Page 756

Karger_ESC London_2013

22. European Stroke Conference 776 Stroke prevention SOS CARE: The Stroke East Saxony Pilot Project for Integrated Care Pathway and Case Management after Stroke J. Kepplinger1, U. Helbig2, K. Barlinn3, L.P. Pallesen4, C. Zerna5, F. Piepenbrock6, K. Moeser7, I. Dzialowski8, H. Reichmann9, V. Puetz10, U. Bodechtel11 Department of Neurology, Dresden University Stroke Center, University of Technology Dres-den, Dresden, GERMANY1, Department of Neurology, Dresden University Stroke Center, Univer-sity of Technology Dresden, Dresden, GERMANY2, Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, GERMANY3, Department of Neurolo-gy, Dresden University Stroke Center, University of Technology Dresden, Dresden, GERMANY4, Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, GERMANY5, German Stroke Foundation, Guetersloh, GERMANY6, Dresden Internation-al University, Dresden, GERMANY7, Department of Neurology, Dresden University Stroke Cen-ter, University of Technology Dresden, Dresden, GERMANY8, Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, GERMANY9,Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, GER-MANY10, Department of Neurology, Dresden University Stroke Center, University of Technology Dresden, Dresden, GERMANY11 Background: Coordinated post-stroke care is a crucial key when goals for secondary prevention are defined. We developed a standardized pathway for integral aftercare facilitated through case man-agement (CM) to ensure minimization of risk factors, life-style changes and continuation of second-ary prevention medication. Methods: Consecutive acute ischemic and hemorrhagic stroke patients were prospectively assigned to a certified case manager based on their health insurance membership. The 1-year post-stroke care pathway comprised initial educational discussion, personal patients’ home visits and quarterly tele-phone contacts. Further personal contacts were conducted when judged necessary. Target values for vascular risk factors were pre-defined according to current stroke guidelines, compared with regular check-ups and intervened when necessary. In addition, assistance in stroke-associated social needs was provided. A closing meeting including assessment of stroke recurrence was performed. Results: Between 12/2011 and 11/2012 we enrolled 47 of 70 screened patients: 30/47 (64%) were male, mean age was 68+/-14 years, 33/47 (70%) had an ischemic, 3/47 (6%) a hemorrhagic stroke and 11/47 (24%) patients had a TIA. Six out of 47 patients refused follow-up care. In total 229 per-sonal (4.9/patient) and 663 phone (14/patient) contacts were performed by the CM. Achieved vascu-lar risk values are presented in the Table. One hundred specific interventions were necessary mostly due to missing medication, non-compliance and social needs (e.g., rejection of rehabilitation). No recurrent stroke occurred so far. Conclusion: The preliminary data of our pilot project suggest that CM is capable of achieving pre-defined goals for secondary prevention. To prove its impact on stroke recurrence risk and prevention of long-term care dependency, we currently initiate a prospective cohort study. 756 © 2013 S. Karger AG, Basel Scientific Programme Risk factor/ goal 3 months (n, %) 6 months (n, %) 9 months (n, %) 12 months (n, %) Blood pressure 32/33 (97) 27/28 (96) 23/23 (100) 12/12 (100) BMI 24/33 (73) 23/28 (82) 19/23 (83) 10/12 (83) Non-Smoking 19/33 (58) 23/28 (82) 19/23 (83) 9/13 (69) Lipids - 27/28 (96) - 12/12 (100) HbA1c - 24/28 (86) - 11/12 (92) Table: Number of patients that achieved vascular risk factor goals in quarterly check-ups so far (Status as of December 2012).


Karger_ESC London_2013
To see the actual publication please follow the link above