An Integrated Stroke Transitional Care Intervention Improves Physical Functioning, Self-Management and Patient Experience in Older Adults with Stroke and Multimorbidity: A Multisite Pragmatic Randomized Controlled Trial
Bibliographic record
Abstract
Background: The hospital-to-home transition for older adults with stroke is often fragmented, resulting in hospital readmissions and reduced quality of life, patient satisfaction and safety. There is limited evidence for strategies to improve transitions in care for older adults with stroke and multimorbidity. This study aimed to test, in real-world clinical practice, the effectiveness of the Transitional Care Stroke Intervention (TCSI) versus usual care on health outcomes, 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 was conducted among older adults with a stroke and multimorbidity discharged from the hospital to the community 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 team from hospital-based outpatient stroke rehabilitation clinics (Physiotherapist, Occupational Therapist, Speech Language Pathologist, Registered Nurse, and Social Worker). The TCSI is a complex, integrated intervention which includes care coordination/system navigation support, phone/video visits, monthly interprofessional case conferences, and an online resource to support system navigation. Data analysis was performed by intention to treat. The primary outcome was risk of hospital readmission (all-cause) after 6 months. Secondary outcomes were mental and physical functioning, depressive symptoms, stroke self-management, patient experience, number of hospital days and readmissions, number of ED visits, survival rates to first hospital and ED visit, risk of ED visits, and health and social service use costs. Older adults with stroke were engaged as co-investigators and informed the research design, implementation, and evaluation through participation in the Patient Partner Advisory and the TCSI Steering Committees. Results: Ninety participants were enrolled (44 intervention, 46 control); 11 (12%) participants were lost to follow-up, leaving 79 (39 intervention, 40 control). Most participants were men (60%), with an average of 7 comorbid conditions, and 78% had experienced their first-ever stroke. No significant group differences were seen for the baseline to six-month risk of hospital readmission (all-cause). However, stroke survivors in the intervention group reported higher levels of physical functioning (SF-12 Physical Component Summary Score 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) compared with the usual care group. No significant group differences were seen for the other secondary outcomes. Discussion: The TCSI improved physical functioning, stroke self-management and patient experience in older adults with stroke and multimorbidity without increasing total healthcare costs compared to usual care. Conclusion:The results provide evidence for the effectiveness of an integrated intervention to optimize transitional care outcomes for older adults with stroke and multimorbidity receiving outpatient stroke rehabilitation services. Suggestions for future research: Future research is needed to further evaluate this intervention in diverse settings and populations, with a larger sample size and a full economic evaluation.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.004 | 0.008 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.004 | 0.004 |
| Bibliometrics | 0.001 | 0.001 |
| Science and technology studies | 0.001 | 0.001 |
| Scholarly communication | 0.001 | 0.001 |
| Open science | 0.001 | 0.001 |
| Research integrity | 0.002 | 0.002 |
| Insufficient payload (model declined to judge) | 0.006 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".