STRACK: improving post-stroke patient management outcomes

STRACK Consortium

STRACK, a three-year VBHC project led by Bellvitge University Hospital (Spain), has set a precedent in
post-stroke patient care. Launched in May 2021, STRACK has evolved the continuum of care for >300
patients by integrating comprehensive monitoring of cardiometabolic risk factors (heart failure, diabetes,
atrial fibrillation, dyslipidemia, hypertension) into a patient discharge plan.
The first year included a thorough analysis of the current ways of working, the identification of improvement
areas, and designing new care pathways and ways of working for professionals. Patients were interviewed to
understand their point of view and to collect ideas for improvement. Afterwards, the digital platforms and
infrastructure were configured and deployed, and training was provided to over 150 staff.
Now, prior to discharge, patients receive a bespoke care plan, home monitoring devices, and access to a
digital platform for clinical data logging and telerehabilitation exercises. This holistic approach is supported
by asuite of digital tools that enhance patient-professional communication, facilitate real-time data sharing,
and enable proactive patient management through alerts and monitoring.
For a year post-discharge, a nursing and administrative team follows the data that the patient enters
remotely or is automatically available on their mobile application. The most sensitive parameters identified
as key to avoiding stroke recurrence and improving control of vascular risk factors are monitored.
Additionally, patients can communicate via the digital platform with staff, and vice versa: patients receive
notifications or information regarding their illness, visits, and reminders. This channel allows the sending of
surveys and health scales such as PROMs, EQ5L and PREMs. Patient treatment is saved and accessible in the
application.
In addition to surveys, point-of-care devices are provided to monitor outcomes, and data is available in the
digital platform. Among the devices, a non-implantable holter supported by artificial intelligence stands out,
for the search, among others, of hidden atrial fibrillation, which would explain 25% of strokes of
unknown/cryptogenic cause. In addition, depending on individual risk factors, patients can also receive a
blood pressure monitor, glucometer, coagulometer, and/or smart scale. These devices allow for clinicians to
closely monitor patient progress, reducing the number of patient visits and readmissions.
There is also a digital rehabilitation module for physical and cognitive activities prescribed at discharge by
physiotherapists, which is monitored during the first weeks by rehabilitation physicians.
The digital platform allows different interoperability options with hospital and primary care information
systems, including searching for patient candidates to enroll in STRACK according to inclusion criteria, or
extracting patient lists with devices or epidemiological data such as functional status or death.
New epidemiological and affiliation data have been added to the digital platform for exhaustive patient
monitoring and reliability in follow-up.
Preliminary results of the project (ongoing):
● Reductioninunnecessary visits (weighted):-26,3%
● Reductioninadmissions for stroke recurrence:
○ Stroke,30d:-100%
○ Relatedtostroke,365d:-47,7%
○ Relatedtostroke,30d:-57,0%
● Reductionincardiovascularadmissions:
○ 30d:-100%
○ 365d:-31,4%
● Treatmentadherence:81,2%(72%previously)
● Dayswithoutrehabilitation:0d