Longer term patient management following stroke: A systematic review

Healthcare provider perceptions of support provision for people with stroke: a qualitative study

PURPOSE

This study aimed to explore healthcare providers' perceptions of support provision for people who have experienced stroke.

MATERIALS AND METHODS

A qualitative descriptive study was conducted. Snowball sampling was used to recruit Australian healthcare workers providing care to people with stroke. Semi-structured one-on-one interviews were audiotaped and transcribed. An inductive thematic analysis of all transcripts was undertaken by two authors.

RESULTS

Fourteen participants who worked across the care continuum in three Australian states were interviewed. Responses fit into three overarching themes: (1) attitudes to supports; (2) availability and accessibility of supports; and (3) awareness of supports. These themes encompassed perceptions of the support options available for people with stroke and the factors affecting support provision decision making among healthcare providers.

CONCLUSIONS

The healthcare providers in this study thought people with stroke would benefit from a greater range of available supports. Supports should take into account the diverse experiences and acute and long-term needs of people with stroke, as well as be accessible to people from all cultural, linguistic, and socioeconomic backgrounds. Healthcare providers and people who have experienced stroke may benefit from a roadmap for post-stroke support that clearly outlines where responsibility lies for support provision.

Evaluation of Cost-Effectiveness of a Virtual Multidisciplinary Stroke Care Clinic for Community-Dwelling Survivors of Stroke

BACKGROUND

A technologically integrated, multidisciplinary approach to stroke rehabilitation service was delivered and embedded into conventional health care practice. This article reports an evaluation of cost-effectiveness analysis of a new Virtual Multidisciplinary Stroke Care Clinic (VMSCC) service for community-dwelling survivors of stroke.

METHODS AND RESULTS

A randomized controlled trial was conducted. Adults with a first/recurrent ischemic/hemorrhagic stroke were recruited from 10 hospitals. Eligible participants were randomly assigned to receive the VMSCC service (individual virtual consultations with a registered nurse, home blood pressure telemonitoring, and unlimited access to an online resource platform) plus usual care or usual care alone. Cost-effectiveness analyses were performed based on incremental cost-effectiveness ratios expressed as incremental cost per emergency admission reduced, and day of hospitalization reduced over the study period. A total of 256 participants (intervention group n=141 versus control group n=115) with complete cost and health care use data were included in the cost-effectiveness analyses. The VMSCC service, on average, resulted in a greater reduction in the number of emergency admission (-0.06 [95% bootstrapped CI, -0.14 to 0.01]) and fewer days of hospitalization (-0.08, [95% bootstrapped CI -0.40 to 0.24]) but incurred a higher total cost of HK$375 (95% bootstrapped CI, -2103 to 2743) compared with the usual care. The incremental cost-effectiveness ratios of the VMSCC service compared with the usual care were HK$6070 and HK$4826 per an emergency admission and a day of hospital stay reduced respectively.

CONCLUSIONS

The study provides preliminary but not confirmative evidence that the VMSCC service could be more effective but more costly than usual care in reducing health service use.

REGISTRATION

URL: https://www.chictr.org.cn. Unique identifier: ChiCTR1800016101.

Challenges and needs in cerebrovascular disease pathway: A qualitative descriptive study from the patients' and healthcare professionals' perspectives

AIM(S)

To understand patients' and healthcare professionals' experiences to improve care in and across different domains of the cerebrovascular disease pathway.

DESIGN

A qualitative descriptive study.

METHODS

Semi-structured in-person interviews were conducted among 22 patients diagnosed with acute cerebrovascular disease and 26 healthcare professionals taking care of them in a single tertiary-level hospital from August 2021 to March 2022. Data were analysed using deductive and inductive content analysis. The consolidated criteria for reporting qualitative research was used to ensure reliable reporting.

RESULTS

Overall, 19 generic and 79 sub-categories describing perceived challenges with 17 generic and 62 sub-categories describing perceived needs were identified related to primary prevention, organization of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment, and life after stroke.

