Evaluating the Effectiveness of Targeted Interventions on the Quality of Life for Patients with Ischemic Stroke Open Access

Stroke is a significant global health issue, characterized by the rapid onset of focal or global cerebral dysfunction of vascular origin, resulting in death or long-term disability.^[1] Stroke has a profound effect on the emotional and psychological well-being of both survivors and their caregivers, significantly reducing their quality of life (QoL). Stroke survivors often experience a range of emotional and behavioral changes, including feelings of irritability, forgetfulness, carelessness, inattention, and confusion.^[2] In the Kingdom of Saudi Arabia, a rapidly developing nation with considerable lifestyle and environmental changes, the incidence and risk of stroke have increased substantially, with a prevalence of 43.8 per 100,000 individuals.^[3] Ischemic stroke is the most predominant form of stroke affecting the Saudi population.^[4] This high burden of stroke is projected to escalate, with the mortality rate expected to nearly double by 2030.^[5]

Understanding factors affecting the QoL of stroke survivors and their caregivers is crucial for providing the appropriate support. Sociodemographic characteristics,^[2] as well as emotional, physical, and cognitive impairments,^[6] are among those factors, which emphasizes the importance of identifying and addressing individual circumstances in stroke management.

Case management is a dynamic process in healthcare that involves assessment, planning, implementation, coordination, monitoring, and evaluation, with the aim of improving healthcare value, outcomes, and experiences.^[7] In case management, the needs of the individual patient are the central issue instead of the disease. Case management addresses the complex needs of individual patients across multiple domains of care.^[7] Case management can play a crucial role in the comprehensive care of patients with stroke, particularly during the transition from hospital to home. The gap in integration of case management strategies in current health practices for stroke management may hinder efforts for improving stroke health outcomes.

Implementing poststroke care programs based on standardized treatment pathways supported by case management has the potential to prevent secondary strokes and minimize risk factors associated with stroke, resulting in improved stroke outcomes, reduced hospitalization rates, and decreased overall cost of care for patients with stroke.^[8] However, there is a need to develop evidence-based interventions that specifically address the unique needs of individuals with stroke care challenges.

In this study, we established a comprehensive case management stroke care pathway to effectively address the challenges faced by patients with ischemic stroke, with the aim of improving patient experience and QoL and diminishing risk factors of stroke.

This study was conducted at Al Hada Armed Forces Hospital, a tertiary-care hospital in Taif, Saudi Arabia. The study design was exempt from the ethical committee review of Al Hada Armed Forces Hospital as per hospital policy.

The manuscript was prepared in accordance with the SQUIRE 2.0 guidelines,^[9] which provide a framework for reporting on quality improvement initiatives in healthcare.

Despite the initiation of a stroke committee and a comprehensive stroke program at Al Hada Armed Forces Hospital at the time of its inception, challenges in implementing the program resulted in lower than optimum outcomes for patients with stroke. Baseline data acquired regarding patients with stroke were quite alarming. In the first quarter of 2021, there was a concerning increase in-hospital readmission rates of post-stroke patients due to secondary strokes, with an average rate of 6.2%. In addition, the QoL as measured by the average modified Rankin Scale (mRS), a widely used tool for assessing the functional status of patients with stroke,^[10,11] was estimated at 3.33, indicating a poor QoL for stroke patients. This necessitated addressing the significant challenges faced by patients with stroke = in our healthcare setting.

When the factors contributing to the suboptimal outcomes for patients with stroke in our healthcare setting were studied, they were found to be grouped into three major categories: lack of a streamlined pathway for stroke care, limited public awareness regarding early detection of stroke, and ineffective benchmarking (stroke registry) for assessing patient progress and needs (Supplemental Fig. S1, available online).

