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Olson DWM, Bettger JP, Alexander KP, et al. Transition of Care for Acute Stroke and Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary Prevention. Rockville (MD): Agency for Healthcare Research and Quality (US); 2011 Oct. (Evidence Reports/Technology Assessments, No. 202.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

Future Research

In this section, we propose activities through which identified gaps could be filled by future research studies that investigate issues related to transition of care for patients following stroke and MI. We began our review process by creating a model that described the transition of care as a process that starts during hospitalization at the stage of planning for discharge (intervention type 1); includes education of the patient and caregivers during hospitalization (intervention type 2a) as well as in the community (intervention type 2b); and is followed up by community support services (intervention type 3) and transitioning to long-term, chronic models of care (intervention type 4).

Although we defined a taxonomy for the purposes of our review, we believe that a consensus needs to be reached among investigators on a unified taxonomy and conceptual framework that defines the constituent components in the transition of care process. A clearer set of guidelines and terms that would be used to define interventions to be studied is needed for each component of the transition of care process (intervention types 1–4). We found significant heterogeneity in the definition of discharge planning among studies. Even the term “early supported discharge” was used to define a process that varied from center to center in terms of its constituent parts. This form of heterogeneity makes cross-study comparisons difficult and multicenter studies challenging.

We found that transition of care following stroke and MI could be evaluated in the context of four different types of interventions, each with a multitude of components. These components could be evaluated individually for clinical and statistical effectiveness (i.e., the effects of an education program on medication compliance) or together as components of an integrated system (the effectiveness of “early supported discharge” on functional recovery after stroke when compared to “standard rehabilitation”). Regardless of the method chosen, the intervention being tested needs to be clearly defined at the outset of the study as well as the expected outcome measures that will be used to evaluate the effectiveness of the intervention.

The control treatment used for comparison against the intervention also needs to be clearly defined in terms of the standard prehospitalization and posthospitalization care offered because the standard of care in one health care system may be quite different in another. This is most relevant in the setting of multicenter trials. Having a manual of operations with clear definitions of interventions and control therapies would allow for standardization of treatments across centers. Given the heterogeneity of the interventions as well as the systems under which these studies are carried out, measures of intervention fidelity (adherence to the protocol) need to be built into each study in order to evaluate whether the interventions were feasible and effective.

In addition to consistency in the terms used to describe the components of transition, there also needs to be a set of validated and clinically relevant outcomes. The outcomes chosen for a study should, by definition, be ones that are responsive to the intervention being tested. For example, using an outcome such as the severity of neurological deficit as measured by the NIH Stroke Scale at 6 months after an acute stroke cannot be considered an appropriate measure of the effectiveness of an educational program focusing on medication compliance. After an appropriate primary outcome is selected for study, the expected treatment effect needs to be presented along with statistical justification for the sample size chosen for the study—thus reducing the likelihood of having an underpowered trial. Secondary outcomes could serve as the basis for hypothesis testing in future trials. A number of the studies we reviewed showed a promising trend toward benefit; however, they were underpowered, and outcomes were diluted by incorporating too many variables. There are interventions that would allow an investigator to focus on one component of the system at a time and potentially create, in a stepwise fashion, a set of clinically proven interventions in a transition of care pathway. Furthermore, many of the stroke articles enrolled and reported outcomes in a mixed stroke population. Stratifying randomization and/or separating out the outcomes of ischemic and hemorrhagic stroke in future publications would be helpful to differentiating the effects on these stroke subpopulations.

We found that despite multiple different strategies aimed at educating the patient and family about the patient’s medical condition (intervention type 2), the long -term benefit of this effort seemed less clear. How to optimize health care education in order to modify behavior needs further study if it is going to be incorporated as a significant component of the transition process. It is already a cornerstone for the Joint Commission Primary Stroke Center designation for a hospital, yet there are few data on the optimal method for stroke education or whether it is associated with any benefit to the patient or family.

We found little evidence regarding the optimal method of maintaining continuity of care following hospital discharge (intervention types 3 and 4). Despite the rapid development of electronic medical records, there was limited evidence about the effectiveness of this tool as a component of transition of care. The costs associated with widespread implementation are not insignificant, and yet an optimal method for implementation in a system of health care such as that in the U.S. has not been evaluated.

Two examples of components that are suited for focused study are the role of health-related educational efforts in evaluating medication compliance (intervention type 2) and the optimal implementation of an electronic medical record to facilitate communication among multiple providers (primary care, specialty care, care coordinators, rehabilitation specialists) after an acute hospitalization (intervention type 4). Potential study designs could include patient-level randomized trials, cluster randomized trials, quasi-experimental methods, interrupted time series, or best practices research depending on whether the aim of the project is an evaluation of efficacy in controlled settings or effectiveness in real-world settings.

In other circumstances, it may not be possible to study subcomponents of an intervention; instead, a systems approach to care would need to be evaluated. Multidisciplinary discharge-planning teams (composed of doctors; nurses; social workers; and physical, occupational, and speech therapists)are an example of the latter. In that case, the entire team program could be tested against “standard” single-provider discharge planning.

For the results of an intervention to be generalizable to health care systems across the U.S., the study should involve multiple centers across states as well as across health care systems (private practice groups, academic medical centers, health maintenance organizations, etc.). Many of the studies we reviewed were conducted in Europe, Australia, and Canada with single-payer systems that could affect the ability to extrapolate their study conclusions to the U.S. More studies should be conducted under the health care system for which the intervention is intended to benefit.

Finally, future studies on transition of care could assess whether there should be separate care coordination trajectories for stroke and MI, or whether there is sufficient overlap in these interventions such that these care paradigms can translate to the general hospitalized population as a whole. For example, the disease state most studied in transition of care research (and demonstration projects) is congestive heart failure.8 Programs developed for congestive heart failure in the future could be applied to acute MI or stroke and systematically evaluated. Future research that addresses whether transition of care interventions should be disease-specific or be recommended for a general high-risk population would answer this important question. The challenges around transition of care are being recognized in all health care reform initiatives, and the Affordable Care Act of 2010, Section 3026, provides funding to test transition of care models for high-risk Medicare beneficiaries.

Cover of Transition of Care for Acute Stroke and Myocardial Infarction Patients
Transition of Care for Acute Stroke and Myocardial Infarction Patients: From Hospitalization to Rehabilitation, Recovery, and Secondary Prevention.
Evidence Reports/Technology Assessments, No. 202.
Olson DWM, Bettger JP, Alexander KP, et al.

AHRQ (US Agency for Healthcare Research and Quality)

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