[Position paper on stroke aftercare of the German Stroke Society-Part 1: long-term care after stroke: status quo of the reality and deficits of care in Germany]. / Positionspapier Schlaganfallnachsorge der Deutschen Schlaganfall-Gesellschaft ­ Teil 1: Nachsorge nach einem Schlaganfall: Status quo der Versorgungsrealität und Versorgungsdefizite in Deutschland.

The acute treatment of stroke patients in Germany is of a very high standard, guaranteed by its system of stroke units. Stroke as a disease has an acute phase followed by a chronic phase that requires a high level of qualified aftercare given by multidisciplinary and interdisciplinary teams. In 2020, the German Stroke Society (DSG) founded a commission for long-term stroke care. The aim is to evaluate the current situation of long-term aftercare and suggest improvements for its structure. In this paper the status quo of aftercare is presented and possible deficits are identified. Contributions of various stakeholders from the German healthcare system are analyzed and different projects for post-acute care are presented. Germany has no acknowledged structured aftercare concepts for patients after stroke. The general practitioner-based care is currently the focus of patient management but without a greater, more coordinated integration of neurologists, guideline-led and quality-controlled aftercare will be harder to implement in the future. The assignment of duties and the necessary training standards for the specialist groups in order to comply with the guidelines do not exist. Besides medical health, the needs of physical, social and emotional domains are too seldom considered by a multiprofessional care team. Further developments of a regional care management concept are discussed. The results and costs of any aftercare concepts must be evaluated before widespread implementation.

[Position paper on stroke aftercare of the German Stroke Society-Part 2: concept for a comprehensive stroke aftercare]. / Positionspapier Schlaganfallnachsorge der Deutschen Schlaganfall-Gesellschaft ­ Teil 2: Konzept für eine umfassende Schlaganfallnachsorge.

Long-term management after stroke has not been standardized in contrast to acute and rehabilitative stroke care. The fragmented outpatient sector of healthcare allows a high degree of flexibility but also variability in the quality of care provided. The commission on long-term stroke care of the German Stroke Society developed a concept on how to provide standardized multiprofessional long-term stroke care with a focus on patient-centered comprehensive care. We propose a diagnostic work-up in stages, with an initial patient-reported screening, followed by an adapted in-depth assessment of affected domains. This includes internistic domains (management of risk factors) and also genuine neurological domains (spasticity, cognitive deficits etc.) that must be considered. This information is then merged with patient expectations and prioritization to a standardized treatment plan. Special challenges for the implementation of such a comprehensive care system are the intersectoral and intrasectoral communication between healthcare providers, patients and relatives, the need to create a compensation system for providers and the establishment of appropriate quality management services. Digital health applications are helpful tools to provide aspects of diagnostics, treatment and communication in long-term stroke care.

[Position paper on stroke aftercare of the German Stroke Society-Part 3: structural concepts for future forms of care of stroke aftercare]. / Positionspapier Schlaganfallnachsorge der Deutschen Schlaganfall-Gesellschaft ­ Teil 3: Strukturelle Konzepte für zukünftige Versorgungsformen der Schlaganfallnachsorge.

BACKGROUND: Irrespective of the great impact stroke exerts on the society as a whole and far-reaching advances in acute treatment and rehabilitation of stroke, so far outpatient services for post-stroke care have not been established on a national level in Germany. OBJECTIVE AND METHODS: Against the background of this contemporary lack of care, in May 2020 the German Stroke Society (DSG) established the stroke aftercare commission. This position paper discusses structural models of future services addressing outpatient post-stroke care. RESULTS AND DISCUSSION: The specialized care by a neurologist should be central to a multidisciplinary, interprofessional and transsectoral treatment. Structural concepts of post-stroke care must take regional differences but also effective strategies for quality control into account. Certification processes and appropriate financing of follow-up registries at state and federal levels may pave the way for improvement over the medium term. Structured outpatient post-stroke care services should be open to all subgroups of stroke patients. Additionally, innovative technologies can make an important contribution to post-stroke care; however, the implementation of specialized services demands adequate funding as well as separate financial incentives for the providers. The solution must carefully balance the advantages and disadvantages of the specific care and financing models. Currently the discussion of new models of post-stroke care is gaining new momentum, which opens up perspectives for the advancement of the otherwise still insufficient contemporary care structures.

Long-term mortality and risk of stroke after transient ischemic attack: a hospital-based cohort study.

BACKGROUND: Stroke and mortality rates in patients with transient ischemic attack (TIA) differ widely between community-based studies and research cohorts. Our aim therefore was to provide a reliable estimate for TIA patients treated in German neurology departments with an acute stroke unit. METHODS: A total of 1951 consecutively admitted TIA patients were prospectively documented in 13 centers and 1480 (75.9%) gave consent for long-term follow-up. During a mean follow-up of 23.4 months, we assessed recurrent cerebrovascular events and cause of death in 1448 patients via standardized telephone interview including confirmation of endpoint events by the treating physician. RESULTS: Overall 94 patients (6.5%) suffered a stroke and 118 patients (8.1%) died, 21 due to stroke. The Kaplan-Meier estimate for stroke during the first year was 4.4% (95% CI 3.2-5.6%) which corresponds to a relative risk of 9.5 (95% CI 7.4-12.3) compared to the population-based stroke incidence in Germany. The annual rates after the first year were 2.2% (95% CI 1.7-2.7%) for stroke and 3.2% (95% CI 2.7-3.8%) for death. Independent predictors for stroke during follow-up were age and previous cerebrovascular events. The ABCD(2) score did not provide any meaningful prediction of stroke risk at 90 days. CONCLUSION: While the in-hospital risk of stroke was low, long-term stroke rates in our well-defined multicenter hospital-based cohort were comparable to a large randomized trial. In patients with a well-established diagnosis of TIA, only age and previous cerebrovascular events seem to constitute independent predictors for stroke during long-term follow-up.