"Lessons Learned" Preventing Recurrent Ischemic Strokes through Secondary Prevention Programs: A Systematic Review

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.

A retrospective analysis of the social determinants of health affecting stroke outcomes in a small hospital situated in a health professional shortage area (HPSA)

Where someone lives is a major determinant of population health. In the United States, people who live in Health Professional Shortage Areas are considered medically underserved and have a higher propensity for conditions such as stroke, hypertension, and diabetes. Our goal was to better understand the diverse needs of patients presenting to the Crouse Hospital emergency department with stroke symptoms. Crouse Hospital is a small community hospital located in a shortage area serving both urban and rural populations in and around Syracuse, New York. Despite its small size, Crouse Hospital quickly became a major comprehensive stroke center in Central New York. With this study we assessed the social factors affecting the stroke patient population in the community and compared these characteristics between those living in served and underserved areas. Informed by the social determinants of health framework, we analyzed 1731 incidents of stroke that occurred between January 2019 and January 2021, and observed that the circumstances associated with stroke varied by service category and race, with White patients and those from served areas having better stroke outcomes compared to those residing in underserved areas and those that were not White. Our analyses help us to understand the underlying factors influencing the observed disparities and allow us to move forward by implementing informed community-based interventions to decrease stroke incidence and improve post-stroke care. Using our example other small hospitals can enact similar strategies to address the social determinants affecting their patients to improve stroke outcomes in their region.

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

BACKGROUND

Stroke is a significant public health concern that causes severe and long-lasting disability. The recurrence of stroke is increasing due to lack of patients' knowledge and compliance with treatment to control modifiable risk factors and lifestyle changes. Health education can be an effective way to increase knowledge about behavioral changes in patients who had a stroke.

OBJECTIVE

The aim of this study is to evaluate the effectiveness of a health education program in Bangladesh for patients who had their first stroke and their family caregivers in order to reduce the recurrence of stroke by controlling modifiable risk factors.

METHODS

This is a parallel, open-label, prospective randomized controlled trial conducted at the National Institute of Neurosciences & Hospital in Dhaka, Bangladesh. We enrolled ≥18-year-old patients of both sexes who had a history of first stroke attack (transient ischemic attack, hemorrhagic stroke, lacunar stroke, atherothrombotic stroke, or cardioembolic stroke). We stratified patients into those aged <65 years and those aged ≥65 years and according to types of strokes for randomization. Our estimated sample size was 432. The intervention group receives face-to-face counseling on lifestyle modifications, blood pressure monitoring, and medication compliance-related health education during enrollment and monthly follow-ups. However, the control group receives only usual care from the hospital. The primary end point of this study is the reduction in the stroke recurrence rates at the end of the 12-month follow-up period. The secondary end points are to (1) assess the occurrence of all adverse events such as other cardiac events and all-cause mortality, (2) evaluate the status of the controlling modifiable risk factors such as blood pressure, glycated hemoglobin, and non-high-density lipoprotein cholesterol, (3) assess the knowledge related to stroke by using the investigator-developed questionnaire, (4) evaluate the lifestyle behavior related to stroke by using the investigator-developed questionnaire, (5) assess medication adherence, and (6) evaluate the quality of life of patients who had a stroke and their family caregivers. The evaluation points will be at baseline, 6 months, and 12 months for both groups.

RESULTS

Patients' enrollment started on October 2022, and follow-up will be completed in March 2024. A total of 432 participants were included in both the intervention (n=216) and control groups (n=216). This study was approved by the institutional review board and the ethics review board of the National Institute of Neurosciences & Hospital (IRB/NINSH/2022/151) on August 30, 2022.

CONCLUSIONS

Our health education program is expected to reduce the recurrence of stroke and improve the quality of life of patients who have had the first stroke. The results of this study will provide insights into the importance of health education for (self)-management and prevention of stroke.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05520034; https://clinicaltrials.gov/ct2/show/NCT05520034.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51178.

The structured ambulatory post-stroke care program for outpatient aftercare in patients with ischaemic stroke in Germany (SANO): an open-label, cluster-randomised controlled trial

BACKGROUND

Patients with ischaemic stroke are at risk of recurrent stroke. In this study, we aimed to compare the effect of a structured ambulatory post-stroke care programme versus usual care on recurrent vascular events and death and control of cardiovascular risk factors.

