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Age and Ageing Advance Access originally published online on November 14, 2007
Age and Ageing 2008 37(1):32-38; doi:10.1093/ageing/afm133
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Copyright © The Author 2007. Published by Oxford University Press on behalf of the British Geriatrics Society.

Bridging the gap: the effectiveness of teaming a stroke coordinator with patient's personal physician on the outcome of stroke

Nancy E. Mayo1,, Lyne Nadeau1, Sara Ahmed2, Carole White3, Roland Grad4, Allen Huang5, Mark J. Yaffe4,6 and Sharon Wood-Dauphinee1,7

1 Division of Clinical Epidemiology, McGill University Hospital Centre, Montreal, Quebec, Canada
2 Clinical and Health Informatics Research Unit, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
3 University of Texas Health Science Centre, San Antonio, Texas, USA
4 Department of Family Medicine, McGill University, Montreal, Quebec, Canada
5 Division of Geriatrics, McGill University Health Center, Montreal, Quebec, Canada
6 St. Mary's Hospital Centre, Montreal, Canada
7 School of Physical and Occupational Therapy, McGill University, Montreal, Quebec, Canada

Address correspondence to: Nancy E. Mayo. Tel: (514) 934 1934 36922, Fax: (514) 843 1493. Email: nancy.mayo{at}mcgill.ca


   Abstract
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Objectives: to test the hypothesis as to whether persons newly discharged into the community following an acute stroke and assigned a stroke case manager would experience, compared to usual post-hospital care, better health-related quality of life (HRQL), fewer emergency room visits and less non-elective hospitalisations.

Design: a stratified, balanced, evaluator-blinded, randomised clinical trial.

Setting: five university-affiliated acute-care hospitals in Montreal, Quebec, Canada.

Participants: persons (n = 190) returning home directly from the acute-care hospital following a first or recurrent stroke with a need for health care supervision post-discharge because of low function, co-morbidity, or isolation.

Intervention: for 6 weeks following hospital discharge a nurse stroke care manager maintained contact with patients through home visits and telephone calls designed to coordinate care with the person's personal physician and link the stroke survivor into community-based stroke services.

Measurements: the primary outcome was the Physical Component Summary (PCS) of the Short-Form (SF)-36 survey. A secondary outcome was utilisation of health services. Also measured was the impact of stroke on functioning. Measurements were made at hospital discharge (baseline), following the 6-week intervention and at 6-months post-stroke.

Results: the average age of the participants was 70 years. Discharge was achieved on average 12 days post-stroke and most participants had had a stroke of moderate severity. There were no differences between groups on the primary outcome measure, health services utilisation, or any of the secondary outcome measures.

Conclusion: for this population, there was no evidence that this type of passive case management inferred any added benefit in terms of improvement in health-related quality of life or reduction in health services utilisation and stroke impact, than usual post-discharge management.

Keywords: stroke, case management, health services research, quality of life, co-morbidity, elderly


   Introduction
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 Introduction
Methods
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One of the challenges faced by the health care system today is how to offer high-quality, comprehensive and coordinated care to an increasingly frail and elderly population [1]. This becomes a predominate concern when elderly persons experience an acute health event, for either a new or established condition, and have to make a transition from hospital to community-based care. In this situation, concerns arise about continuity of care [2].

Shortening the length of acute-care hospital stay for virtually all conditions means that patients are returning to the community much earlier in the course of their recovery than in past decades. Health conditions that affect the elderly, like stroke, pose a particular challenge and methods to optimise the provision of post-stroke care would be welcomed by patients and providers alike [2–4]. Early supported discharge, in the form of provision of medical and rehabilitation services in the home, has been shown by a meta-analysis of 11 trials [5] to be effective in reducing disability, length of stay, and costs of care. However, these studies, conducted mostly in Europe, have targeted stroke survivors with moderate disability for whom some form or rehabilitation is recommended. The trial conducted by our team, and included in the meta-analysis [6], found that most persons discharged home directly from the acute-care hospital usually do not have major disability from stroke but nevertheless have complex needs for follow-up and service provision which could potentially be facilitated through nursing case management. The evidence for this type of intervention for other conditions is mixed, with some studies showing benefit and other studies showing little or none. There have been few studies of this management strategy in stroke. Therefore, the objective of this study is to determine whether persons newly discharged into the community following an acute stroke would report better HRQL and have fewer emergency room visits and non-elective hospitalisations if assigned to a stroke case manager who would interact with the patient's personal physician to coordinate and provide continuity of care in comparison to those receiving usual procedures for post-hospital care.


