Managing Aftercare for Stroke (MAS): MAS-I - a Cross Sectional Study of Post-rehabilitation Stroke Burden and Patients' Needs

Study Overview
=================
Brief Summary
-----------------
In this first step of the study the investigators will assess the needs, disease burden and current treatments of long-term stroke patients (phase MAS-I). The ultimate aim of the complete MAS project (MAS I, II & III) is the development of a model of stroke aftercare delivery that can be evaluated to estimate effects in both our local and the wider stroke population.

Detailed Description
-----------------
After discharge from hospital the current healthcare system in Germany allows considerable flexibility (therefore complexity) of patient access and mobility between multiple care providers in the community setting. The investigators believe this aftercare could be better coordinated by a specialized coordinated stroke aftercare service. Comprehensive coordinated multidisciplinary care is a proven concept with proven benefits in both acute and rehabilitation care provided in stroke units and neurorehabilitation centres. In this study the investigators postulate that a similar coordinated approach to care can be extended to the phase after in-patient rehabilitation has ended (i.e. long-term management as opposed to early supported discharge) for disabled patients with stroke living in the community.

Official Title
-----------------
Managing Aftercare for Stroke (MAS): MAS-I - a Cross Sectional Study of Post-rehabilitation Stroke Burden and Patients' Needs

Conditions
-----------------
Ischemic Stroke

Participation Criteria
=================
Eligibility Criteria
-----------------
Inclusion Criteria: Age ≥18 years Participation in one of the previously conducted stroke cohort studies: STRAWINSKI or PREDICT Modified Rankin Score (mRS) recorded as = 1 - 5 (at last follow up during cohort study) Informed consent signed by patient or legal representative Exclusion Criteria: Unwilling to have pseudonymised data stored, analyzed & anonymously published. Patients participating in the previous studies recruited in centres outside Berlin

Ages Eligible for Study
-----------------
Minimum Age: 18 Years

Sexes Eligible for Study
-----------------
All

Accepts Healthy Volunteers
-----------------
No

Study Plan
=================
How is the study designed?
-----------------

Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| stroke patients<br>post-rehabilitation stroke patients | |

What is the study measuring?
-----------------
Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Prevalence of unmet Needs | Unmet needs of patients and carers after discharge from Rehabilitation. Score of variables examined (self-reported stroke related need, post-stroke spasticity, post-stroke pain, post-stroke aphasia, neuropsychological impairment, post-stroke depression, post-stroke dementia, inadequate secondary prevention, social care need and carer burden). | once | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| post-stroke checklist | Evaluation of post-stroke checklist as a valid tool to screen for relevant burden of disease after stroke. | once | 
| Standard practice evaluation | Comparison of Standard practice in relation to evidence-based recommendations and current Clinical Guidelines for the management of stroke. | once | 

 Terms related to the study
=================
Keywords Provided by Centre Hospitalier Valida
-----------------
stroke, aftercare