University of Limerick
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Transitioning to home and beyond following stroke: a prospective cohort study of outcomes and needs

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journal contribution
posted on 2024-05-09, 11:36 authored by Geraldine O’Callaghan, Martin Fahy, Sigrid O’Meara, Mairead Chawke, Eithne Waldron, Marie Corry, Sinead Gallagher, Catriona Coyne, Julie Lynch, Emma Kennedy, Thomas Walsh, Hilary Cronin, Niamh Hannon, Clare Fallon, David J. Williams, Peter Langhorne, Rose GalvinRose Galvin, Frances Horgan

Introduction Understanding of the needs of people with stroke at hospital discharge and in the first six-months is limited. This study aim was to profile and document the needs of people with stroke at hospital discharge to home and thereafter.

Methods A prospective cohort study recruiting individuals with stroke, from three hospitals, who transitioned home, either directly, through rehabilitation, or with early supported discharge teams. Their outcomes (global-health, cognition, function, quality of life, needs) were described using validated questionnaires and a needs survey, at 7–10 days, and at 3-, and 6-months, post-discharge.

Results 72 patients were available at hospital discharge; mean age 70 (SD 13); 61% female; median NIHSS score of 4 (IQR 0–20). 62 (86%), 54 (75%), and 45 (63%) individuals were available respectively at each data collection time-point. Perceived disability was considerable at hospital discharge (51% with mRS≥3), and while it improved at 3-months, it increased thereafter (35% with mRS≥3 at 6-months). Mean physical health and social functioning were “fair” at hospital discharge and ongoing; while HR-QOL, although improved over time, remained impaired at 6-months (0.69+/-0.28). At 6-months cognitive impairment was present in 40%. Unmet needs included involvement in transition planning and care decisions, with ongoing rehabilitation, information, and support needs. The median number of unmet needs at discharge to home was four (range:1–9), and three (range:1–7) at 6-months.

Conclusion Stroke community reintegration is challenging for people with stroke and their families, with high levels of unmet need. Profiling outcomes and unmet needs for people with stroke at hospital-to-home transition and onwards are crucial for shaping the development of effective support interventions to be delivered at this juncture.

ISRCTN registration 02/08/2022; ISRCTN44633579.



BMC Health Servies Research, 24, 449



Other Funding information

Funding for this study was provided by the Health Research Board (HRB) in Ireland through the Collaborative Doctoral Award Scheme (iPASTAR-Improving Pathways for Acute STroke And Rehabilitation) (HRB-CDA-2019-004). The authors gratefully acknowledge this support.

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  • Health Research Institute (HRI)

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  • (3) Good Health and Well-being

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  • Allied Health

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