Duncan Pamela W, Bushnell Cheryl D, Jones Sara B, Psioda Matthew A, Gesell Sabina B, D'Agostino Ralph B, Sissine Mysha E, Coleman Sylvia W, Johnson Anna M, Barton-Percival Blair F, Prvu-Bettger Janet, Calhoun Adrienne G, Cummings Doyle M, Freburger Janet K, Halladay Jacqueline R, Kucharska-Newton Anna M, Lundy-Lamm Gladys, Lutz Barbara J, Mettam Laurie H, Pastva Amy M, Xenakis James G, Ambrosius Walter T, Radman Meghan D, Vetter Betsy, Rosamond Wayne D
Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC.
Department of Epidemiology, Gillings School of Global Public Health (S.B.J., A.M.J., A.M.K.-N., L.H.M., W.D.R.), University of North Carolina at Chapel Hill.
Circ Cardiovasc Qual Outcomes. 2020 Jun;13(6):e006285. doi: 10.1161/CIRCOUTCOMES.119.006285. Epub 2020 Jun 1.
Background The objectives of this study were to develop and test in real-world clinical practice the effectiveness of a comprehensive postacute stroke transitional care (TC) management program. Methods and Results The COMPASS study (Comprehensive Post-Acute Stroke Services) was a pragmatic cluster-randomized trial where the hospital was the unit of randomization. The intervention (COMPASS-TC) was initiated at 20 hospitals, and 20 hospitals provided their usual care. Hospital staff enrolled 6024 adult stroke and transient ischemic attack patients discharged home between 2016 and 2018. COMPASS-TC was patient-centered and assessed social and functional determinates of health to inform individualized care plans. Ninety-day outcomes were evaluated by blinded telephone interviewers. The primary outcome was functional status (Stroke Impact Scale-16); secondary outcomes were mortality, disability, medication adherence, depression, cognition, self-rated health, fatigue, care satisfaction, home blood pressure monitoring, and falls. The primary analysis was intention to treat. Of intervention hospitals, 58% had uninterrupted intervention delivery. Thirty-five percent of patients at intervention hospitals attended a COMPASS clinic visit. The primary outcome was measured for 59% of patients and was not significantly influenced by the intervention. Mean Stroke Impact Scale-16 (±SD) was 80.6±21.1 in TC versus 79.9±21.4 in usual care. Home blood pressure monitoring was self-reported by 72% of intervention patients versus 64% of usual care patients (adjusted odds ratio, 1.43 [95% CI, 1.21-1.70]). No other secondary outcomes differed. Conclusions Although designed according to the best available evidence with input from various stakeholders and consistent with Centers for Medicare and Medicaid Services TC policies, the COMPASS model of TC was not consistently incorporated into real-world health care. We found no significant effect of the intervention on functional status at 90 days post-discharge. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02588664.
背景 本研究的目的是在实际临床实践中开发并测试一项全面的急性卒中后过渡护理（TC）管理计划的有效性。方法与结果 COMPASS研究（急性卒中后综合服务）是一项实用的整群随机试验，以医院作为随机分组单位。20家医院实施干预措施（COMPASS-TC），另外20家医院提供常规护理。医院工作人员纳入了2016年至2018年间出院回家的6024例成年卒中及短暂性脑缺血发作患者。COMPASS-TC以患者为中心，评估健康的社会和功能决定因素以制定个性化护理计划。由不知情的电话访员评估90天的结局。主要结局为功能状态（卒中影响量表-16）；次要结局包括死亡率、残疾、药物依从性、抑郁、认知、自评健康、疲劳、护理满意度、家庭血压监测和跌倒。主要分析采用意向性分析。在实施干预的医院中，58%持续提供干预措施。干预医院中35%的患者参加了COMPASS门诊就诊。59%的患者测量了主要结局，干预措施对其无显著影响。TC组的卒中影响量表-16平均得分（±标准差）为80.6±21.1，常规护理组为79.9±21.4。72%的干预组患者自我报告进行家庭血压监测，常规护理组为64%（调整优势比，1.43 [95%CI，1.21-1.70]）。其他次要结局无差异。结论 尽管COMPASS TC模式依据最佳现有证据设计，有多方利益相关者参与，并与医疗保险和医疗补助服务中心的TC政策一致，但该模式并未始终如一地纳入实际医疗保健中。我们发现干预措施对出院后90天的功能状态无显著影响。注册网址：https://www.clinicaltrials.gov；唯一标识符：NCT02588664。
