The stroke transitional care intervention for older adults with stroke and multimorbidity: a multisite pragmatic randomized controlled trial

Abstract

Background This study aimed to test, in real-world clinical practice, the effectiveness of a Transitional Care Stroke Intervention (TCSI) compared to usual care on health outcomes, self-management, patient experience, and health and social service use costs in older adults (≥ 55 years) with stroke and multimorbidity (≥ 2 chronic conditions). Methods This pragmatic randomized controlled trial (RCT) included older adults discharged from hospital to community with stroke and multimorbidity using outpatient stroke rehabilitation services in two communities in Ontario, Canada. Participants were randomized 1:1 to usual care (control group) or usual care plus the 6-month TCSI (intervention group). The TCSI was delivered virtually by an interprofessional (IP) team, and included care coordination/system navigation support, phone/video visits, monthly IP team conferences, and an online resource to support system navigation. The primary outcome was risk of hospital readmission (all cause) after six-months. Secondary outcomes included physical and mental functioning, stroke self-management, patient experience, and health and social service use costs. The intention-to-treat principle was used to conduct the primary and secondary analyses. Results Ninety participants were enrolled (44 intervention, 46 control); 11 (12%) participants were lost to follow-up, leaving 79 (39 intervention, 40 control). No significant between-group differences were seen for baseline to six-month risk of hospital readmission. Differences favouring the intervention group were seen in the following secondary outcomes: physical functioning (SF-12 PCS mean difference: 5.10; 95% CI: 1.58–8.62, p = 0.005), stroke self-management (Southampton Stroke Self-Management Questionnaire mean difference: 6.00; 95% CI: 0.51—11.50, p = 0.03), and patient experience (Person-Centred Coordinated Care Experiences Questionnaire mean difference: 2.64, 95% CI: 0.81, 4.47, p = 0.005). No between-group differences were found in total healthcare costs or other secondary outcomes. Conclusions Although participation in the TCSI did not impact hospital readmissions, there were improvements in physical functioning, stroke self-management and patient experience in older adults with stroke and multimorbidity without increasing total healthcare costs. Challenges associated with the COVID-19 pandemic, including the shift from in-person to virtual delivery, and re-deployment of interventionists could have influenced the results. A larger pragmatic RCT is needed to determine intervention effectiveness in diverse geographic settings and ethno-cultural populations and examine intervention scalability. Trial registration ClinicalTrials.gov Identifier: NCT04278794. Registered May 2, 2020.

What are the available online resources targeting psychosocial burden among stroke survivors and their informal caregivers: A scoping review

“…Regarding the impact on depression for stroke survivors, two interventions (an educational website with remote monitoring 37 and an information website combined with monthly follow-up with a nurse 39 ) significantly reduced anxiety or depressive symptoms for stroke survivors ( P < 0.001 and P = 0.008, respectively), while the three other did not. 36 , 40 , 41 Another study found that increased mastery and social support gained using a website were significantly correlated with reduced depression of stroke survivors (respectively r = −0.49: P < 0.005, and r = −0.37; P < 0.05) at one month. 42 In addition, the qualitative study reported by Smith et al 44 characterized the process of emotional adjustment after stroke and the role of the online forum in this process.…”

“…Six online resources combined access to a website and additional support from a professional: the Michigan Stroke Transition Trial (MISTT) (Strong et al 34 and Reeves et al 35 ) combined access to the MISTT website with home visit and telephone-based case management; the RESCUE website (Lelaurin et al 36 ), was combined with a nurse follow-up; the STROKE-CARD (Willeit et al 37 ) combined access to an educational website with remote monitoring and an appointment with a multidisciplinary team; the TEMpEST website (Demir Avci and Gözüm 38 ) combined access to a website with nurses and coordinator follow-up and home visits; the Virtual Multidisciplinary Stroke Care Clinic (VMSCC) (Lo et al 39 ) combined a website with video-based consultation and telephone calls with a nurse; and the Transitional Care Stroke Intervention (TCSI) (Markle-Reid et al 40 ) combined access to the My Stroke Recovery Journey website with a coordinator and interprofessional team follow-up. Two studies used only a website without additional professional support: the Caring∼Web© (Pierce et al 41 ) website and the resource evaluated by Smith et al 42 …”

“… 35 , 36 , 41 Websites dedicated to stroke survivors included specific information dedicated to caregivers. 35 , 36 Three websites specified that content included empowerment tools designed to improve self-management and problem-solving skills 36 , 39 , 40 and one website provided information about home care 38 ( Table 3 ).…”

“…Among them, four included stroke survivors and/or informal caregivers’ perspectives in their development 35 , 39 , 40 , 42 mainly through focus groups or scientific committees involving health professionals and patients, 35 , 39 , 42 and one involving the patient's partner in research. 40 Three described structured pilot and usability tests. 38 , 41 , 42 , 45 …”

“…Need assessment was conducted at discharge (TEMpEST 38 and TCSI 40 ), at discharge and three months (MISTT 35 ), solely at three months (STROKE-CARD 37 ), or monthly during the intervention (VMSCC 39 ). The needs assessment was either done by the professional in charge of the follow-up (MISTT 35 , VMSCC, 39 and TEMpEST 38 ), by a multidisciplinary team assessment (STROKE-CARD 37 ), or both the health professional in charge of the follow-up in collaboration with a multidisciplinary team (TCSI 40 ). The other studies did not mention conducting a needs assessment during the intervention.…”