CONCLUSION

Several challenges and needs were identified in and across the different domains of the cerebrovascular disease pathway. There is a requirement for adequate resources, early initiation of treatment, early diagnostics and recanalization, dedicated rehabilitation services, long-term counselling and support, and impact evaluation of services to improve cerebrovascular disease care. Future research on caregivers', and clinical leadership experiences in and across the cerebrovascular disease pathway is needed to explore the provision of services.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

The results of this study can be applied by organizations, managers and research for developing and improving services in the cerebrovascular disease pathway.

IMPACT

This study identified several patient-related, organizational and logistical needs and challenges, with suggestions for required actions, that can benefit the provision of effective, high-quality cerebrovascular disease care.

REPORTING METHOD

We have adhered to relevant EQUATOR guidelines with the COREQ reporting method.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public involvement.

Caregiver burden after stroke: a 10-year follow-up study of Polish caregivers for stroke patients

BACKGROUND

A long-term assessment of stroke outcomes from the perspectives of patients and their caregivers is important for optimising long-term post-stroke care. The extended effects of stroke caregiving, particularly caregiver burden beyond 5 years since stroke, remain to be determined. Hence, this study aimed to determine caregiver burden at 10 years after stroke, compare the burden severity at 10 years with its levels at 5 years and 6 months after stroke, and identify predictors of the burden severity at 10 years post-stroke.

METHODS

A longitudinal follow-up study including a group of first-ever stroke patients/informal continuous caregivers pairs was followed for 10 years and interviewed face-to face at their home setting. Caregiver burden was evaluated with the Caregiver Burden Scale. Potential predictors were examined using standardised measures and identified by applying the Classification and Regression Tree.

RESULTS

A total of 40 caregiver/patient pairs participated in the study. At 10 years, 47.5% of the caregivers experienced a considerable burden. This was more than after 5 years (17.5%) and comparable to that after 6 months (37.5%), p < 0.003. Longer time spent caregiving, caregivers' weaker sense of coherence, more severe stroke, and caregivers' anxiety were the independent predictors of considerable burden 10 years after stroke.

CONCLUSIONS

Caregivers' burden in the late chronic post-stroke phase is a significant problem, as nearly half of the caregivers experience a substantial burden. This problem mainly concerns individuals who spend at least 7 h daily caregiving and have a lower Sense of Coherence. The long-term evaluation of stroke consequences reported by stroke patients and their caregivers can be an important source of information for healthcare professionals in order to optimise the care and support they provide at various stages of life after stroke.

The Perspectives of Individuals with Chronic Stroke on Motor Recovery: A Qualitative Analysis

The priorities of individuals with chronic stroke are not always reflected in clinical practice. This study provides insight into meaningful factors related to long-term motor recovery in stroke survivors. Thirty individuals with chronic stroke participated in semi-structured interviews about movement, recovery, and barriers to and facilitators of mobility and paretic arm use. The interviews were analyzed using inductive thematic analysis. Three categories, the individual, environment, and task, defined five emergent themes. Individual: (1) mindset is a strong and consistent influencer of daily physical activity and overall recovery; (2) severe physical impairment limits physical activity and recovery, regardless of other factors; and (3) a negative perception of disability impacts mindset and willingness to move in public. Environment: (4) social and physical environments influence physical activity and recovery. Task: (5) participation in meaningful activities increases physical activity and promotes long-term recovery. Strategies to incorporate paretic arm use, exercise, and encouragement from others facilitate physical activity. Insufficient paretic limb function, environmental obstacles, and fear are barriers to physical activity. Neurorehabilitation must address the factors that are meaningful to stroke survivors. Building motor capacity is essential and must be integrated with factors such as a positive mindset and proper environment. Individual differences reinforce the need for personalized care.

Cost-Effectiveness of an Individualised Management Program after Stroke: A Trial-Based Economic Evaluation

INTRODUCTION

Evidence on the cost-effectiveness of comprehensive post-stroke programs is limited. We assessed the cost-effectiveness of an individualised management program (IMP) for stroke or transient ischaemic attack (TIA).

