Case Manager Guided Organized Post-stroke Care Aids in Achieving Risk Factor Goals

Introduction: Our ongoing post-stroke care program aims at risk factors control, life-style changes and adherence to secondary prevention medication to reduce stroke recurrence and persistent disability. Methods: Consecutive acute ischemic and hemorrhagic stroke patients were prospectively included in a 1-year post stroke care program that is accomplished through a certified stroke case manager. Scheduled and non-scheduled personal contacts were regularly provided to check on risk factor control and whenever felt necessary. Target values for vascular risk factors followed current recommendations of the European stroke guidelines. Results: Between 12/2011 and 07/2014 we enrolled 101 of 155 screened patients: 58/101 (57%) were male, mean age was 71+/-13 years, median baseline NIHSS score was 2 (range 0-16), 80/101 (79%) had an ischemic stroke, 3/101 (3%) hemorrhagic stroke and 18/101 (18%) patients had a TIA. Twelve out of 101 patients withdrew from the program and three patients died due to non-vascular causes. In total 628 personal (6.2/patient) and 2683 phone contacts (26.6/patient) were conducted by the case manager. Three hundred-seventy nine specific interventions were necessary mostly due to missing medication, non-compliance and social needs. No recurrent stroke occurred during the program. Achieved vascular risk factor values are presented in the Table. Conclusion: Our findings underline that organized post-stroke care may aid in achieving pre-defined goals for secondary prevention of stroke. Further data is needed to explore its impact on stroke recurrence, prevention of persistent disability and health-care costs.