Risk factor management and depression post-stroke: the value of an integrated model of care

Shared care initiatives, albeit commonly utilised in managing other chronic conditions have not been implemented in the area of stroke in Australia. The aims of this project were to adopt a shared care approach for stroke survivors comparing an experimental "shared-care" group with a "treatment-as-usual" control group in reference to the normalization or reversal of vascular risk factors and the detection and management of post-stroke depression.

A randomised controlled experimental research design was implemented with participants randomized to an intervention or control group and followed over a 12-month period. The treatment group consisted of a randomly selected group of patients, discharged from an acute stroke unit and transferred into the shared care model. Risk factors for stroke and depression were compared between the two groups.

Of 97 patients originally included in the study, 17 dropped out. At 12 months, 80 patients remained for analysis (35 in the intervention group and 45 in the control group). The findings demonstrated positive trends for patients within the intervention group that were not found within the control group. The percentage of intervention patients reaching target systolic blood pressure (sBP) of 140 mmHg after 12 months tended to be greater than in the control group (p=0.11, NS). In the intervention group, at 12 months, the total cholesterol greater than 5.18 mmol/L was 12.5% compared to 58.8% at discharge. In contrast this trend was not so distinct in the control group (57.7% to 42.9%). The percentage of patients reaching target (recommended) total cholesterol of 5.18 mmol/L was significantly greater in the shared care patients intervention group relative to the control group (p=0.02). The average number of walks per week was also significantly greater in intervention group compared to the control group (p=0.048). Moreover, 45% of the control group screened as depressed compared with 20% of the intervention group at 12 months (p=0.06).

This study demonstrates that major risk factors for recurrent stroke and vascular disease in general are better managed with the shared care model than with usual post-discharge care. The significantly reduced depression as found on the screening PHQ9 at 12 months indicated that the intervention was beneficial not only in the detection of depression but also treatment.