METHODS

A cost-utility analysis alongside a randomised controlled trial with a 24-month follow-up, from both societal and health system perspectives, was conducted. Adults with stroke/TIA discharged from hospitals were randomised by primary care practice to receive either usual care (UC) or an IMP in addition to UC (intervention). An IMP included stroke-specific nurse-led education and a specialist review of care plans at baseline, 3 months, and 12 months, and telephone reviews by nurses at 6 months and 18 months. Costs were expressed in 2021 Australian dollars (AUD). Costs and quality-adjusted life years (QALYs) beyond 12 months were discounted by 5%. The probability of cost-effectiveness of the intervention was determined by quantifying 10,000 bootstrapped iterations of incremental costs and QALYs below the threshold of AUD 50,000/QALY.

RESULTS

Among the 502 participants (65% male, median age 69 years), 251 (50%) were in the intervention group. From a health system perspective, the incremental cost per QALY gained was AUD 53,175 in the intervention compared to the UC group, and the intervention was cost-effective in 46.7% of iterations. From a societal perspective, the intervention was dominant in 52.7% of iterations, with mean per-person costs of AUD 49,045 and 1.352 QALYs compared to mean per-person costs of AUD 51,394 and 1.324 QALYs in the UC group. The probability of the cost-effectiveness of the intervention, from a societal perspective, was 60.5%.

CONCLUSIONS

Care for people with stroke/TIA using an IMP was cost-effective from a societal perspective over 24 months. Economic evaluations of prevention programs need sufficient time horizons and consideration of costs beyond direct healthcare utilisation to demonstrate their value to society.

Cost-Effectiveness of a Government Policy to Incentivise Chronic Disease Management following Stroke: A Modelling Study

INTRODUCTION

Little is known about the cost-effectiveness of government policies that support primary care physicians to provide comprehensive chronic disease management (CDM). This paper aimed to estimate the potential cost-effectiveness of CDM policies over a lifetime for long-time survivors of stroke.

METHODS

A Markov model, using three health states (stable, hospitalised, dead), was developed to simulate the costs and benefits of CDM policies over 30 years (with 1-year cycles). Transition probabilities and costs from a health system perspective were obtained from the linkage of data between the Australian Stroke Clinical Registry (cohort n = 12,368, 42% female, median age 70 years, 45% had CDM claims) and government-held hospital, Medicare, and pharmaceutical claims datasets. Quality-adjusted life years (QALYs) were obtained from a comparable cohort (n = 512, 34% female, median age 69.6 years, 52% had CDM claims) linked with Medicare claims and death data. A 3% discount rate was applied to costs in Australian dollars (AUD, 2016) and QALYs beyond 12 months. Probabilistic sensitivity analyses were used to understand uncertainty.

RESULTS

Per-person average total lifetime costs were AUD 142,939 and 8.97 QALYs for those with a claim, and AUD 103,889 and 8.98 QALYs for those without a claim. This indicates that these CDM policies were costlier without improving QALYs. The probability of cost-effectiveness of CDM policies was 26.1%, at a willingness-to-pay threshold of AUD 50,000/QALY.

CONCLUSION

CDM policies, designed to encourage comprehensive care, are unlikely to be cost-effective for stroke compared to care without CDM. Further research to understand how to deliver such care cost-effectively is needed.

Feasibility of an Application-Based Outpatient Rehabilitation Program for Stroke Survivors: Acceptability and Preliminary Results for Patient-Reported Outcomes

BACKGROUND

The majority of stroke survivors experience long-term impairments. Regular physical activity and other lifestyle modifications play an important role in rehabilitation. Outpatient rehabilitation using telemedicine might be suitable to improve functional ability and long-term secondary prevention. The Strokecoach Intervention Program (SIP, Strokecoach GmbH, Cologne, Germany) comprises training, coaching and monitoring with the aim of improving or at least maintaining functional independence and preventing further stroke through more targeted physical activity. The SIP is provided as blended care, which refers to the integrated and coordinated delivery of healthcare services that combines traditional in-person interactions with technology-mediated interventions, optimizing the use of both face-to-face and virtual modalities to enhance patient outcomes.

OBJECTIVE

The aim of this study was to evaluate the acceptance of the SIP by the participants and its practical application, as well as to obtain initial indications of effects of the SIP on the basis of patient-related outcome measures, blood pressure measurements and recording of physical activity in parallel with the intervention.

