Results Summary
What was the research about?
Strokes occur when blood supply to the brain is blocked. After a stroke, people often have a hard time with daily activities like walking. Getting care and support after leaving the hospital may help people recover from a stroke and prevent problems like falls.
In this study, the research team wanted to learn if a care program called COMPASS-TC helped stroke survivors recover after leaving the hospital. The team compared COMPASS-TC with hospitals’ usual follow-up care.
What were the results?
Among hospitals assigned to COMPASS-TC, only 58 percent offered COMPASS-TC consistently; only 35 percent of patients at those hospitals received the program.
After three months, COMPASS-TC and usual care didn’t differ in:
- Patients’ physical disability, physical activity, and ability to do daily activities
- Patients’ overall health, fatigue, depression, and ability to think clearly
- How often patients took their medicine as directed
- Patients’ satisfaction with care
- Fall and death rates
- Family caregiver stress
Patients assigned to COMPASS-TC were more likely to check their blood pressure at home than patients assigned to usual care.
Who was in the study?
The study included 5,882 patients receiving care for a stroke at one of 41 hospitals in North Carolina and 4,208 of their caregivers. Among patients, 72 percent were White, and 25 percent were Black. The average age was 67, and 50 percent were women.
What did the research team do?
The research team assigned hospitals by chance to provide COMPASS-TC or usual care. In COMPASS-TC, a nurse called patients two days after they left the hospital. Within two weeks, patients had a follow-up visit at the clinic. Patients worked with doctors and nurses to create a care plan that could help patients get services like transportation or support with cooking. After 30 and 60 days, a nurse called patients to see if they were following the plan. All patients received information about managing and tracking their blood pressure.
Three months after leaving the hospital, patients and caregivers completed surveys. The research team looked at health records and stroke registries for data about patients’ health and use of health care.
Stroke survivors, caregivers, and staff from hospitals, community groups, and advocacy groups helped design the study.
What were the limits of the study?
Most patients assigned to COMPASS-TC didn’t receive it. Some hospitals had a hard time staffing the program; some patients preferred to see their regular doctors. Only 59 percent of patients and 29 percent of caregivers completed surveys. Results may have differed if more patients received COMPASS-TC and responded to surveys.
Future research could look at other ways to improve stroke follow-up care.
How can people use the results?
Hospitals can use the results when considering ways to support stroke survivors.
Professional Abstract
Objective
To compare the effectiveness of the Comprehensive Post-Acute Stroke Services Transitional Care model (COMPASS-TC) versus usual care after hospital discharge in improving functional status among patients with stroke or transient ischemic attack (TIA)
Study Design
| Design Element | Description |
|---|---|
| Design | Pragmatic cluster randomized trial |
| Population | 41 hospitals in North Carolina providing care for 5,882 patients with mild to moderate stroke or TIA and 4,208 of their family caregivers |
| Interventions/ Comparators |
|
| Outcomes |
Primary: functional status Secondary: caregiver strain, 90-day mortality, self-reported disability, medication adherence, depression, cognition, self-rated health, physical activity, fatigue, satisfaction with care, home BP monitoring, falls, all-cause hospital admissions, admissions to skilled nursing and inpatient rehabilitation facilities, ambulatory care and emergency department visits |
| Timeframe | 3-month follow-up for primary outcome |
This cluster randomized trial compared the uptake and effects of COMPASS-TC versus usual care on patient functional status and health outcomes, caregiver burden, and healthcare utilization among patients with stroke or TIA.
Researchers randomly assigned hospitals to provide COMPASS-TC or usual care when discharging patients after stroke or TIA. All patients received information on managing and tracking their blood pressure (BP). In COMPASS-TC, a nurse called patients within two days of discharge. Within two weeks of discharge, patients had a clinic visit with an advanced practice provider or doctor to develop a care plan that included referrals to rehabilitation and community resources. A nurse called patients after 30 and 60 days to evaluate plan adherence. Usual care was the hospitals’ standard post-acute care.
