Results Summary
What was the research about?
After a stroke, it can be hard for patients to manage their health and health care when they return home from the hospital or a rehabilitation, or rehab, facility. Emotional, social, and health problems can slow recovery and increase the chance that a patient must go back to the hospital. These problems can also increase stress for caregivers. Support from social workers during this time may help.
In this study, the research team compared three types of support to help patients and their caregivers transition home after a stroke:
- Support from a social worker
- Support from a social worker plus access to a stroke education website
- Usual care consisting of access to standard services, such as stroke education and referrals
What were the results?
Patients who received social worker support plus website access
- Reported that their quality of life related to physical health improved more than patients who only received social worker support or usual care
- Felt more confident to manage and improve their health than patients who only received social worker support
The three types of support didn’t differ in
- Patients’ quality of life related to mental health and symptoms of depression and anxiety
- How likely patients were to have unplanned hospital trips or another stroke
- The number of days at home, defined as days not spent in a medical facility
- Caregiver reports of life changes, depression symptoms, social support, or number of unhealthy days
Who was in the study?
The study included 265 patients who’d had a stroke and 169 of their caregivers. Patients received care at three hospitals in Michigan. They either went directly home from the hospital or went to a rehab facility first and then went home within four weeks. Of the patients, 79 percent were white, 17 percent were black, 3 percent were other races, and 1 percent were more than one race. Also, 2 percent were Hispanic, and 11 percent didn’t report their ethnicity. The average age was 66, and 51 percent were men.
Of the caregivers, 81 percent were white, 11 percent were black, 5 percent were more than one race, and 3 percent were other races. Also, 10 percent were Hispanic, and 9 percent didn’t report ethnicity. The average age was 58, and 77 percent were women.
What did the research team do?
The research team assigned patients by chance to one of three groups. In the first group, social workers visited patients at home and made a plan to address unmet health and other needs. Social workers called patients weekly for the next eight weeks and made another home visit after four weeks. In the second group, patients had the same social worker support and also had access to a website with education and resources for stroke survivors. In the third group, patients received usual care.
Patients and caregivers responded to telephone surveys 7 and 90 days after the patient went home.
Stroke survivors, caregivers, and healthcare professionals gave input on the study.
What were the limits of the study?
Most patients in the study were white. Results may differ for patients of different races. Most of the patients in the study had mild strokes; results may differ for patients with more severe strokes.
Future research could see whether results differ for patient of other backgrounds.
How can people use the results?
Hospitals can use the results of this study when considering how to help patients and their caregivers return home from the hospital after a stroke.
Professional Abstract
Objective
To compare the effects of a social worker-led case management program with or without access to a stroke education website versus usual posthospital care on quality of life (QOL) and patient activation among stroke survivors and on caregiver-reported life changes and depression among caregivers
Study Design
| Design Element | Description |
|---|---|
| Design | Randomized controlled trial |
| Population | 265 patients who have had a stroke and 169 caregivers |
| Interventions/ Comparators |
|
| Outcomes |
Primary: patient-reported QOL related to physical and mental health, patient activation; caregiver-reported life changes and depression symptoms Secondary: patient-reported depression symptoms, anxiety, hospital readmissions, stroke recurrence/transient ischemic attacks, and home time (defined as the number of days not in a medical facility); caregiver-reported informational and emotional support and number of unhealthy days (defined as the days a caregiver reports poor mental or physical health) |
| Timeframe | 90-day follow-up for primary outcomes |
This randomized controlled trial compared the effects of three approaches for helping stroke survivors and their caregivers transition from the hospital or a rehabilitation facility to home: a social worker-led case management program, the case management program plus access to a stroke education website, and usual posthospital care.
Researchers randomly assigned patients to one of the three approaches. In the first approach, a social worker provided case management. During a home visit within a week after discharge, the social worker conducted a medical and psychosocial needs assessment and developed a plan to meet patient and caregiver goals. Social workers called weekly for 8–12 weeks, depending on need, and made another home visit one month later. The second approach consisted of the same case management program plus access to an educational website that included stroke education, medication information, community resources, stroke support groups, and caregiver resources. In the third approach, patients received only standard posthospital services such as routine stroke education or a referral to outpatient rehabilitation or home health care.
The study included 265 stroke survivors receiving care at three Michigan hospitals and 169 of their caregivers. After hospital discharge, some patients went directly home; others went to a rehabilitation facility first and then went home within four weeks. Of the patients, 79% were white, 17% were black, 3% were other races, and 1% were more than one race; 2% were Hispanic, and 11% did not report ethnicity. The average age was 66, and 51% were male. Of the caregivers, 81% were white, 11% were black, 5% were more than one race, and 3% were other races; 10% were Hispanic, and 9% did not report ethnicity. The average age was 58, and 77% were female.
Patients and caregivers completed telephone surveys 7 and 90 days after they returned home from the hospital.
Stroke survivors, caregivers, and healthcare professionals provided input on recruitment strategies and educational materials.
Results
Patient outcomes. Patients who received case management plus website access reported more improvement in physical health QOL than patients who received usual care (p<0.001) or case management alone (p=0.02). Compared with patients who received case management alone, patients who also had website access had higher patient activation (p=0.02).
The three approaches did not differ in hospital readmission rates, stroke recurrence, number of days not in a medical facility, mental health QOL, depression symptoms, or anxiety.
Caregiver outcomes. Life changes, depression symptoms, informational or emotional support, and unhealthy days did not differ among approaches.
Limitations
Most patients in the study were white. Results may differ for patients from other racial groups. Because most patients in the study had mild strokes and all returned home quickly, some outcomes may have had little potential for improvement resulting from the program.
Conclusions and Relevance
In this study, social work case management support and educational website access improved physical health QOL and patient activation, but not mental health or healthcare utilization outcomes.
Future Research Needs
Future research could evaluate these programs in a more diverse patient population or among patients with moderate and severe strokes.
Final Research Report
View this project's final research report.
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Peer-Review Summary
Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.
The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.
Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:
- Reviewers had questions about the use of a patient activation measure as a primary outcome when other primary outcomes assessed health and quality of life, which seemed to be more direct measures of improvement. The researchers said patient activation is an important measure that helps providers tailor their care to the patient’s current activation level. They stated that the measure has become popular to assess in recent studies of disease management. Given the growing recognition that patients need to be active partners in their health care, the researchers felt that patient activation was an important primary outcome to include.
- Reviewers asked for more-detailed descriptions of the interventions, including usual care, so that others would be able to replicate them. In particular, the reviewers suggested using Consolidated Standards of Reporting Trials for Social and Psychological Interventions (CONSORT-SPI). The researchers expanded the description of their interventions but explained that they did not track the exact nature of the care delivered to patients in the control group. The researchers did emphasize that usual care was not at all similar to the two interventions in the study.
- Reviewers asked about the duration of follow-up, noting that most similar interventions have followed people for longer than 7 and 90 days as in this report. The researchers said that they based the 90-day follow-up on the well-recognized fact that most improvement in physical function after a stroke occurs in the first 90 days. They said many stroke trials measure outcomes at 3 months. The researchers agreed that longer-term outcomes would have been good to measure, but the three-year duration of the study prevented this.
- Reviewers questioned the interpretation of study results. In particular, they questioned how the combined treatments impacted global health but not mental health, given poor uptake of interventions by participants and the large number of measures and comparisons used, combined with potential bias in assessing outcomes. The researchers agreed that the results were challenging to understand and explain. They revised their discussion to address these concerns and to make sure the text did not overstate what the data showed. The researchers said more work will be required in the future to distinguish how much of the results were artifactual.