Results of a four-year multi-channel regional program for monitoring stroke survivors in Franche-Comté, France

Clinical monitoring of stroke survivors after hospital discharge was initiated in France in 2012 and funding for its model began in 2016. A regional program in Franche-Comté relying on various assessment methods including telehealth was initiated. The objective of this study was to describe the implementation and quality of the program. A retrospective observational study was conducted from 1st January 2016 to 31st December 2019. Patients were included if they were adults, hospitalized for stroke or transient ischemic attack in one of the six public hospitals in the region and discharged alive. There were five types of monitoring methods: physical consultation, day hospital, nurse-led phone consultation, postal mail or medical record analysis. Characteristics, method of monitoring and discharge delay were described. In total, 7166 patients were identified; male gender predominated (52.9%); mean age was 72.2years. Monitoring coverage increased from 89.2% to 92% within the period. Most patients had ischemic stroke (68.5%, n=4912) and were at home at the time of monitoring (71.6%, n=5130). The main method was nurse-led phone consultations (40.8%, n=2921) followed by physical consultation (16%, n=1143). Day hospital monitoring increased (1.5% to 14.4%) while the postal mail method decreased (18.7% to 8.1%). The average delay decreased from 240.3 to 148.6days. Monitoring period of less than four months was 46.2% in 2019 and 75.3% for thrombolysis. In 2019, 99.3% of patients were being monitored at one year. Mortality decreased from 10% to 6.3%. The program improved over time with an increase in the number of patients and reduction in delays and mortality rate.