Integrated post-stroke care improves risk factor control

20 November 2008

MedWire News: Ongoing integrated care of stroke patients improves their vascular risk profile and functional status, a randomized trial shows.

Jacques Joubert (Royal Melbourne Hospital, Australia) and colleagues randomly assigned 186 stroke survivors to usual care or to an integrated care model (ICARUSS).

“The model aims to correct recognized inadequacies in standard care: poor patient knowledge about risk factors after a stroke event, lack of systematic risk assessment in hospital, doctors’ unfamiliarity or disagreement with guidelines, and neurologists who did not consider risk factor modification their responsibility,” explains the team.

ICARUSS targets seven modifiable risk factors: blood pressure, cholesterol, atrial fibrillation, body mass index, smoking, alcohol intake, and physical activity. It focuses on preventive medications and advice given by stroke specialists and nurse coordinators before patients are discharged, and continuing management to the same targets by general practitioners (GPs).

The GPs of patients assigned to care under the ICARUSS model were supplied with evidence-based advice. They saw their patients every 3 months and had telephone access to a stroke specialist.

After 12 months, systolic blood pressure had fallen by 6.0 mmHg in the ICARUSS group, but risen by 1.8 mmHg in the usual care group. Body mass index was 0.5 kg/m² lower but 0.3 kg/m² higher in each group, respectively.

Also, the number of walks taken purely for exercise had risen by 0.8 per week in the ICARUSS group but fallen by 0.7 per week among patients receiving usual care.

Changes in diastolic blood pressure and total cholesterol level did not differ between the two groups, however.

The proportions of patients who smoked, consumed more than one alcoholic drink per day, and had atrial fibrillation did not differ according to care assignment. But 83% of atrial fibrillation patients assigned to ICARUSS were receiving warfarin, compared with 65% of those assigned to usual care.

These benefits seemed to be reflected by functional improvements, the team reports in the Journal of Neurology, Neurosurgery, and Psychiatry. Patients assigned to ICARUSS achieved a 0.4-point improvement in their average modified Rankin Scale score, compared with no change in the usual care group. They also reported a better quality of life.

J Neurol Neurosurg Psychiatry 2008; Advance online publication