Methods of Implementation of Evidence-Based Stroke Care in Europe: European Implementation Score Collaboration

From healthcare system to individuals through stroke rehabilitation pathways.Outcomes, information, and satisfaction along 12 months prospective cohort in Portugal

BACKGROUND

The nature and quality of stroke survivor rehabilitation varies throughout Europe, including in Portugal, having not been widely monitored or benchmarked.

OBJECTIVES

This study analyses the stroke care pathway from three perspectives: healthcare system, process, and patient.

METHODS

The study uses data from a one-year single-center prospective cohort of first stroke patients, assessed at baseline, 3, 6, and 12 months. Care pathways and settings were described in terms of organizational model, funding, patient involvement, frequency and intensity and multidisciplinary team. Patient-level information and satisfaction were evaluated using a 10-point numeric rating scale. Kruskal - Wallis and post-hoc tests were used to compare EQ-5D-3 L, National Institute of Health Stroke Scale (NIHSS), Modified Rankin Scale (mRS), Barthel Index, Mini-Mental State Examination scores between pathways and settings.

RESULTS

A total of 391 acute stroke patients, with a mean disability of 3.7 (mRS) and severity of 11.7 (NIHSS) participated. Six pathways and eight settings were described. A lack of compliance between guidelines and care was identified. There were significant differences in the four outcomes between the six pathways (p-values 0.007 to 0.020) suggesting inefficiency and inequalities, with an inadequate level of information and patient satisfaction. After post-hoc analysis, pathways 1 and 2 showed highest outcomes (p-values 0.001 to 0.002). Within settings, short-term units showed high scores, followed by rehabilitation center, outpatient hospital, and community clinic (p-values 0.001 to 0.040).

CONCLUSION

A multilevel characterization of the post-stroke rehabilitation pathway showed a more complete perspective on stroke management which may contribute to future rehabilitation and stroke policies.

Effect of an educational intervention to increase stroke awareness among Italian high school students: A prospective study in Tuscany

INTRODUCTION

Stroke in young people shares traditional modifiable risk factors with older groups, and greatly affects quality of life. However, evidence on the effectiveness of educational interventions in young populations, aiming at spreading stroke knowledge and enhancing prevention, is still scarce. We evaluated baseline knowledge of stroke and possible improvements after an educational intervention among Italian high school students, also considering differences related to sex and type of school.

SUBJECTS AND METHODS

Using a mixed educational strategy, a prospective evaluation of stroke knowledge was performed in five humanities and sciences (lyceums) and five vocational high schools of Tuscany (students of the 12th and 13th grade). A baseline assessment with a structured questionnaire (21 questions) was followed by a standardized oral presentation, using audiovisual materials. After 3 months, the same questionnaire was re-administered to evaluate the long-term impact of the educational intervention.

RESULTS

Overall, 573 students (50.8% males; age range, 17-19 years) were enrolled; 288 (50.3%) were from lyceums and 285 (49.7%) from vocational schools. Follow-up participation was 97.2%. Baseline performances were comparable between groups for most variables examined. At 3 months, all groups showed a significant improvement from baseline regarding reaction to a stroke event, identification of stroke risk factors, such as smoking (from 62.9% to 83.7%; p < 0.001) and alcohol abuse (from 49.6% to 67.2%; p < 0.001), and symptoms. Knowledge of the existence of stroke units and thrombolysis increased from 25.4% to 60.7% (p < 0.001) and from 35.8% to 84.0% (p < 0.001), respectively.

CONCLUSIONS

Our educational intervention improved stroke awareness in high school students. The effects persisted after 3 months. Improved knowledge in young populations may reduce stroke burden in adult life, increase timely access to therapies, and spread knowledge across families.

Cardiorespiratory optimal point as a submaximal evaluation tool in endurance athletes: An exploratory study

Introduction: The cardiorespiratory optimal point (COP) represents the lowest minute ventilation to oxygen consumption ratio (VE/VO2) and can be estimated during a CPET at submaximal intensity when an exercise test until volitional fatigue is not always advisable (i.e., a conflict zone where you cannot be confident of the security because near-competition, off-season, among other). COP's physiological components have not been wholly described yet. Therefore, this study seeks to identify the determinants of COP in highly trained athletes and its influence on maximum and sub-maximum variables during CPET through principal c omponent analysis (PCA) (explains the dataset's variance). Methods: Female (n = 9; age, 17.4 ± 3.1 y; maximal VO2 [VO2max]), 46.2 ± 5.9 mL/kg/min) and male (n = 24; age, 19.7 ± 4.0 y; VO2max, 56.1 ± 7.6 mL/kg/min) athletes performed a CPET to determine the COP, ventilatory threshold 1 (VT1) and 2 (VT2), and VO2max. The PCA was used to determine the relationship between variables and COP, explaining their variance. Results: Our data revealed that females and males displayed different COP values. Indeed, males showed a significant diminished COP compared to the female group (22.6 ± 2.9 vs. 27.2 ±3.4 VE/VO2, respectively); nevertheless, COP was allocated before VT1 in both groups. Discussion: PC analysis revealed that the COP variance was mainly explained (75.6%) by PC1 (expired CO₂ at VO2max) and PC2 (VE at VT2), possibly influencing cardiorespiratory efficiency at VO2max and VT2. Our data suggest that COP could be used as a submaximal index to monitor and assess cardiorespiratory system efficiency in endurance athletes. The COP could be particularly useful during the offseason and competitive periods and the return to the sports continuum.

