Nurse-led stroke aftercare addressing long-term psychosocial outcome: a comparison to care-as-usual

Figures & data

Figure 1. Flowchart of stroke and transient ischemic attack patients’ admission to the hospital in the period of 1st April 2016 to 15th May 2017, to participation in the stroke aftercare study. The local university hospital admits nearly 700 stroke and transient ischemic attack cases annually.

Table 1. Characteristics of persons who participated in the stroke aftercare cohort versus non-responders.

	Stroke aftercare (n = 87)		Non-responders (n = 206)
Personal factors	n	Mean (SD) or n (%)	n	Mean (SD) or n (%)
Age at stroke onset (years)	87	66.5 (10.0)*	206	70.4 (12.9)
Age at visit stroke aftercare (years)	87	67.1 (10.0)*	206	71.1 (12.9)
Sex (male)	87	59 (67.8%)	206	122 (59.2%)
Marital status (in relationship)	87	68 (78.2%)	178	126 (70.8)
Education level (high)	80	30 (37.5%)		n.a.
Stroke severity (NIHSS)	56	3.6 (4.1)	106	3.7 (4.0)
No stroke symptoms (NIHSS = 0)		9 (16.1%)		9 (8.5%)
Minor stroke symptoms (NIHSS 1-4)		32 (57.1%)		69 (65.1%)
Moderate stroke symptoms (NIHSS 5-12)		13 (23.2%)		23 (21.7%)
Moderate to severe stroke symptoms (≥ 13)		2 (3.6%)		5 (4.7%)
Stroke type	87		206
Ischemic		66 (75.9%)		170 (85.5%)
Hemorrhagic		8 (9.2%)		14 (6.8%)
Transient ischemic attack		13 (14.9%)		22 (10.7%)
Stroke hemisphere	87		206
Left		37 (42.5%)		101 (49.0%)
Right		35 (40.2%)		77 (37.4%)
Other (e.g., brainstem)		15 (17.2%)		28 (13.6%)
Discharge destination	87		206
Home		63 (72.4%)		132 (64.1%)
Rehabilitation		18 (20.7%)		29 (14.1%)
Geriatric rehabilitation		5 (5.7%)*		43 (20.9%)
Other		1 (1.1%)		2 (1.0%)
Time from stroke to T0 (months)	87	7.2 (1.7)	206	7.9 (7.9)
Psychosocial and emotional outcome at T0
Emotional problems in daily life (CLCE-24)	79	3.5 (2.6)	175	3.8 (3.8)
Cognitive problems in daily life (CLCE-24)	83	4.3 (3.3)*	186	5.7 (3.9)
Anxiety (HADS)	83	5.0 (4.3)	181	5.2 (4.1)
Mild anxiety symptoms (≥8)		19 (22.9%)		49 (27.1%)
Depression (HADS)	83	4.1 (3.8)*	182	5.8 (4.7)
Mild depressive symptoms (≥8)		17 (20.5%)*		63 (34.6%)
Fatigue symptoms (FSS)	82	4.0 (1.4)*	180	4.6 (1.6)
Fatigued (≥4)		41 (50%)**		127 (70.6%)
Restrictions in participation (USER-P)	82	84.8 (17.1)**	181	69.6 (25.6)

CLCE-24: Checklist for Cognitive and Emotional Consequences of Stroke; FSS: Fatigue Severity Scale; HADS: Hospital Anxiety and Depression Scale; NIHSS: National Institutes of Health Stroke Scale; SD: Standard Deviation; USER-P: Utrecht Scale for Evaluation of Rehabilitation – Participation.

*p < 0.05 when compared to non-responders.

**p ≤ 0.001 when compared to non-responders.

Table 2. Characteristics of the stroke aftercare cohort versus care-as-usual cohort.

	Stroke aftercare (n = 87)		Care-as-usual (n = 363)
Personal	n	Mean (SD) or n (%)	n	Mean (SD) or n (%)
Age at stroke onset (year)	87	66.5 (10.0)	363	66.0 (12.3)
Sex (male)	87	59 (67.8%)	363	238 (65.6%)
Marital status (in relationship)	87	68 (78.2%)	363	255 (70.2%)
Education level (high)	80	30 (37.5%)	363	95 (26.5%)
Stroke severity (NIHSS)	56	3.6 (4.1)*	363	2.5 (3.0)
No stroke symptoms (NIHSS = 0)		9 (16.1%)		94 (23.8%)
Minor stroke symptoms (NIHSS 1–4)		32 (57.1%)		221 (55.9%)
Moderate stroke symptoms (NIHSS 5–12)		13 (23.2%)		71 (18.0%)
Moderate to severe stroke symptoms (NIHSS ≥ 13)		2 (3.6%)		9 (2.3%)
Stroke type	87		363
Ischemic		66 (75.9%)**		338 (93.1%)
Hemorrhagic		8 (9.2%)		25 (6.9%)
Transient ischemic attack		13 (14.9%)**		0 (0.0%)^a
Stroke hemisphere	87		358
Left		37 (42.5%)		150 (41.9%)
Right		35 (40.2%)		148 (41.3%)
Other (e.g., brainstem)		15 (17.2%)		60 (16.8%)
Discharge destination	87		363
Home		63 (72.4%)		277 (73.5%)
Inpatient rehabilitation		24 (27.6%)		86 (23.7%)

NIHSS: National Institutes of Health Stroke Scale; SD: Standard Deviation.

