Transitions of Care Stroke Disparity Study (TCSD-S)

The TCSD Study will identify disparities in transitions of stroke care and key factors
associated with effective transitions of care through structured telephone interviews to
evaluate medication adherence, healthy lifestyle, utilization of rehabilitation interventions
and medical follow-up 30 days after hospital discharge to home in 2,400 participants across 6
comprehensive stroke centers (CSC) in Florida. A novel Transitions of Stroke Care Performance
Index (TOSC PI) will be derived and validated. The primary outcomes are the TOSC PI and
90-day readmission. Other stroke outcomes include stroke disability, recurrence,
cardiovascular events, and death at 3 months. Outcomes will be collected through telephone
interviews and review of patient charts. Predictors of disparities in transition of care and
outcomes will be evaluated using baseline in-hospital data during acute stroke
hospitalization obtained from the Florida Stroke Registry and Social Determinants of Health
obtained through novel data collected from publicly available records. Based on identified
predictors of disparities in TOSC, we will develop and demonstrate feasibility of initiatives
for interventions to reduce disparities in TOSC that target systems of care with a TOSC
disparities dashboard, and health care providers with a training module for enhanced
education and support at discharge and during follow-up. We will evaluate any temporal
improvements in the TOSC Performance Index and outcomes before and after the interventions.

Inclusion Criteria:

- Ischemic stroke or intracerebral hemorrhage patients age >/=18 years that are
discharged directly to home with a modified Rankin Scale >/= 1.

Final diagnosis of ischemic stroke or intracerebral hemorrhage, included in the Get With
The Guidelines- Stroke (GWTG-S) database.

Patient or legally authorized representative provides consent Available by phone and
willing to receive two follow-up calls.

Exclusion Criteria:

- Cases with subarachnoid hemorrhage, transient ischemic attack (TIA), stroke not
otherwise specified, no stroke related diagnosis, and admission for elective carotid
intervention will be excluded.

Prisoners will be excluded. The purpose of the project is to study the hospital-to-home
transition of stroke care.

Discharged to inpatient rehabilitation, nursing home, subacute rehabilitation facilities or
assisted living facilities. These facilities support medication adherence, provide
prescribed diets, often provide in-house medical follow-up, and therefore disparities in
TOSC are less likely to be detected and not amenable to the proposed interventions.

Modified Rankin Scale of 0 after stroke. These individuals usually do not require any
rehabilitation interventions and to avid the inclusion of predominately mild stroke
patients.

Unable to obtain consent from patient or legally authorized representative. Unavailable or
unwilling to participate in the 30 and 90 day follow up telephone calls.