The study included 5,882 patients with stroke or TIA who received care at one of 41 hospitals in North Carolina and 4,208 caregivers. Among patients, 72% were White, and 25% were Black. The average age was 67, and 50% were female.
Three months after discharge, patients completed phone surveys; caregivers completed mail surveys. Researchers reviewed electronic medical records, stroke registries, and claims data for clinical outcomes and healthcare utilization data one year after discharge.
Patients, family caregivers, and representatives from hospitals, community-based services, and advocacy organizations helped design the study.
Results
Among hospitals assigned to COMPASS-TC, only 58% delivered COMPASS-TC without interruption; only 35% of patients at those hospitals received it.
COMPASS-TC and usual care did not differ significantly in patients’ 90-day functional status or any patient-reported outcome except home BP monitoring. Patients assigned to COMPASS-TC were more likely to monitor home BP than patients assigned to usual care (odds ratio: 1.43; 95% confidence interval [CI]: 1.21, 1.70).
Patients with Medicare fee-for-service plans assigned to COMPASS-TC had higher rates of ambulatory care visits within one year than patients assigned to usual care (hazard ratio: 1.27; 95% CI: 1.14, 1.41). Within the first 30 days, fewer patients with Medicaid (12%) had an ambulatory care visit than patients with Medicare fee-for-service plans (89%) or private insurance (78%). Other healthcare utilization outcomes did not differ significantly.
Limitations
Most patients assigned to COMPASS-TC did not receive it because of system-level barriers like lack of funding for staff, patient-reported barriers like transportation, and patient preference for their primary care doctor. Only 59% of patients and 29% of caregivers completed outcome surveys. Results may have differed if more patients received the intervention and responded to surveys.
Conclusions and Relevance
In this study, COMPASS-TC was not consistently incorporated into care and did not improve patients’ functional status or other outcomes except for BP self-monitoring compared with usual care.
Future Research Needs
Future research could evaluate the feasibility of health systems providing transitional care and effectiveness of other approaches to help patients with stroke or TIA after hospital discharge.
Final Research Report
View this project's final research report.
Engagement Resources
Journal Citations
Results of This Project
Related Journal Citations
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. Those comments and responses included the following:
- The reviewers praised the researchers for undertaking this difficult pragmatic study and for providing such a forthright description of the problems the study experienced in its implementation as well as the lack of treatment effect on the primary outcome. The reviewers asked whether the researchers had considered looking for factors that may have interfered with the effect of the delivered interventions. The reviewers thought that identifying and measuring the mediating factors at the individual, hospital, and societal levels could explain why the intervention did not work and where the researchers could invest their energies in the future. The researchers added to the report’s discussion to reference these ideas and explain why there would be considerable difficulties measuring any of the constructs that could interfere with the effect of the intervention on patients.
- The reviewers questioned whether the lack of a treatment effect could have been caused by poor communications between the hospital team and community resources. The researchers explained that at each site they established a community research network to encourage collaboration between stroke units and community resources.
- One reviewer noted that an important lesson from this study appeared to be that hospitals did not appear to be sufficiently equipped to provide comprehensive patient support post stroke. The researchers agreed that this remains a concern given the continuing focus on acute care rather than rehabilitation and the difficulties obtaining reimbursement for transitional care management that is needed post stroke. The researchers suggested additional research on ways to incentivize institutions to set up the financial and staffing resources necessary to provide care transitions for these vulnerable patients.
- The reviewers asked whether the results of this study would be generalizable to patients with more disabling stroke symptoms than the participants of this study. The researchers acknowledged that the study was specifically focused on individuals with mild stroke or transient ischemic attack because there is substantial evidence that even individuals who are less disabled have high healthcare utilization post stroke and do not know the risk factors for future stroke. The researchers did not think that the results would be generalizable to more disabled stroke survivors and that including these more severe cases would likely increase uptake of their transitional care intervention and may have significantly affected outcome results related to physical function compared to patients with mild stroke symptoms and limited disability.