Therefore, we initiated this project to work towards improving the health outcomes for patients with stroke at Al Hada Armed Forces Hospital via addressing the gaps in resource use, service provision, and evidence-based care. The aim of this project was to establish an intervention protocol that integrated case management approaches into a standardized stroke care pathway, and to evaluate the effectiveness of the intervention in improving the QoL and overall satisfaction of patients with stroke and in reducing stroke risk factors to lower the incidence of stroke reoccurrence. A team of stakeholders was assembled as a central part of setting up and facilitating the improvement project. The committee comprised the director of the case management department, a continuous quality improvement and patient safety (CQI & PS) coach, a case manager and bed coordinator, a nursing representative, and representatives from the neurology, medical administration, and materials management departments.

In this project, a comprehensive case management pathway for stroke care was planned and implemented for patients diagnosed with ischemic stroke. Quality of care was defined by the Donabedian framework, comprising indicators of structure, process, and outcome,^[12] to enable assessment of the quality of provided care and to identify the areas for improvement (Fig. 1).

The intervention was implemented from May 2022 through July 2023, addressing patients with the diagnosis of ischemic stroke (N = 136) admitted to the inpatient (medical and surgical) wards.

The intervention involved a stroke interdisciplinary committee comprising primary care physicians, social workers, physiotherapists, case managers, and other supporting staff (Fig. S2) to provide coordinated care, support, and advocacy for patients with stroke. The team worked collaboratively to develop individualized care plans and to coordinate care through regular communication. The COMPrehensive Post-Acute Stroke Services (COMPASS) study^[13] was used as a guide for developing individualized care plans (via identifying patient needs and tailoring care to patient challenges, facilitating collaboration among health providers, tracking recovery indicators, and providing targeted education to patients and caregivers) to deliver patient-centered care for stroke survivors.

A stroke case management pathway was established (Fig. S3) to provide timely assessments and treatments, to involve family members in the care plan, and to coordinate referrals for additional services such as rehabilitation.

The intervention focused on developing a one-on-one role for case management in the care of patients struggling with stroke health challenges (Table 1, Fig. S4). The relationship of patients with stroke and case management started from the time of admission. Patients were seen daily during case management rounds. Patients were provided with educational materials on poststroke recovery promoting self-management and adherence to prescribed medications and offering guidance on lifestyle changes. Moreover, a poststroke support group (virtual and face-to-face) was established, in which discharged poststroke patients could inquire, and verbalize their feelings, about the recovery journey in a safe environment to help them cope with and adapt to their new situation. Furthermore, a virtual multidisciplinary stroke care clinic^[14] involving a stroke interdisciplinary committee was established to ensure convenient follow-up consultations and ongoing monitoring of patient progress. Case management appointments and services were free and bilingual.

In addition, the intervention focused on raising public awareness on stroke to promote early detection of stroke cases. The intervention used social media platforms to disseminate information about the symptoms of stroke, the importance of timely intervention, and the available treatment options.

By addressing the specific needs of patients with stroke, coordinating care, providing education and support, and raising community awareness, the intervention aimed to improve health outcomes and enhance the overall well-being of patients with stroke. Constant monitoring and evaluation were performed throughout the project, according to which necessary adjustments and adaptations to our strategies were made based on the outcomes we needed to measure.

The study used a quasi-experimental preintervention and postintervention evaluation design to assess the effectiveness of the case management intervention. Study participants were evaluated by neurology senior registrars at admission (baseline) and 90 days after discharge to quantify poststroke health symptoms, QoL, and functioning. In parallel, qualitative data were collected by case managers through one-on-one interviews to explore patient compliance and satisfaction. By using both quantitative and qualitative approaches to analyze the effect of the case management intervention on poststroke outcomes, this study may provide valuable insights into the effectiveness of case management in improving outcomes for patients with stroke.

Data sources for this study included patient reports from the case management department and through the stroke interdisciplinary committee. For estimating the study measures, data were collected on a weekly and monthly basis from the hospital information system (WIPRO) and submitted to the CQI & PS department for analysis. All data were initially validated by the CQI & PS department. Subsequently, 10% of our data (through random sampling) were independently validated by other reviewers. If the results exceeded 90%, the data were considered valid. Shadowing methodology was also used in data collected by observation through case management rounds.

