Effectiveness of a postdischarge care management model for stroke and transient ischemic attack: A randomized trial

doi:10.1053/jscd.2002.127106

Journal of Stroke and Cerebrovascular Diseases

Volume 11, Issue 2, March–April 2002, Pages 88-98

https://doi.org/10.1053/jscd.2002.127106 Get rights and content

Abstract

Background: This randomized controlled trial tested the effectiveness of comprehensive, interdisciplinary postdischarge care management in improving a profile of indicators of health recovery and secondary prevention (profile of health and prevention) in stroke and transient ischemic attack (TIA) patients. Methods: Ninety-six stroke/TIA patients were randomized to usual care or intervention at discharge from our acute stroke unit. The intervention group received an in-home biopsychosocial assessment by an advanced practice nurse at 1 month. A care plan was developed by an interdisciplinary team and implemented in collaboration with the patient's primary care physician. The profile of health and prevention, measured at 3 months, was comprised of 5 domains: (1) Neuromotor Function, (2) Severe Complications, (3) Quality of Life, (4) Management of Risk for common poststroke complications and recurrent stroke, and (5) Stroke Knowledge. A single global hypothesis test across multiple end points was used to compare the 2 groups. Results: The intervention significantly improved the profile of health and prevention (P <.0001). In addition, each domain showed a positive effect of the intervention. Effect sizes (in standard deviation units) of the intervention on domains were.1 for Neuromotor Function (90% confidence interval [CI] = −.3 to.5);.4 for Severe Complications (90% CI =.1 to.8);.5 for Quality of Life (90% CI =.1 to.9);.6 for Management of Risk for common poststroke complications and recurrent stroke (90% CI =.3 to 1.); and 1.0 for Stroke Knowledge (90% CI =.6 to 1.4). Conclusions: This model of care management resulted in a significantly better profile of health and prevention for stroke/TIA patients 3 months postdischarge. Copyright © 2002 by National Stroke Association

Section snippets

Study design and patients

This study was conducted at Summa Health System (SHS), a 963-bed community teaching hospital affiliated with Northeastern Ohio Universities College of Medicine. It was approved by the SHS Institutional Review Board. Ninety-six patients diagnosed with ischemic stroke or TIA were enrolled in the study approximately 48 hours prior to discharge from the SHS acute stroke unit. All patients on the stroke unit received comprehensive interdisciplinary care and extensive stroke education.¹² Included in

Results

No follow-up data were available for 3 of the 96 patients: 2 moved out of state and 1 became too cognitively impaired to continue in the study and had no available caregiver. Complete data on all outcomes were obtained for 73 of the 93 remaining patients. Of the 20 patients with some missing data, 3 became permanent nursing home residents, 5 died, and 12 refused a follow-up visit. Information on the severe complications domain was complete on all of these 20 patients, and 9 of the 20 patients

Discussion

The delivery of postdischarge stroke care is often fragmented due, in part, to the lack of an established care model and guidelines that ensure comprehensive assessment and follow-up for common problems faced by stroke survivors. Interdisciplinary team management has been established as an effective method for improving health outcomes for patients who have complex medical conditions.36, 37, 38, 39 Likewise, an interdisciplinary team model seems appropriate for posthospitalization stroke/TIA

Acknowledgements

We extend our appreciation to the following without whom completion of this study would not have been possible: The Stroke Unit Interdisciplinary Team, Judy Agner, Lynn Clough, MA, Michele Gareri, RN, Don Jackovitz, Rob Lada, MD, William Smucker, MD, Sally Nash, and the library staff at SHS.

