Structured Post-stroke Follow-up in Malmö, Sweden (SUESIM)

Background Approximately 600 patients with acute stroke are treated in-hospital at Skåne University Hospital in Malmö. Of those, approximately 450 patients can be discharged straight to their own home after hospital stay. Currently, there is no structured follow-up routine for patients with stroke discharged from Skåne University Hospital in Malmö, and Primary care health providers are managing most follow-ups for stroke depending on individual patient needs. Previous research has shown that one in four patients with stroke are not followed up within three months after hospital discharge in Skåne.

Stroke-related medical complications are common both in the acute phase after stroke and in the longer term. Acute medical complications comprise infections, falls and fractures, confusion, deep venous thrombosis and pulmonary embolism, and also epileptic seizures. The risk of medical complications increases with co-morbidity, but can also be a consequence of the stroke itself. Beyond the acute phase, other stroke-related health problems occur in the majority of patients. They comprise fatigue, impaired cognition, low mood, incontinence, sexual impairment, post-stroke pain, spasticity, relational problems, isolation, inadequate secondary preventive treatment and impaired mobility and daily activities. Previous studies have shown that these problems are common and can persist for years post-stroke. Knowledge of how to best organize and manage stroke and stroke-related health problems in the long-term is sparse, even though there are guidelines on some general principles for secondary prevention and rehabilitation.

Post-stroke Checklist (PSC) was developed by an international stroke expert group. It is a simple checklist collecting eleven common stroke-related health problems, and can be used as a clinical tool to identify common and treatable complications to stroke. The feasibility of the 11-items PSC as a screening tool for stroke-related health problems has been tested systematically and it has been considered implementable. Modified versions of PSC are being implemented in different countries.

PSC can be used both by nurses, physicians and other health professions. The National Guidelines for Stroke Care in Sweden from 2018 recommend the use of PSC for stroke follow-up. PSCs use has not been systematically tested in Sweden though and PSC is not yet routinely used. A modified 14-item PSC is recommended by Region Skåne (the county council of Southern Sweden).

Aims The aims of this study are to test the feasibility of a structured and multimodal follow-up model for stroke systematically, as well as to test the validity of the PSC as a screening tool for stroke-related health problems. The study aims further at studying the prevalence, and changes over time, of stroke-related health problems as well as survival, functional outcome following stroke, and patient satisfaction.

Working plan Study design The study design is longitudinal and explorative. This is a feasibility and validation study where the intervention consists of a structured follow-up visit, a multidisciplinary team rounds resulting in an individual treatment plan for stroke-related health problems, and a final follow-up at 12 months. Individual items in PSC will be validated towards routinely used validated tools. The prevalence, and changes over time, of stroke-related health problems will be investigated, as well as survival, functional outcome following stroke, and patient satisfaction. The study takes place in the clinical setting at the stroke unit, using clinical stroke team professional to mimic the normal clinical situation.

Study population We plan to include 200 consecutive patients with acute ischemic stroke or intracerebral hemorrhage, treated in-hospital at Skåne University Hospital in Malmö and discharged straight to own home. The estimated inclusion rate is 3- 5 patients per week, and the estimated time for including 200 patients is one year. Two hundred patients represent 40% of the total population of the 500 patients who can be discharged straight to own home, and are expected to be representable of the population with respect to age, sex, vascular risk and stroke severity. The generalizability of the population will be assessed through comparison to the Swedish Stroke Register.

Procedure for inclusion Eligible patients are identified daily in the stroke ward and included by written informed consent.

Follow-up procedure The three-months visit is managed by a stroke nurse and include the semi-structured PSC interview, additional validated diagnostic tools, secondary prevention status, comorbidity, and functional outcome.

The three-months visit is followed by a multidisciplinary team rounds with stroke physician, stroke nurse, occupational therapist and if needed physiotherapist, speech therapist, dietician, psychologist and/or social worker. The rounds result in an individual treatment recommendation plan that is sent to the family doctor and other relevant instances. The amount and type of referrals and other interventions warranted by the results of the follow-up visits and rounds are recorded.

The 12-months visit is managed by a stroke nurse and include a new semi-structured PSC interview, secondary prevention status, comorbidity, and a met needs assessment. The 12-month visit is followed by a multidisciplinary team rounds leading to referrals and other interventions are if warranted.

Use of other register data Patient baseline characteristics and three- and 12-month data on living conditions and functional level will be obtained from the Swedish Stroke Register (Riksstroke). Mortality at 12 and 18 months will be obtained by linkage to the Swedish Causes of Death register.

Data management, statistical analyses and ethical considerations The database will be built and managed in close cooperation with Clinical Studies Sweden, Forum South. Analyses will be performed on de-identified data after the dataset has been closed.

All statistical analyses will be performed in SPSS. Data will be presented using descriptive statistics and graphs, as well as linear models. Power calculations are not relevant for this study type.

The local Ethics approval committee has approved of the project (Dnr 2017/1028)