   Methods
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 Methods
Results
 Discussion
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Subject selection
This study targeted all persons returning home directly from the acute-care hospital following a first or recurrent stroke with any of the following criteria indicating a specific need for health care supervision post-discharge: lives alone; mobility problem requiring assistive device, physical assistance or supervision; mild cognitive deficit, dysphagia; incontinence; social service consultation during acute hospitalisation; or need for post-discharge medical management for diabetes, congestive heart failure, ischemic heart disease, arthritis, chronic obstructive pulmonary disease (COPD), atrial fibrillation, kidney disease, peripheral vascular disease. Excluded were persons discharged to an in-patient rehabilitation facility or to long-term care.

The population was drawn from the five acute-care hospitals within the McGill University hospital network. The study was approved by each hospital's research ethics board.

Design
A stratified, balanced, evaluator-blinded, randomised clinical trial was carried out. Persons were stratified according to whether they identified a personal physician. Randomisation was done at discharge, in random blocks of four, six or eight and sealed envelopes were prepared in advance. The intervention period was 6 weeks with 6-months follow-up post-stroke.

Case-management intervention
Case management was defined according to the Case Management Association of Canada (www.cmsa.org) as ‘a collaborative process of assessment, planning, facilitation and advocacy for options and services to meet an individual's health needs through communication and available resources to promote quality cost-effective outcomes’. Case management was done through home visits and telephone contacts for a period of 6 weeks. Case managers were two nurses with extensive experience with geriatric nursing, including stroke. Training involved establishing guidelines for assessments to be carried out and creating a documentation system for recording the interactions. The first task was to establish contact with the patient's existing personal physician and arrange for an appointment and for documentation about the stroke to be forwarded to the physician. For persons without personal physicians, the local community health centre (CLSC) was contacted for physician follow-up. The stroke patients were also provided with a 24-h contact number for the nurse, which was used sparingly mostly on weekends or in the early evening mostly prompted by visits from family members.

The interactions and interventions that the nurse case-manager carried out with the patient, family, caregiver and physician were recorded and subsequently coded using the Nursing Intervention Classification (NIC) system by an independent team [7]. The results of this coding have previously been reported [8]; the interventions provided were surveillance (91%), information exchange (80%), medication management (70%), health system guidance (41%), active listening (34%), family support (31%), teaching (23%) and risk identification (19%).

Usual care comparison
For persons assigned to usual care, the patient and family were instructed to make an appointment with the patient's personal physician or, if the patient did not have a physician, at their CLSC as soon as possible. They were provided with a list of these centres. No other interventions were provided to persons in this group.

Measurement
The primary outcome was the Physical Component Summary PCS of the SF-36 survey where a difference of 5 points is equivalent to a moderate effect size of 0.5 and is also clinically important [9]. The study was powered at 90% to detect this difference (type I error 0.05). A number of other measures were included to quantify the impact of stroke on functioning: Mental Component Summary (MCS) of the SF-36 [9], Euroquol EQ-5D [10], Preference-Based Stroke Index (PBSI) [11], Reintegration to Normal Living Index [12], Barthel Index [13], Geriatric Depression Scale [14], gait speed [15] and Timed Up and Go (TUG) test [16]. A secondary outcome was utilisation of health services as identified through linkage of participants’ health insurance number to the provincial billing database, Régie d'assurance de Maladie du Québec (RAMQ). Two additional explanatory variables were cognitive status and stroke severity. The telephone version of the Mini-Mental State Examination [17] has a maximum correct response score of 22. Stroke severity was assessed using the Canadian Neurological Scale [18].

Statistical analyses
The principal analysis was a comparison of the two groups at 6 weeks on the main outcome, physical health measured by the PCS of the SF-36 with an ‘intention-to-treat’ approach using linear regression with multiple imputation for missing data. This approach was used for all other outcomes and time-points. The assumption of linear regression, normality of the residuals, was verified and only seriously violated for one secondary outcome, the TUG test, the values for which were subjected to a log transformation. The impact of adjusting for gender, age and stroke severity was assessed. For health services outcomes, either t-tests or chi-square tests were used to compare the two groups.


