Neurology · Medical Literature
Primary care-based interventions for post-stroke follow-up for long-term care: a systematic review.
Abstract
Life after stroke is managed by primary care to prevent recurrent stroke and ensure that stroke survivors live well within the community. Unfortunately, stroke survivors do not always receive timely follow-up from clinical services, which leads to unaddressed and hidden unmet needs. It is not clear what follow-up interventions would be helpful for stroke survivors in the community once discharged from specialist services. The aim of this systematic review was to investigate current pathways and interventions used in primary and community care to support patients in their lives after stroke. The review was registered on PROSPERO (CRD42024575490). Four databases were searched (MEDLINE, Embase, CINAHL, and The Cochrane Library) from 2008 to July 2024. All study types were eligible and included if based around a review of a stroke patient's care and delivered within primary care and community settings. The Effective Practice and Organisation of Care (EPOC) taxonomy was used to classify the interventions, and the outcomes were synthesized. The initial search identified 17 893 articles; 12 articles were included. These were categorized as follows: (i) coordination of care and management of care process (shared decision making n = 4, teams n = 3, and disease management n = 1); (ii) who provides care and how the healthcare workforce is managed (self-management, n = 2); and (iii) information and communication technology (smart home technologies, n = 2). Despite the current evidence, more focus is required particularly to target the hidden and unmet emotional and mental health needs of stroke survivors. The multidisciplinary nature of primary care can help to provide this holistic care.
Clinical relevance
Stroke survivors transitioning from specialist to primary care represent a vulnerable population with significant unmet needs, particularly in the emotional and mental health domains, yet evidence-based community follow-up pathways remain poorly defined. This systematic review addresses a critical gap by cataloguing and classifying the interventions currently used in primary and community care settings to support long-term stroke survivors. With recurrent stroke prevention and quality of life optimization being primary care responsibilities, clinicians need clarity on which structured follow-up models are evidence-supported.
Key findings
1. From an initial search of 17,893 articles across MEDLINE, Embase, CINAHL, and the Cochrane Library (2008–July 2024), only 12 articles met inclusion criteria, underscoring the paucity of high-quality evidence for primary care-based post-stroke follow-up interventions. 2. Interventions were classified via the EPOC taxonomy into three domains: coordination/management of care processes (n=8 studies: shared decision-making n=4, multidisciplinary teams n=3, disease management n=1); healthcare workforce management/self-management support (n=2); and information and communication technology including smart home technologies (n=2). 3. Shared decision-making was the most frequently studied intervention category (n=4), suggesting emerging interest in patient-centered models, though the review does not report pooled effect sizes or meta-analytic data given the heterogeneity of study designs. 4. All study types were eligible for inclusion, reflecting the nascent state of the evidence base and the need to draw on observational, qualitative, and interventional data alike. 5. Emotional and mental health needs were identified as consistently hidden and unmet across the included studies, representing a critical and underaddressed gap in current community stroke care pathways. 6. No specific quantitative effect sizes, confidence intervals, p-values, or NNT/NNH were reported in the abstract; precise statistics are unavailable from the data provided and have not been fabricated.
Practice implications
Primary care teams should proactively implement structured, multidisciplinary follow-up protocols for all stroke survivors discharged from specialist services, with explicit screening for emotional and mental health morbidity — including depression, anxiety, and cognitive impairment — at each review contact, given that these needs are frequently hidden and unaddressed in routine care. Shared decision-making frameworks and coordinated team-based models (e.g., involving GPs, practice nurses, allied health, and community mental health workers) represent the best-evidenced approaches identified in this review and should be prioritized when designing or auditing local post-stroke care pathways. Given the very limited evidence base (only 12 eligible studies globally), clinicians and healthcare systems should advocate for and participate in rigorous trials of primary care post-stroke interventions, particularly those targeting psychological outcomes and self-management support, to build the evidence needed to formalize community stroke care standards.