METHODS

Data from individuals with stroke participating in the SIP were analyzed retrospectively. Within the SIP, participants received an application-based training program, were instructed to measure their blood pressure daily and to wear an activity tracker (pedometer). During the intervention period of either 6 or 12 weeks, the participants were supported and motivated by a personal coach via a messenger application. The primary outcomes of the analysis were recruitment, acceptance of and satisfaction with the SIP. Secondary outcomes included functional measures, mobility and health-related quality of life.

RESULTS

A total of 122 individuals with stroke could be recruited for the SIP. A total of 96 out of 122 were able to start the program (54% female, mean age 54.8 (SD = 13.1), 6.1 (SD = 6.6) years after stroke onset) and 88 completed the SIP. Participants wore the activity tracker on 66% and tracked their blood pressure on 72% of their intervention days. A further analyzed subgroup of 38 participants showed small improvements in patient-reported outcomes such as health-related quality of life (SF-36) with an increase of 12 points in the subdomain mental health, vitality (12.6) and physical functioning (9.1). However, no statistically significant improvements were found in other performance-based measures (Timed Up and Go test, gait speed).

CONCLUSIONS

This study showed that a blended therapy approach for stroke survivors with mild to moderate impairments in the chronic phase is feasible and was highly accepted by participants, who benefitted from the additional coaching.

User profile of people contacting a stroke helpline (StrokeLine) in Australia: a retrospective cohort study

BACKGROUND

StrokeLine is a specialised telephone helpline led by health professionals in Australia.

AIMS

(i) To describe the profile of StrokeLine callers; (ii) to understand the reasons people engage with the service and (iii) how StrokeLine responded to the caller's needs.

METHODS

Routine call data were obtained from the StrokeLine between November 2019 and November 2020. Data were extracted and descriptive analyses performed. De-identified free-text data were obtained separately for November 2019 and June 2020 and analysed using qualitative content analysis.

RESULTS

Of the 1429 calls most were from carers, family and friends (38%) or the stroke survivor themselves (34%). Most calls were made by women (64%) and the average age of the stroke survivor was ≥65 years (33%) with the time since the stroke occurred <1 year. The main reason for calling was to manage stroke-related impairments (40%). Providing information, support and advice was the most common action provided by StrokeLine staff (25%). Content analysis of 225 calls revealed most stroke survivors called for emotional support, while carers sought more practical guidance. StrokeLine provided information for referral to relevant services and guidance on what to do next.

CONCLUSIONS

Most calls were received from family and carers, as well as stroke survivors. They contacted StrokeLine for information and advice, practical solutions, emotional support, and referral advice to other services.

Person-Centered Models for Cardiovascular Care: A Review of the Evidence: A Scientific Statement From the American Heart Association

Cardiovascular disease remains the leading cause of death and disability in the United States and globally. Disease burden continues to escalate despite technological advances associated with improved life expectancy and quality of life. As a result, longer life is associated with multiple chronic cardiovascular conditions. Clinical guidelines provide recommendations without considering prevalent scenarios of multimorbidity and health system complexities that affect practical adoption. The diversity of personal preferences, cultures, and lifestyles that make up one's social and environmental context is often overlooked in ongoing care planning for symptom management and health behavior support, hindering adoption and compromising patient outcomes, particularly in groups at high risk. The purpose of this scientific statement was to describe the characteristics and reported outcomes in existing person-centered care delivery models for selected cardiovascular conditions. We conducted a scoping review using Ovid MEDLINE, Embase.com, Web of Science, CINAHL Complete, Cochrane Central Register of Controlled Trials through Ovid, and ClinicalTrials.gov from 2010 to 2022. A range of study designs with a defined aim to systematically evaluate care delivery models for selected cardiovascular conditions were included. Models were selected on the basis of their stated use of evidence-based guidelines, clinical decision support tools, systematic evaluation processes, and inclusion of the patient's perspective in defining the plan of care. Findings reflected variation in methodological approach, outcome measures, and care processes used across models. Evidence to support optimal care delivery models remains limited by inconsistencies in approach, variation in reimbursement, and inability of health systems to meet the needs of patients with chronic, complex cardiovascular conditions.

