Impact case study database

Following a stroke, it is common for a patient to experience cognitive deficits and failure to detect these can have a significant impact on post-stroke recovery. Cognitive screening is vital to facilitate rehabilitation, ensure appropriate support and enhance the quality of life of stroke survivors. The psychological consequences of stroke are some of the most disabling and are also the complications most feared by people living with stroke. In clinical practice, guidelines recommend that stroke survivors are assessed for cognitive issues, but until recently, the brief tools used for assessing post stroke cognitive problems were ‘borrowed’ from other conditions such as Alzheimer’s disease.

The OCS was the first tool to provide a short, neuropsychology based cognitive assessment, in line with the NICE guidelines on domain specific screening. The current Chair of the Organisation for Psychological Research in Stroke (OPSYRIS), a consultant stroke physician, substantiated the role of the Oxford Cognitive Screen in improving standards in post-stroke assessment, writing that

“... the stroke specific Oxford Cognitive Screen, which is free to use and has accompanying comprehensive, easy access training materials exactly matches the clinical needs. Indeed, the Oxford Cognitive Screen (OCS) has rapidly gained visibility and traction within the clinical and research fields since its publication only a few years ago.

I am now using OCS in preference to other tools in our clinical stroke setting, and I know that other Principal Investigators and lead clinicians are following suit. In a recent International consensus statement (Stroke Recovery and Rehabilitation Roundtable) we collated the essential and desirable characteristics of a cognitive assessment tool for stroke research. It was not our remit to name a preferred tool but OCS maps to all the criteria we specified”. [A(i)]

The OCS is licensed free of charge for publicly funded clinical use through Oxford University Innovation (OUI), with 1,214 users licenced from 31 March 2014 to 31 Dec 2020 [B]. It has been widely adopted for clinical use in the NHS: 169 out of 217 NHS Trusts in England and Wales had taken a licence by July 2020. Outside the UK, other major clinical licensees include: New South Wales, Australia, where the OCS will be the standard screen adopted throughout the care pathway in all of NSW; Policlinico Gemelli IRCCS (a large hospital in Rome); all large hospitals in Belgium (Gent, Leuven, Antwerp, Hasselt) and the Veterans hospital in the USA covering Medicare/Medicaid patients.

In order to estimate the frequency of use by each licencee, a survey was conducted of OCS licensees and training attendees [C(i)], returning responses from a subset of 164 users. The reported use of OCS ranged from occasional and regular use to OCS being the standard screen on the unit, where everyone is screened with OCS (reported by 21 out of 164 survey responses including Oxford University Hospitals and Oxford Health NHS Foundation Trust, Somerset Partnership NHS Foundation Trust, Gloucestershire Health, and Care NHS Foundation Trust Early Supported Discharge). A subset of respondents reported using OCS for specialist screening particularly with patients who have language deficits (21% of respondents). On average, survey responders reported screening 10 patients per month with OCS (responses ranging from 0 to 150). Extrapolating to all licensees suggests that over 100,000 stroke survivors are being screened with OCS every year.

The high frequency of use and familiarity with OCS ‘on the ground’ is further corroborated by an independent study in which the 21 occupational therapists interviewed named both OCS and MoCA as the main tools being used in post stroke cognitive screening [D].

So far, 13 linguistically validated versions of OCS have been published in peer reviewed publications (including Spanish, Russian, Chinese, Brazilian-Portuguese, Italian, Danish, Dutch). These include new normative data and new validation testing against local standard clinical practice. In each case, the Oxford team work closely with the translating teams, providing advice and guidance, and supporting cultural adaptations (e.g. ensuring no meaning is lost, and in adapting stimuli to be appropriate for the country and culture). All translations are done under licence from Oxford University Innovation. A further 22 translations are under development including in German, Greek, Polish, Korean, Arabic, Urdu, Lithuanian and Norwegian. The eagerness of international clinician researchers to translate this tool, along with labour-intensive normative and psychometric data collection demonstrates the perceived gap in domain-specific screening throughout the world, which is being filled by OCS. These adaptations and translations have had widespread uptake: licences have been taken out across the world, including (number of licences in brackets): Australia (56), Belgium (79), Canada (23), China (11), Denmark (34), Hong Kong (7), Ireland (56), New Zealand (17), South Africa (18) and USA (36) [B].