References (40)

K Allen et al.
Utilizing a “prehabilitation” process of care to improve outcomes of patients on a stroke unit
J Stroke Cerebrovasc Dis
(1998)
M Cohen et al.
The tools of disability outcomes research functional status measures
Arch Phys Med Rehabil
(2000)
S. Pocock
Clinical trials with multiple outcomes: A statistical perspective on their design, analysis, and interpretation
Control Clin Trials
(1997)
A Stuck et al.
Comprehensive geriatric assessment: A meta-analysis of controlled trials
Lancet
(1993)
A Forster et al.
Specialist nurse support for patients with stroke in the community: A randomised controlled trial
Br Med J
(1996)
H Andersen et al.
Can readmission after stroke be prevented?
Stroke
(2000)
L Joseph et al.
Risk factor modification in stroke prevention: The experience of a stroke clinic
Stroke
(1999)
G Goldberg et al.
Stroke transition after inpatient rehabilitation
Top Stroke Rehabil
(1997)
M Dennis et al.
Evaluation of a stroke family care worker: Results of a randomised controlled trial
Br Med J
(1997)
A Qureshi et al.
Ineffective secondary prevention in survivors of cardiovascular events in the US population
Arch Intern Med
(2001)

L. Goldstein

Evidence-based medicine and stroke

Neuroepidemiology

(1999)

P Duncan et al.

Outcome measures in acute stroke trials: A systematic review and some recommendations to improve practice

Stroke

(2000)

P. Duncan

Evaluating the outcomes of stroke

Medical Outcomes Trust

(1998)

S Soumerai et al.

Principles of educational outreach (“academic detailing”) to improve clinical decision making

JAMA

(1990)

D Davis et al.

Changing physician performance.. A systematic review of continuing medical education strategies

JAMA

(1995)

R Brown et al.

Use of nursing home after stroke and dependence on stroke severity, A population-based analysis

Stroke

(1999)

E. Pfeiffer

A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients

J Am Geriatr Soc

(1975)

L. Radloff

The CES-D scale: A self-report depression scale for research in the general population

Applied Psychological Measurement

(1977)

L Goldstein et al.

Reliability of the National Institutes of Health Stroke Scale: Extension to non-neurologists in the context of a clinical trial

Stroke

(1997)

F Mahoney et al.

Functional evaluation: The Barthel Index

Maryland State Medical Journal

(1965)

Cited by (69)

The effect of transition care interventions incorporating health coaching strategies for stroke survivors: A systematic review and meta-analysis
2020, Patient Education and Counseling
Citation Excerpt :
Nineteen articles provided information about incomplete outcome data (attrition bias) using a flowchart to adequately report the number of randomly assigned participants, intended treatment, losses and exclusions after randomisation, and reasons for losses in the follow-up intervention period. Five articles used statistical measures, e.g. logistic regression to address incomplete outcome data [19,32,33,38,40]. Eight articles reported that missing outcome data showed similarities across groups [31,34,36,37,39,42,45,47].
To systematically analyse health coaching strategies in transition care and synthesise the effect of these strategies on health care outcomes for stroke survivors.
A systematic search of nine databases in two languages was conducted. Meta-analysis was conducted when data were available.
Twenty-five randomised controlled trials met the inclusion criteria. The meta-analysis revealed that health coaching strategies in transition care interventions significantly improve quality of life (QoL) (p < 0.001), activities of daily living (ADL) (p = 0.002) and reduce depression (p = 0.001) for stroke survivors at 3 months. Further subgroup analysis demonstrated that transition care interventions with a greater number of health coaching strategies are associated with a larger effect size on QoL (SMD=1.15) and ADL (SMD=1.177) at 3 months, and a medium effect size (SMD=0.674) on depression reduction. However, the effects of health coaching strategies on readmission, mortality and falls in stroke survivors remain inconclusive.
This review provides evidence that incorporating health coaching strategies in transitional care improves health outcomes of stroke survivors.
More trials of health coaching interventions to improve transition care with a rigorous study design are much needed to address the lack of support for stroke survivors and their caregivers in this crucial care period.
The Hospital to Home Transition Following Acute Stroke
2019, Nursing Clinics of North America
Citation Excerpt :
Three studies examined length of stay and found shorter, but not statistically significantly different, length of stay was associated with the intervention.17,18,20 The 9 new studies12–20 included in this report have remarkable similarities and deficiencies with the previous 41 stroke articles22–63 from the 2011 AHRQ report.21 Regarding TOC from hospital to home after acute stroke, there is still only limited evidence available to support any specific intervention, outcome, or time point at which to measure outcomes.
From Hospital to Home to Participation: A Position Paper on Transition Planning Poststroke
2019, Archives of Physical Medicine and Rehabilitation
Based on a review of the evidence, members of the American Congress of Rehabilitation Medicine Stroke Group’s Movement Interventions Task Force offer these 5 recommendations to help improve transitions of care for patients and their caregivers: (1) improving communication processes; (2) using transition specialists; (3) implementing a patient-centered discharge checklist; (4) using standardized outcome measures; and (5) establishing partnerships with community wellness programs.
Because of changes in health care policy, there are incentives to improve transitions during stroke rehabilitation. Although transition management programs often include multidisciplinary teams, medication management, caregiver education, and follow-up care management, there is a lack of a comprehensive and standardized approach to implement transition management protocols during poststroke rehabilitation. This article uses the Transitions of Care (TOC) model to conceptualize how to facilitate a comprehensive patient-centered hand off at discharge to maximize patient functioning and health. Specifically, this article reviews current guidelines and provides an evidence summary of several commonly cited approaches (Early Supported Discharge, planned predischarge home visits, discharge checklists) to manage TOC, followed by a description of documented barriers to effective transitions. Patient-centered and standardized transition management may improve community integration, activities of daily living performance, and quality of life for stroke survivors while also decreasing hospital readmission rates during the transition from hospital to home to community.
Effectiveness of self-management interventions during the peri-hospitalization period in patients with stroke: A systematic review and meta-analysis
2024, Clinical Rehabilitation
What follow-up interventions, programmes and pathways exist for minor stroke survivors after discharge from the acute setting? A scoping review
2023, BMJ Open
Effectiveness of a Health Education Program for Patients Who Had a Stroke and Their Caregivers by Controlling Modifiable Risk Factors to Reduce Stroke Recurrence in a Tertiary Hospital in Bangladesh: Protocol for a Randomized Controlled Trial
2023, JMIR Research Protocols

