This document describes the development of a Poststroke Checklist (PSC) to standardize follow-up care for stroke survivors. An international panel of experts identified common long-term poststroke problems and developed a draft checklist. A Delphi method consensus process was used with experts to refine the checklist. The final PSC assesses 11 key problems, including mobility, pain, and incontinence. It links patient responses to appropriate referrals to address problems and improve quality of life outcomes for stroke survivors. The goal is to provide a simple, evidence-based tool for use in primary care settings during long-term poststroke follow-up.

1. Development of a Poststroke Checklist
to Standardize
Follow-up Care for Stroke Survivors
By :
Mohammad Y. El-Zalouey
Neurology Resident – Mansoura University

3. (A) BACKGROUND

4. 1. What is already known on the subject:
• Stroke is the second leading cause of death and one of the leading
contributors to adult disability worldwide.
• Stroke poses a significant personal, social, and financial global burden.
• One review demonstrated that approximately 33% of stroke survivors did
not feel prepared to manage their problems upon discharge from acute-
stroke treatment.
• over the long term, between 18%-46% experienced social problems and
between 19%-62% experienced emotional problems.

5. •Stroke survivors may experience impairments, such as:
• Memory loss
• Pain
• Spasticity
• Fatigue
• Urinary incontinence
• Cognitive impairment
• Communication disorders such as : social isolation , emotional
change.
• Reduced physical functioning (e.g mobility and performing activities
of daily living).

6. • Compounding the long-term problems stroke survivors experience is
the fragmentation of the health care delivery system following the
acute and subacute phases of stroke treatment.
• About 50% of stroke survivors who see health care providers report
unmet needs (eg : incontinence, emotional problems, mobility, pain,
and speaking problems).
• The prevalence of long-term poststroke problems often unidentified
or untreated although potentially amenable to effective
interventions.

7. • In the United Kingdom, the National Stroke Strategy recommends that clinical
assessments be carried out 6 and 12 months poststroke and annually
thereafter.
• The Australian stroke guidelines recommend that stroke survivors have
regular and ongoing review by a member of a stroke team, including at least 1
specialist with an initial review within 3 months and again at 6 and 12 months
post-discharge.
• In the United States, primary care physicians have 140 quality care indicators
covering general aspects of poststroke management, although most are not
implemented into clinical practice.

11. 2. How does this study add to the available literature ?
The practice of long-term care for stroke survivors lacks an
evidence-based and easy-to-use tool that can:
1. Identify long-term problems among stroke survivors.
2. Facilitate their referral from primary/community-based care to
appropriate specialist management.

12. B) Hypothesis and design

13. 1.What is the research question?
1-What are the standards of long-term
management provided to stroke survivors ?
2- How to improve their quality of life ?

14. 2. Is this question relevant ?
•YES, Stroke is the second leading cause of death and one of the leading
contributors to adult disability worldwide.
• Stroke poses a significant personal, social, and financial global burden.
• One review demonstrated that approximately 33% of stroke survivors did
not feel prepared to manage their problems upon discharge from acute-
stroke treatment.
• over the long term, between 18%-46% experienced social problems and
between 19%-62% experienced emotional problems.

15. 3.What type of study was performed ?
• Review Article
A review article is an article that summarizes the current state
of understanding on a topic. A review article surveys and
summarizes previously published studies, rather than reporting
new facts or analysis.

16. C) METHODS

17. 1.What methods were used ?
Delphi Methods

18. What is Delphi methods ?!
• a forecasting process framework based on the results of multiple
rounds of questionnaires sent to a panel of experts.
• Several rounds of questionnaires are sent out to the group of
experts, and the anonymous responses are aggregated and shared
with the group after each round.
• The experts are allowed to adjust their answers in subsequent
rounds, based on how they interpret the "group response" that has
been provided to them.
• Delphi method seeks to reach the correct response through
consensus.

19. 2.Why Delphi Method ? And Why not ?
Advantages
• Aggregate opinions from a
diverse set of experts
• Participants are anonymous
• No need for physical meeting
• individual panelists don't have
to worry about repercussions
for their opinions
Disadvantages
• does not result in the same
sort of interactions as a live
discussion.
• Response times with the
Delphi method can be long

21. •What population was studied ?
Post stroke population.
•There was NO control , intervention or
exposure at this study.