These process measures were chosen to address specific aspects of the case management integration process based on their direct relevance to the desired outcomes. These comprised the percentage of compliance with stroke multidisciplinary team (MDT) review, the percentage of early referral to rehabilitation services, the percentage of patient access to supplies and equipment prior to discharge, the percentage of patient adherence to medications postdischarge, and the percentage of patient compliance with blood pressure (BP) monitoring postdischarge (Supplemental Table S1).

QoL was estimated using the average score of the mRS for neurologic disability, which assesses the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability.^[10,11] The mRS is a six-point disability scale with possible scores ranging from 0 to 5: (0) no residual symptoms; (1) no significant disability and able to carry out prestroke activities; (2) slight disability and unable to carry out all prestroke activities but able to look after self without daily help; (3) moderate disability: requiring some external help but able to walk without the assistance of another individual; (4) moderately severe disability: unable to walk or attend to bodily functions without assistance of another individual; and (5) severe disability: bedridden, incontinent, and requires continuous care. A separate category of 6 is usually added for deceased patients. The lower the mRS score, the more improved patients have become with regards to QoL. The mRS was assessed twice for each patient: initially at admission (baseline) and at 90 days postdischarge (Supplemental Table S1).

Patient satisfaction surveys were conducted by case managers via phone call 2–3 days after discharge. The survey involved a five-point–scale questionnaire tailored for each patient according to the newly implemented strategy personalized for that patient. The survey score was calculated as the sum of points answered by the patient. A score of 4 or 5 was considered a positive response. The postdischarge patient satisfaction outcome measure was estimated by the percentage of positive responses out of the total number of survey responses (Supplemental Table S1).

This tracked the percentage of readmissions due to secondary stroke within 30 days of discharge out of the total number of discharged patients with ischemic stroke (Supplemental Table S1).

Data for baseline and outcome measures are compared in Supplemental Table S2.

We used the study by Wang et al,^[15] involving over 22,000 patients with acute stroke, to calculate quality-adjusted life-years (QALYs) using weights derived from mRS scores. The derived utility-weighted mRS scores for mRS 0–6 were 0.96, 0.83, 0.72, 0.54, 0.22, −0.18, and 0, respectively.

A cost-effectiveness threshold was used to convert QALYs to monetary value. An often-cited international average value for 1 QALY is approximately 50,000–100,000 USD. This range is a broad average and can differ based on specific health economics contexts.^[16]

Data analysis was conducted using SPSS (version 26.0, IBM Corp). Due to the nonnormal distribution of the data, as indicated by a significant Shapiro-Wilk test, nonparametric analysis using the Wilcoxon signed-ranks test was used to compare parameters before and after the implementation of the interventional strategic plan. A p-value of less than 0.05 was considered statistically significant. Process measures were displayed using line charts with trend lines. The outcome QoL measure was presented using a bar graph, with correlation between initial and follow-up measures. Process measures were displayed using line charts with trend lines. The outcome QoL measure was presented using a bar graph, with correlation between initial and follow-up measures.

The intervention addresses 136 patients with the diagnosis of ischemic stroke admitted to inpatient wards throughout the duration of the study. Patients are of both genders, with ages ranging from 20 to 101 years. Fifty-three patients are eligible for rehabilitation services. The QoL measures are improved for a total of 109 patients (80.15%): 58 patients are discharged to home (42.64%) and 51 patients improve with the help of rehabilitation services (37.51%). For the remaining 19.85% of patients, 18 are bedridden with comorbidities and are not eligible for rehabilitation services (13.23%), 7 died during the study (5.15%), and 2 show no improvement with regards to their mRS (1.47%).

The baseline for the percentage of compliance with stroke MDT review is 47.1% in May 2022. Our target was an increase to 50% followed by a 25% increase quarterly. Our initial target was first achieved in July 2022. The compliance percentage has increased to a sustainable target of 100% by the end of July 2023 (p = 0.012) (Fig. 2).

