Clinical Neurology and Neurosurgery 154 (2017) 89–93

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Clinical Neurology and Neurosurgery

journal homepage: www.elsevier.com/locate/clineuro

An individualized coaching program for patients with acute ischemic

stroke: Feasibility study
P. Vanacker a,b,∗ , D. Standaert a , N. Libbrecht a , I. Vansteenkiste a , D. Bernard c ,
L. Yperzeele b , G. Vanhooren d
a
Department of Neurology, Sint-Lucashospital, Bruges, Belgium
b
NeuroVascular Reference Center, Antwerp University Hospital, Edegem, Belgium
c
Medical director, Sint-Lucashospital, Bruges, Belgium
d
Department of Neurology, Sint-Janhospital, Bruges, Belgium

a r t i c l e i n f o a b s t r a c t

Article history: Objectives: An individualized stroke care program was developed to match patients’ education with their
Received 12 December 2016 needs regarding stroke knowledge, secondary prevention and rehabilitation. Our purpose was to assess
Received in revised form 14 January 2017 feasibility of in-hospital and post-discharge, personalized stroke coaching service.
Accepted 23 January 2017
Methods: Acute ischemic stroke patients enrolled in ASTRAL-B stroke registry (Sint-Lucashospital, Bruges
Available online 24 January 2017
Belgium) with: (a) hospitalization between 12/2014–12/2015, (b) hospital-to-home discharge, and
(c) without cognitive decline, were selected. The stroke coach contacted patients individually twice
Keywords:
during hospitalization (2 × 20 min) and post-discharge via phone calls using the standardized WSO
Cerebral infarction
Education
Post-Strokechecklist. Risk factor management, review of therapy and clinical evolution were discussed.
Coaching Participants were contacted at 2 weeks, followed by repeat calls if necessary and ambulatory with the
vascular neurologist at 1, 3, 6 and 12 months.
Results: Of all 255 patients meeting the inclusion criteria, 152 (59.7%) received individualized education
during hospitalization by the stroke coach. Median age of our population was 74 years and median NIHSS
5. Majority of patients had at least two cardiovascular risk factors. Patients were not coached because
of palliative care/decease (10%), unfavorable life expectancy (2%), dementia (8.5%) and lack of time due
to short hospitalization (22%). A quarter of all patients were contacted at least once by phone, 12% were
contacted at least twice after discharge. At three months, low stroke recurrence (5%) and mortality rates
(4%) were identified, probably linked to improved adherence.
Conclusions: We demonstrated feasibility of an individualized coaching service executed by well-trained
stroke nurse. Future research will focus on developing an online portal delivering post-discharge services
to patients and caregivers.
© 2017 Elsevier B.V. All rights reserved.

Introduction
Stroke mortality has been declining over the past decades, par-
tially by reduced incidence of stroke and lower case-fatality rates
[1]. These significant improvements are partially related to the
improved cardiovascular risk factor control interventions on arte-
rial hypertension, diabetes mellitus and dyslipidemia control, and
smoking cessation programs [2]. Despite evidence-based guide-
lines, these therapeutic strategies recommended for secondary
prevention are rather modestly implemented. Significant deficien-
∗ Corresponding author at: Sint-Lucashospital, Sint-Lucaslaan 29, 8310, Bruges,
Belgium.
E-mail address: peter.vanacker@stlucas.be (P. Vanacker).
cies in secondary prevention care in the real world have been
reported [3]. In Belgian patients with stroke recurrence, cardiovas-
cular risk factors were often not satisfactorily controlled, or they
were not taking any antithrombotic agent at all [4].
So far, different types of interventions (educational, moti-
vational, reminders or combinations) were studied to improve
adherence to secondary preventive medication [5]. Until now, no
standardized process for chronic stroke care has been accepted.
As a result, management of post-stroke care varies greatly, and
the needs of stroke survivors are not fully addressed. Implementa-
tion of cerebrovascular disease prevention programs may improve
adherence and reduce stroke recurrence rates in the specific Belgian
clinical practice as has been shown earlier by our group. Persistence
was high with both pharmacological and non-pharmacological

http://dx.doi.org/10.1016/j.clineuro.2017.01.017
0303-8467/© 2017 Elsevier B.V. All rights reserved.
90 P. Vanacker et al. / Clinical Neurology and Neurosurgery 154 (2017) 89–93