View all citing articles on Scopus

^*: Supported by the Summa Health System Research Foundation.

^**: Address reprint requests to Kyle R. Allen, DO, 75 Arch St, Suite 301, Akron, OH 44304. E-mail: [email protected].

View full text

Original ArticlesEffectiveness of a postdischarge care management model for stroke and transient ischemic attack: A randomized trial*,**

Abstract

Section snippets

Study design and patients

Results

Discussion

Acknowledgements

J Stroke Cerebrovasc Dis

Arch Phys Med Rehabil

Control Clin Trials

Lancet

Specialist nurse support for patients with stroke in the community: A randomised controlled trial

Br Med J

Can readmission after stroke be prevented?

Stroke

Risk factor modification in stroke prevention: The experience of a stroke clinic

Stroke

Stroke transition after inpatient rehabilitation

Top Stroke Rehabil

Evaluation of a stroke family care worker: Results of a randomised controlled trial

Br Med J

Ineffective secondary prevention in survivors of cardiovascular events in the US population

Arch Intern Med

Evidence-based medicine and stroke

Neuroepidemiology

Outcome measures in acute stroke trials: A systematic review and some recommendations to improve practice

Stroke

Evaluating the outcomes of stroke

Medical Outcomes Trust

Principles of educational outreach (“academic detailing”) to improve clinical decision making

JAMA

Changing physician performance.. A systematic review of continuing medical education strategies

JAMA

Use of nursing home after stroke and dependence on stroke severity, A population-based analysis

Stroke

A short portable mental status questionnaire for the assessment of organic brain deficit in elderly patients

J Am Geriatr Soc

The CES-D scale: A self-report depression scale for research in the general population

Applied Psychological Measurement

Reliability of the National Institutes of Health Stroke Scale: Extension to non-neurologists in the context of a clinical trial

Stroke

Functional evaluation: The Barthel Index

Maryland State Medical Journal

Original Articles
Effectiveness of a postdischarge care management model for stroke and transient ischemic attack: A randomized trial*,**