Regarding the percentage of early referral to rehabilitation services prior to discharge (Fig. 2), there is a gradual sustainable improvement from 50% during the second quarter of 2022 to 89% in the second quarter of 2023. The target (85%) is reached during the first quarter of 2023 and is sustained until the end of the study.

The percentage of patient access to supplies and equipment prior to discharge shows a gradual sustainable improvement from 64.7% at baseline (May 2022), through an average of 70.4% during the first quarter of the intervention and reaching a 100% average during the final quarter of the intervention. The target is reached during the third quarter of 2022 and is sustained until July 2023 (p = 0.018) (Fig. 2).

Regarding the adherence of patients with stroke to their medications following discharge (Fig. 3), there is a sustainable improvement in the percentage of adherence, from a baseline percentage of 58.8% (May 2022) to an average of 97% after implementation of the new strategies. The target average (50%) is achieved during the third quarter of 2022 and is sustainable through July 2023.

There is a gradual sustainable improvement in the patient compliance with BP monitoring following discharge (Fig. 3). The results improve from a baseline measure of 52.9% (May 2022), with an average of 71.2% during the first quarter of the intervention, to an average of 96% during the final quarter of the intervention. The target (90%) is achieved during the fourth quarter of 2022 and is sustained until July 2023 (p = 0.046).

The QoL of patients with ischemic stroke is assessed using average mRS scores. Of 136 patients, the QoL measures improve for a total of 109 patients (80.15%). As shown in Figure 4, the QoL is improved from a baseline average mRS score of 3.33 at admission to an average score of 0.91 at reassessment 90 days after discharge (target of the intervention: 1.00) (p < 0.001).

Regarding postdischarge patient satisfaction, Figure 4 shows a remarkable increase in patient satisfaction from 45% during the second quarter of 2022 to 94% at the end of the intervention.

Figure 5 shows a significant reduction in the rate of readmission within 30 days due to secondary strokes. The readmission rate is reduced and sustained from an average of 6.2% before the intervention to an average of 4% at the end of the intervention.

The values of the project measures before and after the intervention are summarized in Table 2.

Unintended outcomes are achieved by the intervention, including a positive effect on mortality rates and the percentage of patients with ischemic stroke receiving recombinant tissue plasminogen activator (rtPA), which may be indicators of the effectiveness of the new intervention. There is a remarkable reduction in mortality rates from a preintervention evaluation average of 15% (first quarter of 2021) sustained throughout the intervention and reaching a postintervention evaluation average of 5.7% (Fig. 5). Furthermore, there is a slight improvement in the average rate of patients receiving rtPA (data not shown). In 2022, the percentage of patients with ischemic stroke receiving rtPA was 5%. By the end of the study, the percentage increases to 21%. Nevertheless, the percentage of patients with stroke in the study group who receive rtPA is still considerably low, highlighting the necessity for additional improvements.

Using utility-weighted mRS scores,^[15] the estimated QALY gain per patient, with an improvement in mRS score from 3.33 to 0.91, is approximately 0.41 QALYs. This means, on average, each patient experiences an improvement in QoL equivalent to gaining about 0.41 years of life in perfect health.

Based on the international average values for 1 QALY, the estimated monetary value of the 0.41 QALYs gained per patient is approximately 20,500–41,000 USD (76,897–153,794 Saudi riyals) per QALY (Table 3).