METHODS

We did a prospective, open-label, cluster-randomised controlled trial (SANO) at stroke centres in regions of Germany. A cluster was defined as a region in which acute stroke care is provided by a participating stroke centre. Patients were eligible for participation if they were aged 18 years or older, had no severe disabilities before the index stroke (modified Rankin scale 0-1), had at least one modifiable cardiovascular risk factor, and presented within 14 days of symptom onset of their first ischaemic stroke. The participating regions were randomly assigned (1:1) to the intervention and control group (usual care) by the statistician using block randomisation (block sizes of six), stratified by rural and urban regions. In intervention regions, a cross-sectoral multidisciplinary network was established to provide a 1-year organisational and patient-centred intervention. Due to the type of intervention, masking of participants and study physicians was not possible. Endpoint adjudication was performed by an independent endpoint adjudication committee who were masked to cluster allocation. The primary endpoint was a composite of recurrent stroke, myocardial infarction, and all-cause death within 12 months after baseline assessment, assessed in the modified intention-to-treat (mITT) population, which included all patients who did not withdraw consent and completed the primary endpoint assessment at 12 months. This study was registered with the German Clinical Trials Register, DRKS00015322.

FINDINGS

Between Jan 1, 2019 and Dec 22, 2020, 36 clusters were assessed for eligibility, of which 30 were randomly assigned to the intervention group (n=15 clusters) or control group (n=15 clusters). No clusters dropped out of the study. 1203 (86%) of 1396 enrolled patients in the intervention group and 1283 (92%) of 1395 enrolled patients in the control group were included in the mITT population. The primary endpoint was confirmed in 64 (5·3%) of 1203 patients in the intervention group and 80 (6·2%) of 1283 patients in the control group (unadjusted odds ratio [OR] 0·80 [95% CI 0·49-1·30]; adjusted OR [aOR] 0·95 [95% CI 0·54-1·67]). All-cause deaths occurred in 31 (2·4%) of 1203 patients in the intervention group and 12 (1·0%) of 1283 patients in the control group. The incidence of serious adverse events was higher in the intervention group (266 [23·1%] of 1151) than the control group (106 [9·2%] of 1152). Falls (134 [11·4%] of 1203 patients in the intervention group; 39 [3·3%] of 1152 patients in the control group), hypertensive crisis (55 [4·7%]; 34 [2·8%]), and diagnosis of depression (51 [4·3%]; 13 [1·1%]) were the most frequent adverse events in both groups. No differences were identified in the rate of readmission to hospital between groups.

INTERPRETATION

No differences were identified between patients with ischaemic stroke in the intervention group and control group with regard to the incidence of vascular events 1 year after baseline assessment, despite positive effects with regard to the control of some cardiovascular risk factors. Longer-term effects and other potentially favourable effects on stroke-related sequelae and quality of life require further evaluation.

FUNDING

Innovation Fund of the Federal Joint Committee.

Factors and Behaviors Related to Successful Transition of Care After Hospitalization for Ischemic Stroke

BACKGROUND

Our objective is to describe adoption of the posthospitalization behaviors associated with successful transition of care and related baseline characteristics.

METHODS

This study includes 550 participants in the Transition of Care Stroke Disparities Study, a prospective observational cohort derived from the Florida Stroke Registry. Participants had an ischemic stroke (2018-2021), discharged home or to rehabilitation, with modified Rankin Scale score=0-3 (44% women, 24% Black, 48% White, 26% Hispanic, 35% foreign-born). We collected baseline sociodemographic and clinical characteristics. A structured telephone interview at 30-day postdischarge evaluated outcomes including medication adherence, medical appointment attendance, outpatient therapy, exercise, diet modification, toxic habit cessation, and a calculated composite adequate transition of care measure. Multivariable analyses assessed the association of baseline characteristics with 30-day behaviors.

RESULTS

At 30 days, medication adherence was achieved by 89%, medical appointments by 82%, outpatient therapy by 76%, exercise by 71%, diet modification by 68%, toxic habit cessation by 35%, and adequate transition of care measure by 67%. Successful adequate transition of care participants were more likely to be used full-time (42% versus 31%, P=0.02), live with a spouse (60% versus 47%, P=0.01), feel close to ≥3 individuals (84% versus 71%, P<0.01), have history of dyslipidemia (45 versus 34%, P=0.02), have thrombectomy (15% versus 8%, P=0.02), but less likely to have a history of smoking (17% versus 32%, P<0.001), coronary artery disease (14% versus 21%, P=0.04), and heart failure (3% versus 11%, P<0.01). Multivariable logistic regression analyses revealed that multiple socio-economic factors and prestroke comorbid diseases predicted fulfillment of transition of care measures. There was no difference in outcomes during the Covid-19 pandemic (2020-2021) compared with prepandemic years (2018-2019).

CONCLUSIONS

One in 3 patients did not attain adequate 30-day transition of care behaviors. Their achievement varied substantially among different measures and was influenced by multiple socioeconomic and clinical factors. Interventions aimed at facilitating transition of care from hospital after stroke are needed.

REGISTRATION

URL: https://clinicaltrials.gov/; Unique identifier: NCT03452813.