Managing Aftercare for Stroke (MAS): MAS-II - A Longitudinal Complex-interventional Study in Post-rehabilitation Stroke Patients

Study Overview
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Brief Summary
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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
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Managing Aftercare for Stroke (MAS): MAS-II - A Longitudinal Complex-interventional Study in Post-rehabilitation Stroke Patients

Conditions
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Stroke

Intervention / Treatment
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* Other: comprehensive multidisciplinary stroke care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients with ischemic stroke Age ≥18 years At the time of V1 completion of rehabilitation or no rehabilitation planned Informed consent signed by patient or legal representative stroke patients with a stratified mRS score within six months after the index event Exclusion Criteria: Unwillingness to participate in AmbulanzPartner Unwilling to have pseudonymized data stored, analysed, and anonymously published Patients being committed to psychiatric institutions or prisons

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Health Services Research
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: comprehensive multidisciplinary stroke care<br> | Other: comprehensive multidisciplinary stroke care<br>* Patients will be treated in the pathological domain. Some of this treatment will be applied by the outpatient clinic itself (i.e. changes in medical secondary prevention or additional prescriptions, social work interventions), whereas most of it will be referred to other providers, if possible in vicinity to the patients' home. In order to ease treatment prescriptions and allow to measure treatment uptake, patients will also enrol in the case management system Ambulanzpartner. This allows the outpatient center to streamline prescription processes and measure uptake of therapies.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| EuroQol five dimensions questionnaire (EuroQoL-5D) | questionnaire for self-completion by patients for use as a measure of health outcome | 12 Months | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Post Stroke Checklist (PSC) | checklist that helps identify post-stroke problems | 12 Months | 
| modified Rankin Scale (mRS) | scale for measuring the degree of disability or dependence in the daily activities of people who have suffered a stroke or other causes of neurological disability | 12 Months | 
| Barthel-Index (BI) | scale is used to measure performance in activities of daily living | 12 Months | 
| modified Ashworth Scale (mAS) | scale is used as a measure of spasticity | 12 Months | 
| Pain Detect (PD-Q) | questionnaire for self-completion by patients for the identification of neuropathic pain | 12 Months | 
| Freiburg questionnaire for coping (FKV) | questionnaire is used to assess disease processing modes at the levels of cognition, emotion, and behavior | 12 Months | 
| Montreal Cognitive Assessment (MoCA) | cognitive screening test in the detection of mild cognitive impairment | 12 Months | 
| partial Aachen Aphasia Test (AAT) | test is used to diagnose and describe aphasic disturbances | 12 Months | 
| Hamilton rating scale for depression | questionnaire is used to provide an indication of depression | 12 Months | 
| Morisky Medication Adherence Scale (MMAS) | questionnaire is used to assess patients' medication-taking behaviour | 12 Months | 
| Nikolaus score for evaluation of social conditions (SoS) | score is used to assess patients' social work intervention | 12 Months | 
| Häusliche Pflegeskala (HPS) | questionnaire is used to assess social work Intervention and couple's counselling | 12 Months | 
| Hospital Anxiety Depression Scale (HADS) | questionnaire for self-completion by patients to determine the levels of anxiety and depression | 12 Months | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Comprehensive Care, Stroke, Aftercare