prevention strategies (71%) during the 24 months post discharge Table 1

A selection of baseline characteristics dichotomized based on the participation to the
period [6]. Knowledge of the complexity of the patient and care-
individual coaching program. Values are expressed as medians for continuous vari-
giver characteristics is essential in the promotion of adherence to ables unless stated otherwise and as absolute counts and percentages for categorical
secondary prevention measures. An impact of the particular Bel- variables.
gian health care system can be expected. Secondary prevention and
Participation No participation p-value
clinical follow-up after a stroke is mainly the domain of the fam- (n = 152) (n = 103)
ily doctor, who is guided by recommendations by the supervising
Demographics
neurologist.
Age 74 79 <0.01
In contrast with known predictors influencing the discharge Male gender 73 (48%) 50 (49%) 0.93
destination, the impact of personal education and coaching pro-
Cardiovascular risk factors
grams on the hospitalization duration and discharge destination Arterial hypertension 111 (73%) 77 (75%) 0.76
has not been studied sufficiently [7]. Although, we expect that post- Previous stroke 40 (26%) 32 (31%) 0.41
discharge stroke support services have the potential to shorten Diabetes mellitus 29 (19%) 25 (25%) 0.32
hospitalisation durations, and to improve physical and mental Hyperlipidemia 71 (47%) 48 (47%) 0.98
Atrial fibrillation 44 (29%) 46 (45%) 0.01
health [8].
Smoking 33 (22%) 19 (19%) 0.53
The purpose of this study is to assess the feasibility of an in- Symptomatic peripheral 6 (4%) 5 (5%) 0.07
hospital and post-discharge, personalized stroke coaching program vasculopathy
in the Belgian context. The stroke coach will be the key player in Presentation on arrival
the cerebrovascular disease secondary prevention program. Admission NIHSS 5 (9) 9 (12) 0.02
Discharge home 152 (100%) 41 (39%) <0.01

2. Patients & methods

2.1. Study design and patient selection
We performed a retrospective analysis of a prospectively col-
lected cohort of consecutive acute ischemic stroke (AIS) patients in
a primary stroke center (Sint-Lucas hospital, Belgium). The inclu-
sion criteria for the analysis were acute ischemic stroke with (a)
hospitalization 12/2014–12/2015, (b) hospital-to-home discharge,
and (c) without moderate or severe cognitive decline limiting
the use of the coaching program. Family members of caregivers
were accepted as contactperson for patients with severe cogni-
tive decline. A modified version of the ASTRAL registry (CHUV,
Lausanne) had been used to collect the patient data in a standard-
ized way [9]. Medical variables collected and analyzed included
demographics, cardiovascular risk factors, medication, previous
stroke, type of clinical deficit, NIHSS at admission as described
previously. Etiology was determined according to the TOAST classi-
fication. Medication adherence was defined by the persistence to all
the prescribed pharmacologic and non-pharmacologic prevention
measures proposed at discharge.
2.2. Stroke coach
In the institution, a well-trained and experienced stroke nurse
was appointed as stroke coach from 01.09.2014 (0.4 FTE). The
stroke coach contacted patients twice during their hospitalization
(2 × 20 min) and post-discharge via phone calls using an adapted
version of the standardized WSO Post-Stroke Checklist (PSC) [10].
The Post Stroke Checklist was developed by the Global Stroke
Community Advisory Panel to assess the relevant problems (e.g.
cognition, mood, life after stroke) of stroke survivors in a standard-
ized way [6]. Since its development and endorsement by the World
Stroke Organization, the Post Stroke Checklist has gained inter-
national recognition as a useful tool in stroke survivor follow-up
and care [11]. A pilot study in the United Kingdom and Singapore
demonstrated that WSO PSC may be a feasible and useful measure
for identifying long term stroke care needs in a clinical practice.
It takes approximately 13–17 min time to perform the checklist
and was indicated by the patients and clinicians as useful and
informative [12]. Risk factor management, review of medications
and clinical evolution were discussed in both sessions and if pos-
sible together with the caregivers. The stroke coach tried to see
all patients within the first 48 h after the hospital admission for a
first session. Even that early, the important issue of the discharge
destination was tackled. Participants were contacted at 2 weeks
after discharge, followed by repeat calls if necessary and at ambu-
latory consultations at 1, 3, 6 and 12 months. During these calls, an
adapted version of the WSO post-stroke checklist was used to eval-
uate the patient’s clinical evolution, needs, therapeutic adherence
and reintegration. In case of aphasia, patients can participate if fam-
ily members or caregivers take care of the communication. At these
time points, medication adherence was assessed subjectively.
2.3. Statistical analyses
Continuous variables were described using medians and
interquartile ranges; categorical variable using counts and per-
centages. Univariate comparisons between the patients who
participated at the individual coaching programs and those who
did not, were performed for all available variables. A logistic regres-
sion analysis assessed the significance of each variable separately.
All tests were carried out at the 5% significance level. A histori-
cal cohort of our own stroke patients’ database (12/2013-12/2014-
ASTRAL-B registry) had been used to compare the clinical outcome
with or without the intervention. First, we performed a univari-
ate comparison to evaluate the differences in the study population
(e.g. age, severity of stroke, cardiovascular risk factors). All analyses
were performed using the statistical package R (version 3.0.2).
The collection, analysis and publication of data in the stroke reg-
istries were performed with the approval of the local ethics board.
3. Results
3.1. Baseline characteristics
Out of a total of 255 acute ischemic strokes hospitalized at
the stroke center, 152 (59.7%) received individualized education
during hospitalization by the stroke coach. The median age of
our population was 74 years (IQR 62-88) and they had a median
NIHSS of 5 at admission (IQR 2-11). An important proportion of
patients (193, 76%) could be discharged back home after the hos-
pitalization. The other demographics and baseline characteristics
are shown in Table 1. In general, the proportion of cardiovas-
cular risk factors were similarly distributed in both populations,
except for the more frequent presence of atrial fibrillation (29 vs.
45%) in the non-participation group. Much of patients had at least
two cardiovascular risk factors. Patients were not coached because
of palliative care/decease (10%), unfavorable life expectancy (2%),
 P. Vanacker et al. / Clinical Neurology and Neurosurgery 154 (2017) 89–93 91

