco Mion, Kayleigh Pocrnic, Prof Terry Quinn, Rachel Teasdale-Smith, Nicola Tressler, Dr Grace Turner.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDemeyere N, Riddoch MJ, Slavkova ED, Jones K, Reckless I, Mathieson P, et al. Domain-specific versus generalized cognitive screening in acute stroke. J Neurol. 2016;263(2):306\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHurford R, Charidimou A, Fox Z, Cipolotti L, Werring DJ. Domain-specific trends in cognitive impairment after acute ischaemic stroke. J Neurol. 2013;260(1):237\u0026ndash;41.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLesniak M, Bak T, Czepiel W, Seniow J, Czlonkowska A. Frequency and prognostic value of cognitive disorders in stroke patients. Dement Geriatr Cogn Disord. 2008;26(4):356\u0026ndash;63.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMilosevich E, Moore M, Pendlebury ST, Demeyere N. Domain-specific cognitive impairment 6 months after stroke: the value of early cognitive screening [Internet]. medRxiv; 2023 [cited 2023 Jul 27]. p. 2023.06.14.23291381. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.medrxiv.org/content/\u003c/span\u003e\u003cspan address=\"https://www.medrxiv.org/content/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1101/2023.06.14.23291381v1\u003c/span\u003e\u003cspan address=\"10.1101/2023.06.14.23291381v1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNijsse B, Visser-Meily JMA, van Mierlo ML, Post MWM, de Kort PLM, van Heugten CM. Temporal Evolution of Poststroke Cognitive Impairment Using the Montreal Cognitive Assessment. Stroke. 2017;48(1):98\u0026ndash;104.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTurunen KEA, Laari SPK, Kauranen TV, Uimonen J, Mustanoja S, Tatlisumak T, et al. Domain-Specific Cognitive Recovery after First-Ever Stroke: A 2-Year Follow-Up. J Int Neuropsychol Soc. 2018;24(2):117\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemeyere N, Sun S, Milosevich E, Vancleef K. Post-stroke cognition with the Oxford Cognitive Screen vs Montreal Cognitive Assessment: A multi-site randomized controlled study (OCS-CARE) [Internet]. Vol. 1. 2019 [cited 2022 Nov 8]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.12688/amrcopenres.12882.1\u003c/span\u003e\u003cspan address=\"10.12688/amrcopenres.12882.1\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKusec A, Milosevich E, Williams OA, Chiu EG, Watson P, Carrick C et al. Long-term psychological outcomes following stroke: The OX-CHRONIC study [Internet]. medRxiv; 2023 [cited 2023 Jul 27]. p. 2023.03.27.23287789. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.medrxiv.org/content/\u003c/span\u003e\u003cspan address=\"https://www.medrxiv.org/content/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1101/2023.03.27.23287789v2\u003c/span\u003e\u003cspan address=\"10.1101/2023.03.27.23287789v2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLopes R, Bournonville C, Kuchcinski G, Dondaine T, Mendyk A, Viard R, et al. Prediction of Long-term Cognitive Functions after Minor Stroke, Using Functional Connectivity. Neurology. 2021;96(8):e1167\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWilliams OA, Demeyere N. Association of depression and anxiety with cognitive impairment 6 months after stroke. Neurology. 2021;96(15):e1966\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMole JA, Demeyere N. The relationship between early post-stroke cognition and longer term activities and participation: A systematic review. Neuropsychological Rehabilitation. 2018;30(2):346\u0026ndash;70.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStolwyk RJ, Mihaljcic T, Wong DK, Chapman JE, Rogers JM. Poststroke Cognitive Impairment Negatively Impacts Activity and Participation Outcomes. Stroke. 2021;52(2):748\u0026ndash;60.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIntercollegiate Stroke Working Party. National Clinical Guideline for Stroke for the UK and Ireland. London: NICE; 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIntercollegiate Stroke Working Party. SSNAP Annual Results Portfolio: April 2022 to March 2023. [Internet]. London, United Kingdom: King\u0026rsquo;s College London. 2023. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.strokeaudit.org/Results2/Clinical-audit/National-Results.aspx\u003c/span\u003e\u003cspan address=\"https://www.strokeaudit.org/Results2/Clinical-audit/National-Results.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS. RightCare stroke toolkit. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLin Blei, Mei Y xia, Wang W, na, Wang Sshan, Li Y, shuang, Xu M et al. ya,. Unmet care needs of community-dwelling stroke survivors: a systematic review of quantitative studies. BMJ Open. 2021;11(4):e045560.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen T, Zhang B, Deng Y, Fan JC, Zhang L, Song F. Long-term unmet needs after stroke: Systematic review of evidence from survey studies. BMJ Open. 2019;9(5):e028137.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuo Y, Zhang Z, Lin B, Mei Y, Liu Q, Zhang L, et al. The Unmet Needs of Community-Dwelling Stroke Survivors: A Systematic Review of Qualitative Studies. Int J Environ Res Public Health. 