   Results
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 Results
Discussion
 Declaration of Source of...
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Figure 1 shows the path of subjects through the study. A total of 190 persons were randomised, there were three deaths, one in the case-management group and two in the usual care group; an additional 14 and 16 people, in these two groups respectively could not be fully assessed. Only four persons did not consent to provide their health insurance number for linkage to provincial health insurance databases. There were no important differences between the groups at baseline (Table 1). There were no statistically significant differences in any of these outcomes at any time point (Table 2). The main outcome, PCS, showed a statistically significant change which was similar for both groups and was influenced by gender, age and stroke severity with women, older persons and persons with more severe strokes having lower values (data not shown).


Figure 1
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  		Figure 1. The path of subjects through the study.

 


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  		Table 1. Characteristics of the two groups at baseline

 


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  		Table 2. Two groups are similar on HRQL and related outcomes at each time point

 
Table 3 presents the results of the analysis on health services utilisation. While there was a tendency for the usual care group to use more services, particularly in the period following the intervention (6 weeks to 6 months) only the average number of specialists visits in the post-intervention period (2.2 for the case-management group compared with 3.4 for usual care group) reached statistical significance in the latter period (P = 0.01). Patients received on average 4.8 home visits which lasted approximately 40–90 min depending on the issues identified; on average each participant received 7.8 telephone contacts lasting 5–20 min. Within the 6 weeks intervention period, 14% of the case-management group and 21% of the control group did not have a physician visit; by 6 months only 9% had not yet had a visit recorded.


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  		Table 3. Two groups were similar on use of mostb health services

 

   Discussion
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The stroke survivors recruited into this study differ from those commonly included in studies of stroke because we purposely targeted persons whose motor deficits were milder, who were not referred to in-patient rehabilitation and who had other co-morbidities and stroke consequences that pose management problems at home, the very characteristics that often exclude persons from stroke trials. We felt this population would benefit from nurse-directed case management and did not require home rehabilitation services as we had provided in our trial of early supported discharge [6]. As can be seen from the information presented in Table 2, their score on the Barthel Index averaged 87 at discharge, a full 3-points higher than those in our early supported discharge trial [6]. However, this population would be characterised as borderline community ambulators as their average gait speed was approximately 0.80 m/s just above what is suggested for safe community mobility (0.71 m/s) but well below the speed required for ambulation in a busy, urban environment (1.38 m/s) [22]. The average score on the TUG test (approximately 20 s), is within the range reported for frail, elderly, persons [16]. However, their co-morbidity was similar to that of an unselected sample of stroke survivors recruited for an observational study of quality of life [23].

Nevertheless, there was no impact of the nurse case-management intervention on any of the outcomes and very little on health services utilisation. The question must be raised as to whether any of the interventions offered were potent enough to alter HRQL or health services utilisation [24]. Most of the interventions were ‘passive’ in nature, such as providing surveillance, information and education and psycho-social support [8]. It may be that these interventions are not sufficiently potent to alter health status as perceived by the subject.

There have been several randomised trials of post-hospital support services for vulnerable populations. Lim et al. [25] reviewed 11 of them and a 1998 systematic review covered 17 such trials [26]. These trials were also reviewed as part of an evidence-based summary [24] and the conclusion was that services aimed to alter the course of the disease (e.g. services to enhance function, reduce medication errors and detect health threats) were generally successful in reducing re-admissions. Supportive interventions (e.g. services providing education, phone calls, contact information, reminders about appointments) were not successful in altering re-admission rates. To improve HRQL, the interventions need to target the drivers of HRQL, which are mainly related to physical, psychological and social functioning. The improvement of function requires active ingredients such as physical and occupational therapy, counselling, and community integration.

There have also been new trials in this area [27–29]. Again, with passive interventions such as providing information and coordination [28], the impact on outcomes was negligible. With more active interventions such as described by Anderson et al. [29], which included in-hospital assessments and physical therapy with active follow-up on the home recommendations, there was a reduction in re-admissions (12 versus 44%).

