The Integrated Care Pathway for Post Stroke Patients (iCaPPS) Residing at Home in The Malaysian Community: A Cost Effectiveness Analysis

Post stroke patients under long term care follow up at public primary care health centres are randomised to receive either iCaPPS or conventional care. The iCaPPS is a care pathway document, which provides an itemised checklist guide for the primary care team to provide comprehensive and coordinated delivery of long-term stroke care, using resources available in the Malaysian public healthcare system. The iCaPPS details a task oriented checklist for each member of the primary care team which includes the Family Medicine Specialist (FMS) or Medical Officer-in-charge, the registered staff nurse or community nurse, the Community-based Rehabilitation team (which has either a Physiotherapist and/or Occupational Therapist based at the health centre). The iCaPPS also summarises the current and updated medication list, which the patient is taking. The iCaPPS lists the tasks for each visit in detail, starting at first visit to the health centre after transfer of care from the referral hospital, all relevant assessments done and screening of stroke related complications which have to be scheduled periodically, as recommended by the Expert Panel, using current evidence based recommendations as well as best practice options tailored to available public healthcare delivery system. The FMS will be the main coordinator of care, to administer care as per iCaPPS to the patient receiving long term stroke care at the public primary care healthcentres (i.e. baseline and at 6 months, total duration of observation per patient was 2 visits over a 6-month period). The iCaPPS guides the primary care team at the health centre to deliver a comprehensive medical care plan, which covers: A. Stroke risk factor management (i.e. control of hypertension, dyslipdaemia and/ or diabetes mellitus treated to targets) The FMS will be provide and coordinate treatment (where necessary) to ensure the patient receives adequate medical management for each of the co-morbid conditions and make adjustments to the medications as required. B. The Registered Nurse or Community Nurse will be responsible to take the vital signs (e.g. Blood pressure, pulse rate, Body Mass index or Waist hip ratio) and conduct screening for complications related to stroke using validated screening tools: a. Two Question With Help Questionnaire; TQWHQ for screening for depression (Mohd-Sidik et al, 2011) b. Elderly Cognitive Assessment Questionnaire (ECAQ) (Kua, 1992) for patients aged 60 years and more (using cut off score of less than 5 as cognitive decline) and / or c. Malay- Mini Mental State Examination using a cut of point of 17 and above as normal, for patients aged below 60 years (Zarina, 2007) d. The FMS uses the symptom checklist to help identify possible swallowing abnormalities during consultation. If the patient is suspected to have swallowing abnormalities, the iCaPPS-Swallow (Copyright) algorithm designed by the expert panel to guide the primary care team to channel the patient to the nearest Speech & Language Therapy (SLT) service in the district. e. Patients are also assessed for rehabilitation needs (either initiation for those who have been diagnosed late or continuing rehabilitation for those already referred to community rehabilitation services). The patients’ functional status will be assessed using the modified Barthel Index (MBI) (Mahoney, 1965; Shah, 1989) and the Brody & Lawton’s Instrumental Activities for Daily Living (IADL)(Brody & Lawton, 1988) questionnaire (by the trained Nurse or the Therapist based at the Healthcentres, whichever is available.). The FMS and the Therapist at the healthcentres will then coordinate the rehabilitation program using the iCaPPS-Rehabilitation (Copyright) algorithm to ensure that patients receive the optimal neurorehabiltation as necessary tailored to the individual needs. For the iCaPPS arm, each visit will take up a total of 45 minutes, i.e. a 30-minute consultation with the FMS (A), and 15-minutes for screening with Registered Nurse or Community Nurse or Therapist (whichever is applicable) (B and C). In conventional care arm: post stroke patients are managed by FMS' for their stroke risk factors (i.e. hypertension, diabetes mellitus and/or dyslipdaemia alone), as per a consultation with the physician. There is no local guideline, which the primary care doctors can refer to in cases where rehabilitation should be initiated or continued or even a pathway to review for its effectiveness. The FMS are not trained in principles of neurorehabilitation or rehabilitation per se, and at best, are not aware on how to monitor or coordinate rehabilitation for stroke patients at community level. Patients are observed at baseline and at 6 months, as per the iCaPPS arm. The FMS or Therapist at the healthcentres does not routinely assess functional status of post stroke patients unless they are officially for referred for intervention or evaluation, similarly for swallowing disorders. FMS' on the average take up 20-25 minutes per patient per consultation. Intention to treat analysis was employed, with last observation carried forward for patients who did not turn up for appointments despite 2 reminders / call back. The researchers (i.e. Family Medicine Specialists) are blinded to the intervention (i.e. iCaPPS or conventional care). Assignment of type of intervention was done at healthcentres level.