2021;18(4):2140.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS. The NHS long term plan. 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS England. Research demand signalling: National Stroke Programme. 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHill G, Regan S, Francis R. Research priorities to improve stroke outcomes. Lancet Neurol. 2022;21(4):312\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowen A, Hazelton C, Pollock A, Lincoln N. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database of Systematic Reviews [Internet]. 2013 [cited 2023 Jul 6]; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pubmed-ncbi-nlm-nih-gov.ezproxy-prd.bodleian.ox.ac.uk/23813503/\u003c/span\u003e\u003cspan address=\"https://pubmed-ncbi-nlm-nih-gov.ezproxy-prd.bodleian.ox.ac.uk/23813503/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChung CSY, Pollock A, Campbell T, Durward BR, Hagen S. Cognitive rehabilitation for executive dysfunction in adults with stroke or other adult non-progressive acquired brain damage. Cochrane Database Syst Rev. 2013;2013(4):CD008391.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003edas Nair R, Lincoln N. Cognitive rehabilitation for memory deficits following stroke. Cochrane Database of Systematic Reviews [Internet]. 2007 [cited 2023 Jul 6]; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www-cochranelibrary-com.ezproxy-prd.bodleian.ox.ac.uk/cdsr/doi/10.1002/14651858.CD002293.pub2/abstract?cookiesEnabled\u003c/span\u003e\u003cspan address=\"https://www-cochranelibrary-com.ezproxy-prd.bodleian.ox.ac.uk/cdsr/doi/10.1002/14651858.CD002293.pub2/abstract?cookiesEnabled\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLoetscher T, Lincoln NB. Cognitive rehabilitation for attention deficits following stroke. Cochrane Database Syst Rev. 2013;2013(5):CD002842.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMerriman NA, Gillan D, Pender N, Williams DJ, Horgan F, Sexton E, et al. The StrokeCog study: Development and description of a cognition-focused psychological intervention to address cognitive impairment following stroke. Psychol Health. 2021;36(7):792\u0026ndash;809.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCheng HY, Chair SY, Chau JPC. The effectiveness of psychosocial interventions for stroke family caregivers and stroke survivors: A systematic review and meta-analysis. Patient Educ Couns. 2014;95(1):30\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMou H, Wong MS, Chien WT. Effectiveness of dyadic psychoeducational intervention for stroke survivors and family caregivers on functional and psychosocial health: A systematic review and meta-analysis. Int J Nurs Stud. 2021;120:103969.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKontou E, Kettlewell J, Condon L, Thomas S, Lee AR, Sprigg N, et al. A scoping review of psychoeducational interventions for people after transient ischemic attack and minor stroke. Top Stroke Rehabil. 2021;28(5):390\u0026ndash;400.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSkivington K, Matthews L, Simpson SA, Craig P, Baird J, Blazeby JM, et al. A new framework for developing and evaluating complex interventions: Update of Medical Research Council guidance. BMJ. 2021;374:n2061.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Cathain A, Croot L, Duncan E, Rousseau N, Sworn K, Turner KM, et al. Guidance on how to develop complex interventions to improve health and healthcare. BMJ Open. 2019;9(8):e029954.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChapman JE, Ponsford J, Bagot KL, Cadilhac DA, Gardner B, Stolwyk RJ. The use of videoconferencing in clinical neuropsychology practice: A mixed methods evaluation of neuropsychologists\u0026rsquo; experiences and views. Australian Psychol. 2020;55(6):618\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFox-Fuller JT, Rizer S, Andersen SL, Sunderaraman P. Survey Findings About the Experiences, Challenges, and Practical Advice/Solutions Regarding Teleneuropsychological Assessment in Adults. Arch Clin Neuropsychol. 2022;37(2):274\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWebb SS, Kontou E, Demeyere N. The COVID-19 pandemic altered the modality, but not the frequency, of formal cognitive assessment. Disabil Rehabil. 2022;44(21):6365\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWebb SS, Carrick C, Kusec A, Demeyere N. Introducing the Tele-OCS: A validated remotely administered version of The Oxford Cognitive Screen. Health Open Research [Internet]. 2023 [cited 2023 Dec 21];5(8). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://healthopenresearch.org/articles/5-8/v1?src=rss\u003c/span\u003e\u003cspan address=\"https://healthopenresearch.org/articles/5-8/v1?src=rss\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLees RA, Broomfield NM, Quinn TJ. Questionnaire assessment of usual practice in mood and cognitive assessment in Scottish stroke units. Disabil Rehabil. 2014;36(4):339\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eQuinn TJ, Elliott E, Langhorne P. Cognitive and Mood Assessment Tools for Use in Stroke. Stroke. 