A strong indicator of need for health care management is use of health care services. These are shown in Table 3. The intervention and control groups showed 26 and 30%, respectively as rates of emergency room attendance during the total study period of 6 months. To put these values in context, persons over the age of 65 drawn from family physician practices in Montreal, had a rate of emergency room visits of 15% in 11 months [30]. This would suggest that the stroke sample studied here was in need of health care management as their rate of emergency room attendance was double that of a comparable non-stroke population over half the time. The rate of hospitalisation was also high during the first 6 months post-stroke, 17 and 28% for the intervention and control groups, respectively, compared with 12% reported from the study cited above [30] for an 11 month period.

This intervention was also offered in isolation and not as part of a multi-disciplinary team approach. This single intervention was chosen as the impact of offering home-based rehabilitation, which included un-classified nursing follow-up, as it had already been shown to be effective [6] and subsequently confirmed by a meta-analysis [5].

In conclusion, this study did not provide evidence for this population that passive case management offered alone and not as part of a multi-disciplinary team approach focusing on rehabilitation was successful.


   Declaration of Source of Funding
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 Declaration of Source of...
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Funded by Medical Research Council of Canada now Canadian Institute of Health Research.


   Key points
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 Methods
 Results
 Discussion
 Declaration of Source of...
 Key points
References
 

  • For persons with stroke, nursing case management in the first 6 weeks following discharge to home from the acute-care setting did not have impact on health or on function-related outcomes and had very little impact on health services utilisation.
  • This type of intervention—health surveillance, information, education and psycho-social support—is passive in nature and may not be sufficiently potent to alter health status as perceived by the stroke survivor or health services utilisation, at the time of post-stroke.
  • To alter the disease course or outcome, services targeted to enhance function, reduce medication errors and detect health threats have been shown to be successful.
  • Interventions such as case management have the potency to induce a response shift by changing a person's conceptualisation of the construct or the calibration of the measurement scale, rendering pre–post comparisons difficult to interpret.