Case management is a collaborative process that involves coordination of services and resources to address the unique needs of individual clients.^[7] This project was initiated to establish a standardized and comprehensive case management pathway for stroke care to ensure that patients with stroke receive the most optimal care in our healthcare setting. The aims of the project were to improve the QoL and satisfaction of patients with stroke and to reduce the incidence of stroke reoccurrence. The focus of this study was patients diagnosed with ischemic stroke, the most common form of stroke, accounting for 79–87% of all reported stroke cases in Saudi Arabia.^[17] The consequences of ischemic stroke often encompass cognitive impairments, motor deficits, and communication difficulties that can severely impair daily functioning and independence. The financial cost incurred by patients and their families due to medical treatment, rehabilitation services, and long-term care can be substantial. In addition, the indirect costs due to loss of productivity and diminished work capacity contribute to the economic strain of poststroke patients.^[18] We initiated this work by reviewing the literature to develop evidence-based case management interventions that can effectively address the challenges faced by patients with ischemic stroke. Using the Donabedian framework for healthcare quality assessment^[12] as a guiding principle for continuous assessment and reassessment of our interventions ensured their effectiveness and allowed the introduction of necessary modifications throughout the process. Our approach involved multidisciplinary collaboration within the clinical team, including case managers and social workers.^[19] Interprofessional teamwork involving different service providers is an essential component of integrated care.^[20] A specialized MDT of health professionals specifically trained to work with patients with stroke included a doctor, a nurse, a physiotherapist, an occupational therapist, a speech therapist, a clinical psychologist, and a social worker,^[7] with communication and correct understanding of roles significantly contributing to the work of a multidisciplinary stroke team.^[13] There was a remarkable improvement in our process measures: the percentage of compliance with stroke MDT review (mean = 100%, p = 0.012), the percentage of early referral to rehabilitation services (mean = 87%), the percentage of patient access to supplies and equipment prior to discharge (mean = 100%, p = 0.018), the percentage of patient adherence to medications following discharge (mean = 90%), and the percentage of patient compliance with BP monitoring following discharge (mean = 96%, p = 0.046). Consistent improvement of our process measures directly affected our outcomes, translated as an improvement in QoL (mean mRS = 0.91, p < 0.001) and patient satisfaction (94%). In addition, a considerable decrease in mortality rates was observed for patients with ischemic stroke (mean = 5.7%).

The COMPASS study is a recent trial that aimed at improving poststroke outcomes by focusing on careful patient assessment and ensuring patients receive enough information to know their risk factors. The COMPASS intervention used postacute care coordinators, mostly nurses, to serve as patient case managers. These teamed up with advanced practice providers, such as nurse practitioners, to provide comprehensive care and address self-care and disease management obstacles.^[13] The COMPASS study was used as a guide in this work because it successfully implemented a comprehensive transitional care model for patients with stroke, incorporating evidence-based practices, multidisciplinary collaboration, patient-centered care, and a community-based approach. In contrast to the COMPASS study, our project team used nurses as case managers to fulfill two key roles: enhancing patient functional outcomes and assessing the patient-centered approach. By leveraging the expertise of nurses in these capacities, we aimed to enhance the overall quality of care provided, focusing on improving patients’ functional abilities and ensuring a patient-centered approach to healthcare delivery. This approach was intended to optimize patient outcomes and tailor care plans to meet individual needs effectively within our project framework. The COMPASS study had the advantage of wide-ranging hospitals and a collaborative network of satellites, enabling the implementation of the community-based care model to improve secondary prevention, recovery, and access to community resources for stroke survivors and caregivers, which was not available for our project. Nevertheless, the COMPASS study intervention resulted in only 43% higher odds of home BP monitoring compared with 96% compliance in our study, which may be explained by our limited patient population and the strict implementation of strategies. But then again, we were not able to implement case management community outreach (face-to-face visits) due to staff shortage. The well-established strategies of the COMPASS trial influenced our work to achieve an anticipated excellent outcome. Nevertheless, postacute transitional care should be the next frontier for quality improvement for stroke care systems.

In the single-center study by Barlinn et al,^[8] it was shown that case management–based poststroke care is feasible and may contribute to the effective prevention of secondary stroke. The study provided a result of no recurrent stroke in the study participants. In comparison, we had an average of 4% of hospital readmission rates due to secondary stroke, which is still less than adequate. Nevertheless, in the final quarter of our study, the readmission rate due to secondary stroke was reduced to 0%.

