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Randomized Pragmatic Trial of Stroke Transitional Care: The COMPASS Study.

Pamela W Duncan¹, Cheryl D Bushnell¹, Sara B Jones²

¹Department of Neurology (P.W.D., C.D.B., M.E.S., S.W.C., M.D.R.), Wake Forest School of Medicine, Winston-Salem, NC.

Circulation. Cardiovascular Quality and Outcomes

|June 2, 2020

Summary

The COMPASS transitional care (TC) program for stroke patients did not improve functional status post-discharge. While home blood pressure monitoring increased, the comprehensive intervention was not consistently implemented in real-world clinical practice.

Keywords:

blood pressure monitoring, ambulatory clinical trial patient-centered care patient-reported outcome measures stroke transitional care

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Area of Science:

Neurology
Public Health
Health Services Research

Background:

Stroke transitional care (TC) programs aim to improve patient outcomes after hospital discharge.
Real-world implementation and effectiveness of comprehensive TC models require rigorous testing.

Purpose of the Study:

To develop and test the effectiveness of the COMPASS (Comprehensive Post-Acute Stroke Services) transitional care management program in clinical practice.
To evaluate the impact of the COMPASS-TC intervention on functional status and other patient outcomes 90 days post-discharge.

Main Methods:

A pragmatic cluster-randomized trial (COMPASS study) involving 40 hospitals (20 intervention, 20 usual care).
Enrollment of 6024 adult stroke and transient ischemic attack patients discharged home between 2016 and 2018.
Patient-centered intervention assessing social and functional determinants of health for individualized care plans.

Main Results:

The primary outcome, functional status (Stroke Impact Scale-16), was not significantly influenced by the COMPASS-TC intervention.
Home blood pressure monitoring showed a significant increase in the intervention group (aOR 1.43).
No significant differences were observed in other secondary outcomes, including mortality, disability, medication adherence, depression, cognition, self-rated health, fatigue, care satisfaction, and falls.

Conclusions:

The COMPASS model of transitional care was not consistently incorporated into real-world healthcare delivery.
The study found no significant effect of the intervention on functional status at 90 days post-discharge.
Challenges in implementation may have limited the intervention's overall effectiveness.