Effect of Health Education on Level of Awareness and Knowledge of Nigerian In-School adolescents on Stroke and Its Risk Factors

BACKGROUND

Stroke education in adolescents has been established as an effective method of creating awareness about stroke, its warning signs and risk factors. It contributes to desired behavioural change in the adolescents as well as their parents. Thus, we aimed to determine the baseline knowledge of school attending adolescents about stroke and its risk factors as well as the effect of stroke education on their stroke awareness.

METHODS

This study employed a quasi-experimental study design and was conducted in secondary schools in Ile-Ife, Osun State, Nigeria. The schools were divided into intervention and control groups. We assessed the baseline knowledge of the students on stroke, its risk factors, warning signs, and ways of preventing it using a pre-tested structured questionnaire in both intervention and control groups. In the intervention group, health talks on stroke consisting of oral presentation and distribution of fliers were presented for 30 minutes in each selected school. Each school was visited 2 weeks after the health education intervention to assess their knowledge on stroke, its risk factors, and ways of preventing it. The control group was also visited after 2 weeks for a re-assessment of their stroke knowledge and the conduct of heath talk on other aspects of neurology such as sleep, epilepsy, etc. Results: A total of 1259 adolescents were studied with 661 in the intervention group and 598 in the control group. The mean age of the respondents was 13.56 ± 2.87 the intervention group and 13.38 ± 2.06 in the control group. There were higher mean scores on knowledge of stroke and its risk factors among the intervention group than seen in the control group after the stroke education.

CONCLUSIONS

Stroke education is an effective way of creating and maintaining stroke awareness among school-attending adolescents.

Implementation of a billable transitional care model for stroke patients: the COMPASS study

Background

The COMprehensive Post-Acute Stroke Services (COMPASS) pragmatic trial compared the effectiveness of comprehensive transitional care (COMPASS-TC) versus usual care among stroke and transient ischemic attack (TIA) patients discharged home from North Carolina hospitals. We evaluated implementation of COMPASS-TC in 20 hospitals randomized to the intervention using the RE-AIM framework.

Methods

We evaluated hospital-level Adoption of COMPASS-TC; patient Reach (meeting transitional care management requirements of timely telephone and face-to-face follow-up); Implementation using hospital quality measures (concurrent enrollment, two-day telephone follow-up, 14-day clinic visit scheduling); and hospital-level sustainability (Maintenance). Effectiveness compared 90-day physical function (Stroke Impact Scale-16), between patients receiving COMPASS-TC versus not. Associations between hospital and patient characteristics with Implementation and Reach measures were estimated with mixed logistic regression models.

Results

Adoption: Of 95 eligible hospitals, 41 (43%) participated in the trial. Of the 20 hospitals randomized to the intervention, 19 (95%) initiated COMPASS-TC.

Reach: A total of 24% (656/2751) of patients enrolled received a billable TC intervention, ranging from 6 to 66% across hospitals.

Implementation: Of eligible patients enrolled, 75.9% received two-day calls (or two attempts) and 77.5% were scheduled/offered clinic visits. Most completed visits (78% of 975) occurred within 14 days.

Effectiveness: Physical function was better among patients who attended a 14-day visit versus those who did not (adjusted mean difference: 3.84, 95% CI 1.42–6.27, p = 0.002).

Maintenance: Of the 19 adopting hospitals, 14 (74%) sustained COMPASS-TC.

Conclusions

COMPASS-TC implementation varied widely. The greatest challenge was reaching patients because of system difficulties maintaining consistent delivery of follow-up visits and patient preferences to pursue alternate post-acute care. Receiving COMPASS-TC was associated with better functional status.

Trial registration

ClinicalTrials.gov number: NCT02588664. Registered 28 October 2015.

Impact of acute-phase complications and interventions on 6-month survival after stroke. A prospective observational study

The outcome of stroke patients is complex and multidimensional. We evaluated the impact of acute-phase variables, including clinical state, complications, resource use and interventions, on 6-month survival after first-ever stroke, taking into account baseline conditions exerting a possible effect on outcome.

As part of a National Research Program, we performed a prospective observational study of acute stroke patients in four Italian Regions. Consecutive patients admitted for a period of 3 months to the emergency rooms of participating hospitals were included.

A total of 1030 patients were enrolled (median age 76.0 years, 52.1% males). At 6 months, 816 (79.2%) were alive, and 164 (15.9%) deceased. Survival status at the 6-month follow-up was missing for 50 (4.9%). Neurological state in the acute phase was significantly worse in patients deceased at 6 months, who showed also higher frequency of acute-phase complications. Cox regression analysis adjusted for demographics, pre-stroke function, baseline diseases and risk factors, indicated as significant predictors of 6-month death altered consciousness (HR, 1.70; 95% CI, 1.14–2.53), total anterior circulation infarct (HR, 2.13; 95% CI, 1.44–3.15), hyperthermia (HR, 1.70; 95% CI, 1.18–2.45), pneumonia (HR, 1.76; 95% CI, 1.18–2.61), heart failure (HR, 2.87; 95% CI, 1.34–6.13) and nasogastric feeding (HR, 2.35; 95% CI, 1.53–3.60), while antiplatelet therapy during acute phase (HR, 0.56; 95% CI, 0.39–0.79), and early mobilisation (HR, 0.55; 95% CI, 0.36–0.84) significantly increased 6-month survival.

In a prospective observational study, stroke severity and some acute-phase complications, potentially modifiable, significantly increased the risk of 6-month death, independently of baseline variables. Early mobilisation positively affected survival, highlighting the role of early rehabilitation after stroke.