The improvement in the QoL of patients with stroke and the reduction of hospital readmissions for secondary stroke in our study was achieved in part by regular personal and phone contacts with nurse case managers to monitor interventions and other risk factors, which are well-established techniques in care for patients with stroke.^[21]

The effectiveness of virtual multidisciplinary stroke care clinics in the care of patients with stroke was evaluated in a recent study by Chau and colleagues.^[14] In the study, the virtual clinic was nurse-led, in contrast to the physician-led clinic in our study. Nevertheless, improved health outcomes were achieved in both studies.

Timely rtPA administration to patients with stroke is associated with favorable outcomes and improved QoL through improving sleep patterns and physical, social, and psychological conditions.^[22] Although our study addressed and acknowledged community awareness as an important factor in promoting early intervention for stroke, the percentage of patients receiving rtPA remained low in our hospital setting. This could be caused by the arrival of most patients with stroke to the hospital outside the time window for rtPA administration. Therefore, it is mandatory to explore the various factors that may affect patient compliance with seeking immediate emergency medical attention during the onset of stroke symptoms and to enhance patient and public education on the importance of timely access to appropriate stroke care.

Although the mentioned studies explored the benefits of case management in poststroke care, this study specifically examines the effect of a structured case management approach for stroke care within a specific healthcare system. This study makes a significant contribution to the field of stroke care by providing evidence for the effectiveness of case management in improving patient outcomes and optimizing healthcare resources. Its unique focus on creating a standardized pathway, boosting multidisciplinary collaboration, and prioritizing patient-centered practices, coupled with detailed analysis of process and outcome measures, offers valuable insights for future research and practice.

This project is the first to examine the effectiveness of case management in poststroke care in Saudi Arabia and how it contributes to hospital efficiency and patient outcomes. In addition, the cost savings resulting from improving patient QoL benefit the hospital and improve its efficiency. Ultimately, the findings of this study can potentially improve the QoL for patients with stroke, enhance overall stroke care delivery, and optimize healthcare resources.

The absence of an established systematic stroke pathway at Al Hada Armed Forces Hospital was a hindering factor in this study. Without a standardized pathway, there was a lack of consistency and coordination in the care provided to patients with stroke across different departments and by healthcare professionals involved in their management. Moreover, the hospital lacked a stroke unit and a dedicated neurology intensive care unit, thus limiting the access of patients with stroke to optimal care, which could have had a potential effect on their outcomes and QoL. Furthermore, there is no rehabilitation center in the hospital; patients requiring further care had to be referred to other facilities. In addition, supplies (e.g., BP devices) were not available for all patients, which affected patient self-care and posed a problem in preventing stroke reoccurrence. In addition, the suggested strategies will be difficult to reproduce in healthcare settings lacking well-established case management departments. Despite these challenges, the project team succeeded in implementing its strategies and interventions while using the available resources. One of the limitations of the study is its narrow focus on patient satisfaction, which limits the study’s ability to provide a holistic understanding of the effect of the intervention on caregivers. Another limitation of the study is the absence of a control group, which would have been useful in identifying the effects of the case management pathway.

The study demonstrates the effectiveness of an evidence-based case management intervention in enhancing outcomes for individuals facing poststroke challenges, underscoring the significance of such interventions in meeting the unique needs of this population.

Supplemental materials are available online with the article.

We would like to extend our heartfelt gratitude to Ministry of Defense Health Services (MODHS) in Riyadh, Saudi Arabia, especially Ahmed Mohammed Al Amri, CEO of the Health Services Directorate of Saudi Arabia, for his unwavering support and guidance in enhancing the stroke case management pathway within our healthcare system. We also wish to express our appreciation to Noura Alnowaiser, Executive Healthcare Quality Director (MODHS, Riyadh, Saudi Arabia), and Yasser Alotaibi, Deputy Director of Quality Improvement and Patient Safety (MODHS, Riyadh, Saudi Arabia), for their guidance and unwavering support throughout this transformative journey. Furthermore, we extend our thanks to all medical and nonmedical staff who played a pivotal role in ensuring the success of this intervention.