Fig. 1. Proportions of patients participating at the different aspects of the coaching program during hospitalization and post-discharge. Ambulatory consultations by the
stroke coach and online portal still in developmental phase.

dementia (8.5%) and lack of time due to short hospitalization (22%). Table 2
Medication adherence and clinical outcome at 3 months in the participated stroke
At discharge, antiplatelet or anticoagulating drugs were given in
patients.
97%, blood-pressure lowering drugs in 86%, cholesterol lowering in
82% and antiglycemic drugs in 24%. Pre-Participation At 3 months p-value
(n = 152) (n = 150)

Cardiovascular prevention
Blood-pressure lowering drugs 110 (72%) 131 (87%) <0.05
3.2. Stroke coaching program
Antiglycemic drugs 36 (24%) 44 (29%) 0.26
Antithrombotic drugs 88 (58%) 144 (96%) <0.05
Compared to a historical cohort (12/2013–12/2014) with similar Cholesterol lowering drugs 61 (40%) 111 (74%) <0.05
baseline characteristics on univariate analysis, the median duration
Clinical outcome at 3 months
of the hospitalization dropped from 9 to 8 days by the implemen- Modified Rankin Score (0–6; 0 (0−3) 2 (1–4)
tation of the in-hospital part of the stroke coaching program. After median/IQR)
discharge, a quarter of all stroke patients (n = 36) were contacted at Stroke recurrence NA 8 (5%)
Mortality NA 6 (4%)
least once by phone call, 12% (n = 18) were contacted at least twice.
Although an ambulatory consultation schedule was foreseen as part
of the coaching program, this was not introduced in the first year 4. Discussion
of the coaching program. Instead the vascular neurologist assessed
the adherence to the cardiovascular prevention program during the Our results demonstrate the feasibility of an individualized
ambulatory consultations. A total of 73% of the patients were rou- stroke coaching program involving in-hospital patient counseling
tinely seen at one, three and six months’ follow-up by the vascular with two individual education-sessions and well-organized post-
neurologist and the stroke coach together (Fig. 1). discharge ambulatory follow-up by using the post-stroke WSO
checklist at fixed contact moments. The stroke coach-program
has the potential to influence medication adherence, secondary
3.3. Clinical outcome prevention measures, self-care, health-literacy and stroke recur-
rences by improving cardiovascular health. However, our feasibility
At the follow-up of first three months, few participating patients study was not designed to compare these clinical outcome vari-
suffered a stroke recurrence (5%) and some of them died (4%), most ables to a non-treated cohort. The expected impact is related to
often due to unrelated comorbidities (e.g. lung cancer), see Table 2. an improved implementation of therapeutic strategies in clinical
Medication adherence was assessed by subjective questioning. [4,6]. The potential effects of telemedicine and stroke systems of
These numbers were encouraging with high numbers of patients’ care appear to be strong but have not been in place long enough to
adherent to their secondary cardiovascular preventive treatment: indicate their influence on the decline of stroke recurrence. Future
blood-pressure lowering drugs (87%), antiglycemic drugs (29%), research need to integrate the current monitoring programs into
antithrombotics (96%) and cholesterol-lowering drugs (74%). mobile health in order to improve medication adherence, selfcare
92 P. Vanacker et al. / Clinical Neurology and Neurosurgery 154 (2017) 89–93
and literacy [8]. Smartphone applications have been increasingly
identified as a novel online portal for dissemination of health-
care related and scientifically valid information [12], riskfactor
awareness and management [13–16], rehabilitation assessment
and therapy [17–20], and finally support groups for patients and
their relatives. An increasing number of patients, caregivers and
medical professionals are using online applications or web-based
portals to optimize the post-stroke care on long term [21,22].
Important to the improvement of the delivered health care is the
quality of information disseminated. Paucity of scientific accuracy
and clinical relevance is a major limitating factor for the major-
ity of existing online information [12]. Early supported discharge
by tele-rehabilitation and telemedicine show promise to augment
intensity of practice after discharge, resulting in improved patient-
extended activities of daily living, reduced length of stay with fewer
readmissions post stroke [23].
During the feasibility phase of the study we encountered some