22. Steps
Step 1: Specifying Long-Term Poststroke Problems.
Step 2: Constructing a Draft PSC.
Step 3: Delphi Method to Achieve Expert Consensus on Poststroke
Problem Areas.
Step 4: Finalizing the PSC

23. Step 1 : Specifying Long-Term Poststroke Problems
• create an all-inclusive list of long-term poststroke problems.
• This list was generated by an international and multidisciplinary group of
experts, the Global Stroke Community Advisory Panel (GSCAP).
• GSCAP consists of 21 stroke experts and represents 9 countries: Australia,
Austria, Canada, France, Germany, Singapore, Sweden, United Kingdom, and
the United States.
• The 6 specialty areas represented were stroke neurology,
neurorehabilitation, physical medicine and rehabilitation, and 1 each from
occupational therapy, physical therapy, and care of the elderly.

24. Step 2: Constructing a Draft PSC
• The goal of this activity was to create a preliminary instrument which
is a set of instructions, problem areas, and response areas was
constructed.
• The instrument development team included a subset of GSCAP
experts and Representatives from stakeholder groups involved in
poststroke care including : primary and secondary care physicians,
allied health professionals, community nurses, and representatives of
stroke survivors.

25. Step 3: Delphi Method to Achieve Expert Consensus on
Poststroke Problem Areas
• The Delphi method characterizes a set of structured communication
techniques to facilitate consensus of opinion among experts on a
prespecified content area through a series of questionnaire combined
with controlled feedback.
• During each round of activity, information is collected from experts
anonymously by a Delphi moderator and returned to the panelists for
comment.
• This process continues until a convergence of opinion is reached,
typically after 2 rounds.

26. • It is important to note that the goal was not to evaluate the draft checklist (as developed
in step 2), but rather to achieve consensus as to what the instrument should target for
assessment.
• Between November 2010 and January 2011, there were 2 rounds of controlled
communication and feedback between the expert panelists and a moderator.
• An independent health outcomes research organization (Adelphi Values, Boston,
massachusetts) served as the Delphi moderator, whose role was to facilitate
communication and collect, aggregate, and summarize the data.

27. https://www.adelphivalues.com/

28. Delphi Panel
Round 1
• consider the list of long-term
poststroke problems developed
in step 1 with respect to:
1. those that have the greatest
impact on a survivor’s quality of
life.
2.those for which evidence-based
interventions exist to improve
outcomes.
Round 2
• Panelists were also provided a
summary of the round 1 results
and encouraged to change their
earlier answers.
• Panelists were also given a new
set of long term poststroke
problems to consider (not on the
original list, but generated
during round 1).

29. Step 4: Finalizing the PSC
• If a long-term poststroke problem was added to the list in round 1, and in round 2 at least
50% of panelists rated the problem as moderately important or very important, this
problem was considered for inclusion in the PSC.
• it was determined a priori that problems would only be deleted from the draft checklist if
fewer than 25% of the Delphi panelists suggested including the problem.

32. POST STROKE CHECK-LIST
D) RESULTS

33. s

35. Principles for PSC
(1) to be simple and easy to use by health care professionals in primary care
settings at 6 and 12 months poststroke and annually thereafter.
(2) to focus on problem areas where evidence-based data support the
effectiveness of interventions to improve outcomes.
(3) to focus on areas where an intervention has the largest impact on a stroke
survivor’s quality of life.

36. I) Interpretation
• Points of Strenght :
• This checklist developed by Worldwide Stroke experts.
• Delphi Method was used to Structure this Checklist.
• Points of Weakness :
• Delphi methods does not result in the same sort of interactions as a
live discussion.

37. Take-Home Message
• The PSC assesses 11 long-term problems to ask about and links patient
response to a specific referral (e.g : primary care physician, community
continence adviser, and speech language therapist).
• The PSC was not designed to cover every possible poststroke problem, but
rather target those areas that have the greatest impact on patient quality
of life and are treatable.

38. THANK YOU