2018;49(2):483\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAblewhite J, Geraghty J, das Nair R, Lincoln N, Drummond A. Cognitive Management Pathways in Stroke Services (COMPASS): A qualitative investigation of key issues in relation to community stroke teams undertaking cognitive assessments. Br J Occup Therapy. 2019;82(7):404\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHobden G, Tang E, Demeyere N. Cognitive assessment after stroke: A qualitative study of patients\u0026rsquo; experiences. BMJ Open. 2023;13(6):e072501.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMerriman N, Bruen C, Gorman A, Horgan F, Williams D, Pender N, et al. I\u0026rsquo;m just not a Sudoku person\u0026rsquo;: analysis of stroke survivor, carer, and healthcare professional perspectives for the design of a cognitive rehabilitation intervention. Disabil Rehabil. 2019;42(23):3359\u0026ndash;69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHobden G, Tang EYH, Demeyere N. A qualitative study investigating the views of stroke survivors and their family members on discussing post-stroke cognitive trajectories. Neuropsychological Rehabilitation. 2024;0(0):1\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHobden G, Tabone F, Demeyere N. Cognition after stroke: A scoping review to investigate the information needs of stroke survivors and their family members. In review.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS Improvement. Psychological care after stroke: Improving stroke services for people with cognitive and mood disorders [Internet]. Leicester, UK. 2011. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.nice.org.uk/media/default/sharedlearning/531_strokepsychologicalsupportfinal.pdf\u003c/span\u003e\u003cspan address=\"https://www.nice.org.uk/media/default/sharedlearning/531_strokepsychologicalsupportfinal.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHasson F, Keeney S, McKenna H. Research guidelines for the Delphi survey technique. J Adv Nurs. 2000;32(4):1008\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKeeney S, Hasson F, McKenna H. Consulting the oracle: ten lessons from using the Delphi technique in nursing research. J Adv Nurs. 2006;53(2):205\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKing N. Template analysis. Qualitative methods and analysis in organizational research: A practical guide. Thousand Oaks, CA: Sage Publications Ltd; 1998. pp. 118\u0026ndash;34.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKing N, University H. 2024 [cited 2024 Mar 6]. What is Template Analysis? \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://research.hud.ac.uk/research-subjects/human-health/template-analysis/what-is-template-analysis/\u003c/span\u003e\u003cspan address=\"https://research.hud.ac.uk/research-subjects/human-health/template-analysis/what-is-template-analysis/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMcKevitt C, Fudge N, Redfern J, Sheldenkar A, Crichton S, Rudd AR, et al. Self-reported long-term needs after stroke. Stroke. 2011;42(5):1398\u0026ndash;403.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCare Quality Commission. Supporting life after stroke: A review of services for people who have had a stroke and their carers. 2011.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIntercollegiate Stroke Working Party. Sentinel Stroke National Audit Programme (SSNAP). SSNAP Annual Portfolio for April 2017-March 2018 admissions and discharges [Internet]. 2018 [cited 2023 Dec 21]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.strokeaudit.org/BackupV1/results/Clinical-audit/National-Results.aspx\u003c/span\u003e\u003cspan address=\"https://www.strokeaudit.org/BackupV1/results/Clinical-audit/National-Results.aspx\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDivision of Neuropsychology. Recommendations for Integrated Community Stroke Services: Service design, workforce planning \u0026amp; clinical governance requirements for a high-quality service and rehabilitation outcomes [Internet]. The British Psychological Society; 2023 [cited 2024 Apr 26]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://cms.bps.org.uk/sites/default/files/2023-04/BRE56%20Recommendations%20for%20Integrated%20Community%20Stroke%20Services_April.pdf\u003c/span\u003e\u003cspan address=\"https://cms.bps.org.uk/sites/default/files/2023-04/BRE56%20Recommendations%20for%20Integrated%20Community%20Stroke%20Services_April.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnapp P, Dunn-Roberts A, Sahib N, Cook L, Astin F, Kontou E, et al. Frequency of anxiety after stroke: An updated systematic review and meta-analysis of observational studies. Int J Stroke. 2020;15(3):244\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHackett ML, Pickles K, Part I. Frequency of Depression after Stroke: An Updated Systematic Review and Meta-Analysis of Observational Studies. Int J Stroke. 2014;9(8):1017\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eStroke Association. Shaping stroke research to rebuild lives: The Stroke Priority Setting Partnership results for investment [Internet]. 