An optimal model of long-term post-stroke care

Stroke is a major healthcare challenge that is increasing worldwide. The burden of stroke is significant for the affected individuals as well as for the general population; high-quality care is needed to reduce its negative impacts. This article synthesized information from systematic reviews, guidelines, and primary literature on stroke care and post-stroke rehabilitation and proposes an optimal strategy for long-term post-stroke care. It also highlights the unmet needs of patients who experienced a stroke in terms of early diagnosis of complications and adequate, comprehensive therapy.

Updates in mechanical thrombectomy

Stroke is a leading cause of morbidity and mortality. The advent of mechanical thrombectomy has largely improved patient outcomes. This article reviews the features and outcomes associated with aspiration, stent retrievers, and combination catheters used in current practice. There is also a discussion on clinical considerations based on anatomical features and clot composition. The reperfusion grading scale and outcome metrics commonly used following thrombectomy when a patient is still in the hospital are reviewed. Lastly, there are proposed discharge and outpatient follow-up goals in caring for patients hospitalized for a stroke.

Reconstruction of pseudonymized patient-trajectories in Austria's stroke cohort using medical record-linkage of in-patient routine documentation to establish a nation-wide acute stroke cohort of 102,107 pseudonymized patients between 2015 and 2019

Introduction

Administrative health data are increasingly used for disease surveillance, quality assurance and research purposes. In Austria, reporting of a standardized dataset is mandatory for each patient.

Patients and methods

Routine documentation includes administrative and medical data, including admission and discharge characteristics, disease-diagnosis using ICD-10, medical procedure codes, and coding of involved hospital departments. Since 2015, a three-step pseudonymization on these data is provided including a pseudonym using secure hash algorithm 256, a non-recalculable record-ID, and age-groups of 5 years, allowing the reconstruction of individual patient-trajectories. We included persons aged ⩾20 years with an in-patient treatment in Austrian hospitals for acute stroke or transient ischemic attack (TIA) between 01.01.2015 and 31.12.2019 using medical record-linkage.

Results

This totals 102,107 patients (49.3% women) with 107,055 treatment episodes. An ischemic stroke (IS) occurred in 60.9% (n = 65,133), 27.1% (n = 29,019) had a TIA, 3.3% (n = 3488) a subarachnoid hemorrhage, and 8.8% (n = 9415) an intracerebral hemorrhage (ICH). The study period covers 35.2 million person-years at risk, with a hospitalization rate for acute stroke of 221.8 per 100,000 person-years (95% CI 220.2-223.3), and 185.1 per 100,000 person-years (95% CI 183.7-186.5) for IS. Unscheduled re-admissions within 1 year occurred in 29.2% (95% CI 28.8-29.7) after IS, and 41.7% (95% CI 40.0-43.3) after ICH. Recurrent stroke occurred in 5.3% (95% CI 5.1-5.5) after IS, and 5.6% (95% CI 4.9-6.4) after ICH.

Discussion

We present herein the details of a novel methodology to establish a nation-wide unselected Austrian stroke cohort, and to reconstruct pseudonymized individual longitudinal patient-trajectories on a national level. This approach shows potential applications in epidemiological research, quality assessment and outcome measurement.

Conclusion

This novel approach opens new research fields, facilitates international comparison, and is needed for national benchmarking to assess the achievement of goals according to the Stroke Action Plan for Europe and augment the quality of Austria's integrated stroke care.

Community living after in-hospital specialized rehabilitation in patients with severe disability after stroke: a long-term follow-up after a randomized controlled trial

PURPOSE

Physical functioning after discharge from specialized rehabilitation is a concern. The purpose of this study was to investigate functioning and health after a long period of community living in participants with severe disability after stroke.

MATERIALS AND METHODS

An observational, longitudinal follow-up design was used to investigate 60 participants from a randomized controlled trial. Assessment tools: Short Form 36 health-survey, Functional Ambulation Categories, EU Walking, 10 Meter Walk Test, and questions concerning health and walking ability.