^a Were not included in the care-as-usual cohort.

*p < 0.05 compared to care-as-usual.

**p ≤ 0.001 compared to care-as-usual.

Table 3. Change over time in emotional and psychosocial outcome for the stroke aftercare cohort.

	Baseline (T0)	6-month follow-up (T1)	Change over time
	Mean (SD)	Mean (SD)	Mean	95% CI
Cognitive problems in daily life (CLCE-24)	4.38 (3.35)	3.93 (3.42)	−0.45	−0.98 to 0.10
Emotional problems in daily life (CLCE-24)	3.52 (2.67)	2.91 (2.75)	−0.61*	−1.09 to −0.14
Fatigue (FSS)	4.06 (1.46)	4.21 (1.57)	0.15	−0.10 to 0.39
Stroke impact on daily life (SASIP-30)	12.46 (12.63)	12.76 (14.39)	0.30	−2.05 to 2.66
Quality of life (EQ-5D-5L)	.83 (.16)	.84 (.14)	0.01	−0.02 to 0.04

CI: Confidence Interval: CLCE-24: Checklist for Cognitive and Emotional Consequences of Stroke; FSS: Fatigue Severity Scale; SASIP-30; Stroke-Adapted Sickness Impact Profile; EQ-5D-5L: EuroQol-5D-3L.

*p < 0.05.

Table 4. Rate of change in outcomes of the stroke aftercare cohort versus the care-as-usual cohort.

	Baseline (T0)		6-month follow-up (T1)		Change over time
	Estimate^a	95% CI	Estimate^a	95% CI	Estimates	95% CI
Anxiety (HADS)
Stroke aftercare	4.96	4.13 to 5.80	4.18	3.33 to 5.02	−0.78*	−1.42 to −0.15
Care-as-usual	4.79	4.37 to 5.21	4.59	4.16 to 5.01	−0.20	−0.12 to 0.51
Cohort difference^b	0.18	−1.11 to .76	−.41	−1.35 to 0.54	0.58	−0.12 to 1.29
Depression (HADS)
Stroke aftercare	4.06	3.22 to 4.91	4.34	3.47 to 5.20	0.27	−0.36 to 0.91
Care-as-usual	4.73	4.31 to 5.16	4.88	4.45 to 5.32	0.15	−0.46 to 0.17
Cohort difference^b	0.67	−.27 to 1.62	0.55	−1.51 to 0.42	−0.13	−0.84 to 0.58
Experienced restrictions in participation (USER-P)^c
Stroke aftercare	88.21	82.94 to 93.47	88.14	82.83 to 93.45	−0.07	−4.00 to 3.87
Care-as-usual	78.15	76.01 to 80.28	80.29	78.14 to 82.45	2.15*	0.54 to 3.76
Cohort difference^b	10.06*	4.37 to 15.75	7.85*	2.11 to 13.59	2.21	−2.03 to 6.47
Quality of life (EQ-5D-3L)
Stroke aftercare	0.82	.77 to .86	0.81	0.76 to 0.85	−0.01	−0.05 to 0.03
Care-as-usual	0.76	.73 to .78	0.77	0.75 to 0.79	0.02	−0.01 to 0.04
Cohort difference^b	0.06*	−.11 to −.01	0.04	−0.02 to 0.09	0.02	−0.02 to 0.07

CI: Confidence Interval; EQ-5D-3L: EuroQol 5 D-3L. HADS: Hospital Anxiety and Depression Scale; USER-P. Utrecht Scale of Evaluation of Rehabilitation- Participation.

^a Estimates are estimated marginal means for the cohort scores and unstandardized regression coefficients (b) for cohort difference scores.

^b Difference in effect over time is indicative of the time x cohort interaction effect.

^c Model corrected for stroke severity (NIHSS).

*p < 0.05.

Figure 2. Graphs displaying outcomes over time of the stroke aftercare and care-as-usual. Note: coefficients are estimated marginal means of the multilevel model. HADS: Hospital Anxiety and Depression Scale; USER-P: Utrecht scale for Evaluation of Rehabilitation- Participation; EQ: EuroQol; QoL: Quality of Life.