2021. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.stroke.org.uk/research/stroke-priority-setting-partnership\u003c/span\u003e\u003cspan address=\"https://www.stroke.org.uk/research/stroke-priority-setting-partnership\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMijajlović MD, Pavlović A, Brainin M, Heiss WD, Quinn TJ, Ihle-Hansen HB, et al. Post-stroke dementia \u0026ndash; a comprehensive review. BMC Med. 2017;15(1):11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCraig L, Hoo ZL, Yan TZ, Wardlaw J, Quinn TJ. Prevalence of dementia in ischaemic or mixed stroke populations: Systematic review and meta-analysis. J Neurol Neurosurg Psychiatry. 2022;93(2):180\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNasreddine ZS, Phillips NA, B\u0026eacute;dirian V, Charbonneau S, Whitehead V, Collin I, et al. The Montreal Cognitive Assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFolstein M, Folstein S, McHugh P. Mini-Mental State\u0026rsquo; A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res. 1975;12:189\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMancuso M, Demeyere N, Abbruzzese L, Damora A, Varalta V, Pirrotta F, et al. Using the Oxford Cognitive Screen to detect cognitive impairment in stroke patients: A comparison with the Mini-Mental State Examination. Front Neurol. 2018;9:101.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePendlebury ST, Mariz J, Bull L, Mehta Z, Rothwell PM, MoCA ACE-R. Versus the National Institute of Neurological Disorders and Stroke\u0026ndash;Canadian Stroke Network Vascular Cognitive Impairment Harmonization Standards Neuropsychological Battery After TIA and Stroke. Stroke. 2012;43(2):464\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBowen A, James M, Young G. Royal College of Physicians 2016 National clinical guideline for stroke [Internet]. RCP; 2016 Jan [cited 2022 Jul 20]. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pearl.plymouth.ac.uk/handle/10026.1/10488\u003c/span\u003e\u003cspan address=\"https://pearl.plymouth.ac.uk/handle/10026.1/10488\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-4638082/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4638082/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEnhancing long-term support for post-stroke cognitive impairment is a top research priority. Addressing current gaps in UK post-stroke cognitive care provision requires a pragmatic and scalable intervention that can be integrated in the existing stroke care pathway. This study aimed to develop consensus on core features of a UK-based monitoring and psychoeducational intervention for cognitive changes after stroke.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e An expert panel of UK healthcare professionals and researchers participated in an online modified Delphi survey. Candidate intervention features were identified from clinical guidelines, existing literature, research team/collaborator expertise, and PPI group lived experience. Survey participants indicated whether they agreed/disagreed/had no opinion about including each candidate feature in the intervention and free-text responses were invited. We analysed responses for consensus (\u0026ge;\u0026thinsp;75% agreement) using descriptive statistics, with items not reaching consensus carried into subsequent rounds. Template analysis was used to identify similarities/differences in viewpoints for items that did not reach consensus.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe survey rounds were completed by 36, 29 and 26 participants, respectively. Participants agreed reviews should include a stroke-specific cognitive screen (97% agree) and assessment of other psychological changes (low mood, anxiety, fatigue: 94%, 90%, 89% agree, respectively). They agreed stroke survivors should be offered at least one review, regardless of their psychological presentation in hospital. They agreed on the importance of various psychoeducation topics, and formal (100% agree) and informal (79% agree) training for those conducting reviews. Consensus was not reached on the review mode (in person/remote options: 67% agree), offering reviews one-year post-discharge to patients without impairments detected in hospital (68% disagree), or including a dementia screen (63% disagree) and/or neuropsychological assessment battery (58% disagree). However, there were similarities in participant viewpoints \u0026ndash; for example, participants highlighted the importance of onwards referral where clinically indicated.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe UK-based post-stroke monitoring and psychoeducation intervention was originally conceptualised as a cognitive care pathway, but expert participants agreed on the importance of also addressing related psychological changes (eg low mood, anxiety). There was clear consensus on a minimum set of intervention features. Recommendations outlined here may usefully inform local service improvements. 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