RESULTS

Forty-seven participants (78%) responded, mean age 51.2 years. Non-respondents demonstrated poorer function at hospital discharge. At follow-up, median 11.9 months after discharge, all but three respondents lived in their own home, and 85% received physiotherapy. Twenty-nine (64%) perceived their health as good to excellent, while four (9%) reported poor health. Activities requiring substantial strength and endurance were typically restricted. Most participants (83%) were independent walkers, and fewer (a 27% reduction) used a wheelchair. Among independent walkers, mean walking speed improved by 0.14 m/s. Time elapsed since hospital discharge was not found to correlate with change in walking speed.

CONCLUSIONS

This study demonstrates maintenance or progress in important aspects of functioning and health in most participants at long-term follow-up, but not in all.Implications for rehabilitationPatients with severe disability after stroke may maintain or improve their physical functioning and health after a long period of community living, when they receive continuous individualized rehabilitation including physiotherapy.Patients who maintain or improve walking ability and walking speed after living for a long time in the community, may still need assistance with daily activities, especially if they require substantial muscle strength and endurance.Expectations to long-term functional outcomes after institutional followed by community rehabilitation for patients after stroke, should be considered in light of functional status at hospital discharge.

[Tyrolean stroke pathway]

Hintergrund

In der Behandlung des Schlaganfalls gibt es Fortschritte auf vielen Ebenen. Dies führt zu besseren Heilungschancen und einer Minderung körperlicher Beeinträchtigung. Akuttherapiemaßnahmen sind auf ein kurzes Zeitfenster nach Auftreten limitiert, deshalb ist das Notfallmanagement besonders kritisch. Das Projekt Schlaganfallpfad Tirol wurde realisiert, um die Versorgungskette beim Krankheitsbild Schlaganfall von der prähospitalen Phase bis zum Abschluss der Rehabilitation zu optimieren.

Ziel der Arbeit

Beschreibung des Tiroler Schlaganfallpfads als Beispiel für die Optimierung der Schlaganfallversorgung in einer mitteleuropäischen alpinen Region mit Schwerpunkt auf die prähospitale Versorgung.

Material und Methoden

In vier Teilprojekten von der Prähospitalphase bis zur Nachbehandlung wurden Versorgungsprozesse und Schnittstellen optimiert und mit Qualitätssicherungsmaßnahmen evaluiert.

Ergebnisse

Nach Implementierung hat sich die Thrombolyserate fast verdoppelt und die Rate an gutem funktionellem Outcome nach 3 Monaten verbessert. Komplikationen wie eine Aspirationspneumonie haben deutlich abgenommen. Der Zugang zu rehabilitativen Maßnahmen hat sich verbessert, insbesondere auch wegen des Aufbaus einer qualitätskontrollierten und finanzierten ambulanten Rehabilitation.

Schlussfolgerung

Ein ganzheitliches Versorgungsprojekt kann gut in die Praxis umgesetzt werden und verbessert die Versorgungsqualität beim ischämischen Schlaganfall. Der europäische Aktionsplan Schlaganfall 2018–2030 empfiehlt die Etablierung umfassender Schlaganfallpfade in allen Regionen und Ländern Europas.

OUP accepted manuscript

The management of patients with stroke is often multidisciplinary, involving various specialties and healthcare professionals. Given the common shared risk factors for stroke and cardiovascular disease, input may also be required from the cardiovascular teams, as well as patient caregivers and next-of-kin. Ultimately, the patient is central to all this, requiring a coordinated and uniform approach to the priorities of post-stroke management, which can be consistently implemented by different multidisciplinary healthcare professionals, as part of the patient ‘journey’ or ‘patient pathway,’ supported by appropriate education and tele-medicine approaches. All these aspects would ultimately aid delivery of care and improve patient (and caregiver) engagement and empowerment. Given the need to address the multidisciplinary approach to holistic or integrated care of patients with heart disease and stroke, the European Society of Cardiology Council on Stroke convened a Task Force, with the remit to propose a consensus on Integrated care management for optimizing the management of stroke and associated heart disease. The present position paper summarizes the available evidence and proposes consensus statements that may help to define evidence gaps and simple practical approaches to assist in everyday clinical practice. A post-stroke ABC pathway is proposed, as a more holistic approach to integrated stroke care, would include three pillars of management:

A: Appropriate Antithrombotic therapy.

B: Better functional and psychological status.

C: Cardiovascular risk factors and Comorbidity optimization (including lifestyle changes).