   References
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 Methods
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  1. Clarfield AM, Bergman H, Kane R. Fragmentation of care for frail older people- an international problem. Experience from three countries: Israel, Canada, and the United States. J Am Geriatr Soc (2001) 49:1714–21.[CrossRef][Web of Science][Medline]
  2. Coleman EA, Smith JD, Frank JC, et al. Preparing patients and caregivers to participate in care delivered across settings: The care transitions intervention. J Am Geriatr Soc (2004) 52:1817–25.[CrossRef][Web of Science][Medline]
  3. Bailie RS, Sibthorpe BM, Douglas RM. General practitioners' perceptions regarding coordinated care. Aust Fam Physician (1997) 26(Suppl. 2):S61–5.[Medline]
  4. Brown JB, McWilliam CL, Mai V. Barriers and facilitators to seniors' independence. Perceptions of seniors, caregivers, and health care providers. Can Fam Physician (1997) 43:469–75.[Web of Science][Medline]
  5. Langhorne P, Taylor G, Murray G, et al. Early supported discharge services for stroke patients: A meta-analysis of individual patients' data. Lancet (2005) 365:501–6.[Web of Science][Medline]
  6. Mayo NE, Wood-Dauphinee S, Cote R, et al. There's no place like home: An evaluation of early supported discharge for stroke. Stroke (2000) 31:1016–23.[Abstract/Free Full Text]
  7. McCloskey J, Bulechek GM. Nursing Interventions Classification (NIC). (2000) St. Louis: Mosby-Yearbook.
  8. McBride KL, White CL, Sourial R, et al. Postdischarge nursing interventions for stroke survivors and their families. J Adv Nurs (2004) 47:192–200.[CrossRef][Web of Science][Medline]
  9. Ware JE Jr, Kosinski M, Keller SD. SF-36 Physical and Mental Scales: A User's Manual. (1994) Boston, Massachusetts: The Health Institute, New England Medical Center.
  10. Kind P. Quality of Life and Pharmacoeconomics in Clinical Trials. Spilker B, ed. (1995) Philadelphia: Lippincott-Raven Publishers. 191–201. The EuroQol instrument: An index of health-related quality of life.
  11. Poissant L, Mayo NE, Wood-Dauphinee S, et al. The development and preliminary validation of a Preference-Based Stroke Index (PBSI). Health Qual Life Outcomes (2003) 1:43.[CrossRef][Medline]
  12. Wood-Dauphinee SL, Opzoomer MA, Williams JI, et al. Assessment of global function: The reintegration to normal living index. Arch Phys Med Rehabil (1988) 69:583–90.[Web of Science][Medline]
  13. Granger CV, Hamilton BB. Measurement of stroke rehabilitation outcome in the 1980s. [Review] [11 refs]. Stroke (1990) 21(Suppl. 9):II46–7.[Medline]
  14. Yesavage JA, Brink TL, Rose TL, et al. Development and validation of a geriatric depression screening scale: a preliminary report. J Psychiatr Res (1983) 17:37–49.[CrossRef][Web of Science]
  15. Salbach NM, Mayo NE. Gait speed as a measure of stroke outcome. Arch Phys Med Rehabil (1997) 78:897.
  16. Podsiadlo D, Richardson S. The timed "Up and Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc (1991) 39:142–8.[Web of Science][Medline]
  17. Roccaforte WH, Burke WJ, Bayer BL, et al. Validation of a telephone version of the mini-mental state examination. J Am Geriatr Soc (1992) 40:697–702.[Web of Science][Medline]
  18. Cote R, Battista RN, Wolfson C, et al. The Canadian neurological scale: validation and reliability assessment. Neurology (1989) 39:638–43.[Abstract/Free Full Text]
  19. Cote R, Battista RN, Wolfson CM, et al. Stroke assessment scales: guidelines for development, validation, and reliability assessment. Can J Neurol Sci (1988) 15:261–5.[Web of Science][Medline]
  20. Hopman WM, Towheed T, Anastassiades T, et al. Canadian normative data for the SF-36 health survey. Can Med Assoc J (2000) 163:265–71.[Abstract/Free Full Text]
  21. Mayo N, Goldberg MS, Kind P. Proceedings from 1997 EuroQol Plenary Meeting, Center for Health Policy and Law (1998) Rotterdam, The Netherlands: Erasmus University. 25–40. Calibrating the EQ-5D for a Canadian population.
  22. Robinett CS, Vondran MA. Functional ambulation velocity and distance requirements in rural and urban communities. A clinical report. Phys Ther (1988) 68:1371–3.[Abstract/Free Full Text]
  23. Kelsey JL, Whittemore AS, Evans AS, et al. Methods in Observational Epidemiology. (1996) 2nd edition. New York: Oxford University Press.
  24. Mayo NE. Family support services may improve quality of life for informal carers. Evid Based Healthc (2002) 6:1–2.[CrossRef]
  25. Lim WK, Lambert SF, Gray LC. Effectiveness of case management and post-scute services in older people after hospital discharge. Med J Aust (2003) 178:262–6.[Web of Science][Medline]
  26. Bours GJJW, Ketelaars CAJ, Frederiks CMA, et al. The effects of aftercare on chronic patients and frail elderly patients when discharged from hospital: a systematic review. J Adv Nurs (1998) 27:1076–86.[CrossRef][Web of Science][Medline]
  27. Forster AJ, Clark HD, Menard A, et al. Effect of a nurse team coordinator on outcomes for hospitalized medicine patients. Am J Med (2005) 118:1148–53.[CrossRef][Web of Science][Medline]
  28. Preen DB, Bailey BES, Wright A, et al. Effects of a multidisciplinary, post-discharge continuance of care intervention on quality of life, discharge satisfaction, and hospital length of stay: a randomized controlled trial. Int J Qual Health Care (2005) 17:43–51.[Abstract/Free Full Text]
  29. Anderson C, Deepak BV, Amoateng-Adjepong Y, et al. Benefits of comprehensive inpatient education and discharge planning combined with outpatient support in elderly patients with congestive heart failure. Congest Heart Fail (2005) 11:315–21.[CrossRef][Medline]
  30. Mayo NE, Nadeau L, Levesque L, et al. Does the addition of functional status indicators to case-mix adjustment indices improve prediction of hospitalization, institutionalization, and death in the elderly? Med Care (2005) 43:1194–202.[CrossRef][Web of Science][Medline]
Received 27 November 2007; accepted in revised form 25 May 2007.


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