Between 2016 and 2020, 11 in-person training sessions have taken place at local and regional stroke units on request (approx 20 allied health professionals each), and a ‘train the trainer’ event organised by Oxford University Innovation (March 2019). Example training feedback from a session organised by the College of Occupational Therapists, on Specialist Section Neurological Practice (February 2020), attended by 36 specialist OTs, found that 57% would ‘definitely’ change their practice and 43% were ‘quite likely’ to change their practice having learnt about OCS. Larger externally organised events in which OCS training and dissemination was included include two Stroke Association Masterclasses in 2016 (approx 50 clinicians); and clinical audiences at the regional South-West Conference for Stroke in 2018 and the 2019 Welsh Stroke Conference (approx 200 each). A course is offered by the Somerset Partnership as part of the Stroke-Specific Education Framework [E(i)].

Yearly platforms and invited presentations at the UK Stroke Forum have formed the most direct, national dissemination to clinicians. The UK Stroke Forum is a coalition of over 30 organisations all committed to improving stroke care in the UK, underwritten by the Stroke Association and the British Association of Stroke Physicians. In 2019, the Royal College of Occupational Therapists organised two back-to-back training sessions at the UK Stroke Forum (1,200 attendees). This OCS training was attended by over 200 delegates. The most popular and accessible training consists of a demonstration video on administering the OCS has been widely viewed (over 12,000 views on YouTube) [E(ii)].

Testimonial letters, online conversations and survey responses [A, C] attest that the OCS has had impact on clinical decision making, in particular regarding therapy plans, discharge planning (care packages), and in changing approaches to patient and family communications regarding cognition. In addition, a key attribute of the OCS reported by users is the ability to conduct the screen in patients with aphasia and neglect. This was clear from comments such as “I really like using the OCS with patients who have language deficits, as it gives them the opportunity to score well with a cognitive (standardised) test”, and “Allows different aspects of cognition to be assessed in the presence of visual inattention”. [C(ii)]

The survey by OUI of OCS licencees found that of the 74 respondents to the question, “Has the OCS impacted on clinical decision making? e.g. regarding therapy plans, discharge planning (care packages) or in changing approaches to patient and family communications regarding cognition?”, 64 (90%) answered affirmatively (3 no responses) [C(i)]. Examples of free comments include:

“It has supported and provided evidence in MDT meetings, and to support discharge plans. It has supported education of family members, and patients. It has been an integral part of assessment and treatment planning of the more complex cognitive patients. Particularly around praxis, visual perception and executive function. It has been particularly helpful for patients with language deficits.”

“Yes, the OCS has helped change how we understand cognition on the ward. Whereas before cognition was considered an all or nothing entity based on using a cut off score on a dementia screening test, now the staff feel more confident discussing the individual domains of cognition, and integrating this information into their formulations, discharge plans etc.” [C(i)]

The 2016 Royal Colleges of Physicians Guidelines included OCS alongside MoCA as a first-line screen, only one year after OCS was published [Fi]. Though the Montreal Cognitive Assessment (MoCA) is still a much used cognitive screen in stroke patients, due to historic embeddedness, the research on its usefulness in stroke, sensitivity for detecting impairments and inclusivity (e.g. [3]), as well as newly introduced costs related to training qualifications, has led to a steady rise of clinicians switching to the OCS. New guidelines in countries where OCS has recently been translated are also emerging. For example, the Danish Health Authority has published guidelines in which OCS is recommended [F(ii)]. Chapter 4 of the guidelines, ‘Tracing Cognitive Function’, recommends that: “ *Cognitive function in adults with acquired brain damage is initially assessed with the tool Oxford Cognitive Screen (OCS)...*”.[F(ii), translated]. Other independent studies include a systematic review in 2019 [G] which reported that, “ The Oxford Cognitive Screen (OCS), a multidomain tool, was found to be a better predictor of PSCI/PSD than the MOCA or MMSE.”