Increasing Patient ‘Home Time’ After Stroke: Implications from the PCORI PROSPER Studies for Case Managers

A startling 83.6 percent of patients with a known history of atrial fibrillation who were hospitalized with acute ischemic stroke were not receiving therapeutic guideline-recommended anticoagulation therapy before their stroke in the recent Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) studies supported by the Patient-Centered Outcomes Research Institute (PCORI); https://www.pcori.org/). In the study of 94,474 patients with atrial fibrillation who were admitted for acute ischemic stroke in 1,622 hospitals across the U.S. participating in the American Heart Association’s Get With The Guidelines®-Stroke Program from 2012 to 2015, patients not receiving adequate antithrombotic medication were more likely to experience more severe stroke and had a higher risk for in-hospital mortality.¹ In a companion study of 12,552 warfarin-naïve patients with persistent or paroxysmal atrial fibrillation or flutter admitted for ischemic stroke, patients who were discharged with warfarin after a stroke had a significantly lower rate of major adverse cardiovascular events, all-cause mortality, and readmission for ischemic stroke at 2 years.² In addition, patients treated with warfarin had an average of 79 more days of ‘home time’ in the 2 years following their stroke.²

A unique aspect of the PCORI-supported PROSPER studies was the incorporation of patient feedback into the research strategy, which led to the development of the ‘home time’ measure. In a recent expert panel discussion (available at https://primeinc.org/pcori/stroke?s=cmsa), PROSPER study co-investigator, Emily O’Brien, PhD, describes the development of this measure:

"We assumed that death and preventing another stroke would be important, but what we also heard in our discussions with patients was that this concept of time spent at home really resonated with them – ‘I want to avoid hospitalization, but what I’m really concerned about is how much time I can spend at home over the next few years following my stroke.’" -- Emily O’Brien, PhD, PROSPER study co-investigator

Case managers can be integral in helping patients increase their ‘home time’ after stroke. The PROSPER studies provide clear evidence that many patients can benefit from anticoagulation treatment following stroke. However, placing a patient on an anticoagulant like warfarin can raise complications for the patient and their family, including medication adherence and the burden of ongoing monitoring of the patient’s international normalized ratio (INR).

"Many times what I hear from a case management perspective is, ‘Yes, I’ll go on that medication,’ but unless I drill down as to whether they are going to be adherent to it, there are other factors that prevent that adherence." -- Mindy Owen, RN, CRRN, CCM

Addressing underlying issues, like inadequate transportation or lack of understanding of the need to go for routine INR monitoring, is an important way case managers can support patients’ adherence and increase ‘home time.’

"Ten years of going to the lab and getting my INRs on a regular basis, I just got lazy. I didn’t go for lab work for 8 months and then when I had my stroke my INR was 0.9. My doctor told me that I have to be careful, but I just didn’t understand the severity to which a stroke would limit my life. I think that speaks to case management – it should never go away because somebody can just get very complacent, which is what I did." – Lesley Maisch, stroke survivor and PROSPER study patient investigator

Using home time may be helpful in counseling patients about the importance of adherence to therapy. Sometimes it may be difficult for patients to understand how a potential risk or clinical outcome would really impact their life. Home time is a concept that is tangible and relatable. It is not just about preventing something that may seem rare, like mortality or another stroke. It is about additional time that could be spent at home. It may help overcome some of the frustration or concern with the burden of frequent INR monitoring and medication adherence.

Appropriate anticoagulation treatment has the potential to transform outcomes for patients with atrial fibrillation who are at risk for or who have had a stroke. Through the PCORI-funded PROSPER studies, ‘home time’ was identified as a top meaningful outcome for patients, highlighting key opportunities for case managers to address underlying issues in medication adherence and monitoring and optimize patient time at home. To view more of the expert discussion on the PROSPER study findings, including clinical insights and perspectives from Emily O’Brien, PhD (PROSPER study co-investigator); Lesley Maisch (PROSPER study patient investigator); Mindy Owen, RN, CRRN, CCM; Tiffany Sizemore-Ruiz, DO, FACC; and C Michael White, PharmD, FCP, FCCP, please visit: https://primeinc.org/pcori/stroke.

¹Xian Y, O’Brien E, Liang L, et al. Association of preceding antithrombotic treatment with acute ischemic stroke severity and in-hospital outcomes among patients with atrial fibrillation. JAMA. 2017;317(10):1057-1067.

²Xian Y, Wu J, O’Brien E, et al. Real world effectiveness of warfarin among ischemic stroke patients with atrial fibrillation: observational analysis from Patient-Centered Research into Outcomes Stroke Patients Prefer and Effectiveness Research (PROSPER) study. BMJ. 2015;351:h3786.