points in need of improvement. A significant proportion of the
eligible patients (22%) were not seen by the stroke coach during
their hospitalization. This was related to a lack of time due to the
short(er) hospitalization durations and/or absence of the stroke
coach. Implementation in real clinical practice will be hampered by
these reasons. Next to in-hospital also out-hospital education ses-
sions alone or in combination with telemedicine could be used to
reduce this problem. In the most performant setting, maximal pro-
portions of participating patients will be around 80%. During the
first months of the project, main focus was the in-hospital, indi-
vidual education sessions for patient or family. The post-discharge
follow-up was restricted to the amount of patients the stroke coach
could contact with her limited resources (especially time). This has
been adapted and will improve follow-up numbers in the future.
Another, potentially interesting point could be to assess the
impact of the coaching program on the development of vascular
mild cognitive impairment or dementia in the first years post-
stroke. Especially, for the group of ischemic cerebral small-vessel
disease as this may be a prodrome of subcortical vascular dementia
(>50%) [24].
We acknowledge some limitations to our study: first, validation
in independent cohorts will be necessary to confirm the feasibility
of implementing such personal stroke coach programs on a larger
scale. Secondly, more detailed health economic evaluations need
to be collected to analyze the cost-benefit of the program in the
specific Belgian and more international context. The role of health
economic data in policy making and reimbursement by insurance
companies will be essential for the further roll-out of the project.
Thirdly, a prospective pilot study will be necessary to examine the
effect of the coaching program on medication adherence, secondary
prevention measures, stroke recurrence, quality of life and hospital-
ization duration. For this study, a newly developed digital platform
for coaching of stroke patients will be used. This will allow us to
collect patientdata of the cardiovascular riskfactors on a regular
basis and organize regular contacts with the strokecoach by video-
consultancy. For the current feasibility study a historical cohort of
patients from the same stroke center were used, which may intro-
duce some selection biases and may have influenced the reduction
in the median hospitalization duration. And finally, the integration
with telemedicine and mobile health applications will be chal-
lenging due to the enormous complexity and variety in electronic
medical records [21].
5. Conclusions
The decline in stroke recurrence and mortality during recent
decades has been one of the most important health successes.
Further improvement of the current secondary stroke prevention
programs and post-discharge stroke care may lead to additional
health benefit. We demonstrated that an individualized stroke
coach program can be implemented feasibly and justifies additional
research in this field. Mobile Health-solutions and telemedicine
may play a crucial role in future development of stroke care.
Funding sources
This research is partly supported by a fund of the Sint-
Lucashospital (Bruges, Belgium) and by a grant of the Belgian Stroke
Council.
Disclosures
1- P.V. received funding for travel or speaker honoraria from
Pfizer, Bayer and Boehringer-Ingelheim.
Authors’ contribution
Vanacker P: Study concept and design, data acquisition, analysis
and interpretation, critical revision of the manuscript for important
intellectual content, study supervision.
Standaert D: Data acquisition and analysis, critical revision of
the manuscript for important intellectual content.
Libbrecht N: Data acquisition and analysis, critical revision of
the manuscript for important intellectual content.
Maere P: Data acquisition and analysis, critical revision of the
manuscript for important intellectual content.
Bernard D: study concept and design, critical revision of the
manuscript.
Yperzeele L: Study concept, data interpretation, critical revision
of the manuscript for important intellectual content, study super-
vision.
Vanhooren G: Study concept, data interpretation, critical revi-
sion of the manuscript for important intellectual content, study
supervision.
Acknowledgements
The first two authors (D. Standaert & P. Vanacker), had full access
to all of the data in the study and take responsibility for the integrity
of the data and accuracy of the data analysis.
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