The Comprehensive Post-Acute Stroke Services (COMPASS) study: design and methods for a cluster-randomized pragmatic trial

Background: Patients discharged home after stroke face significant challenges managing residual neurological deficits, secondary prevention, and pre-existing chronic conditions. Post-discharge care is often fragmented leading to increased healthcare costs, readmissions, and sub-optimal utilization of rehabilitation and community services. The COMprehensive Post-Acute Stroke Services (COMPASS) Study is an ongoing cluster-randomized pragmatic trial to assess the effectiveness of a comprehensive, evidence-based, post-acute care model on patient-centered outcomes. Methods: Forty-one hospitals in North Carolina were randomized (as 40 units) to either implement the COMPASS care model or continue their usual care. The recruitment goal is 6000 patients (3000 per arm). Hospital staff ascertain and enroll patients discharged home with a clinical diagnosis of stroke or transient ischemic attack. Patients discharged from intervention hospitals receive 2-day telephone follow-up; a comprehensive clinic visit within 2 weeks that includes a neurological evaluation, assessments of social and functional determinants of health, and an individualized COMPASS Care PlanTM integrated with a community-specific resource database; and additional follow-up calls at 30 and 60 days post-stroke discharge. This model is consistent with the Centers for Medicare and Medicaid Services transitional care management services provided by physicians or advanced practice providers with support from a nurse to conduct patient assessments and coordinate follow-up services. Patients discharged from usual care hospitals represent the control group and receive the standard of care in place at that hospital. Patient-centered outcomes are collected from telephone surveys administered at 90 days. The primary endpoint is patient-reported functional status as measured by the Stroke Impact Scale 16. Secondary outcomes are: caregiver strain, all-cause readmissions, mortality, healthcare utilization, and medication adherence. The study engages patients, caregivers, and other stakeholders (including policymakers, advocacy groups, payers, and local community coalitions) to advise and support the design, implementation, and sustainability of the COMPASS care model. Discussion: Given the high societal and economic burden of stroke, identifying a care model to improve recovery, independence, and quality of life is critical for stroke survivors and their caregivers. The pragmatic trial design provides a real-world assessment of the COMPASS care model effectiveness and will facilitate rapid implementation into clinical practice if successful

Trace elements in glucometabolic disorders: an update

Many trace elements, among which metals, are indispensable for proper functioning of a myriad of biochemical reactions, more particularly as enzyme cofactors. This is particularly true for the vast set of processes involved in regulation of glucose homeostasis, being it in glucose metabolism itself or in hormonal control, especially insulin. The role and importance of trace elements such as chromium, zinc, selenium, lithium and vanadium are much less evident and subjected to chronic debate. This review updates our actual knowledge concerning these five trace elements. A careful survey of the literature shows that while theoretical postulates from some key roles of these elements had led to real hopes for therapy of insulin resistance and diabetes, the limited experience based on available data indicates that beneficial effects and use of most of them are subjected to caution, given the narrow window between safe and unsafe doses. Clear therapeutic benefit in these pathologies is presently doubtful but some data indicate that these metals may have a clinical interest in patients presenting deficiencies in individual metal levels. The same holds true for an association of some trace elements such as chromium or zinc with oral antidiabetics. However, this area is essentially unexplored in adequate clinical trials, which are worth being performed

RAMPING UP INNOVATIONS FOR VETERAN HEALTH—EXERCISE FOR WHOLE HEALTH THE GEROFIT WAY

The provision of exercise/physical activity guidance within the wellness and prevention rubric is challenging and often inadequate as access to exercise specialists outside of rehabilitation is often lacking. Gerofit, an exercise and health promotion program for Veterans ages 65+, is an established program with a strong evidence base of robust outcomes including improved physical and psychological health, reduced cardio-metabolic risk, and high rates of program satisfaction. The program is now serving older Veterans in thirteen VA Medical Centers across the country. The past four years have been devoted to codifying and evaluating outcomes from center-based programs, to development and testing of effective exercise/physical activity delivery to individuals unable to attend center-based programs, and to development of exercise/physical activity innovations for special populations. The first paper describes a VA/Community partnership to facilitate exercise assessments and tailored exercise prescriptions for rural Veterans. The second paper describes findings from a “prehab” exercise program for older Veterans facing surgery. The third paper describes a video telehealth circuit exercise program delivered from a medical center to community-based clinics. The fourth paper describes a proactive approach to screen and reach high numbers of older Veterans eligible for exercise counseling. The fifth paper describes changes in cardiovascular, diabetes, mental health, and opioid medications following one-year of center-based exercise. These papers highlight numerous innovations in exercise delivery that provide wide ranging benefits to older adults. This work contributes to meeting the needs of the fastest growing and largest segment of the Veteran populatio

PROACTIVE REACH: A MODERN MODEL TO INCREASE ACCESS AND DELIVERY OF EXERCISE INTERVENTIONS FOR RURAL VETERANS

Background: The Miami Gerofit program developed ProActive Reach to increase referrals of telephone-delivered-physical activity counseling (TD-PAC) in partnership with rural providers (RP). Methods: Between 2015–2016, over 900 electronic medical records (EMRs) were reviewed by the Gerofit physician. Results: RP approved 302 referrals, 236 (78%) were reached, and 186 (79%) counseled. Of those counseled, 107 (58%) reported rates of resistance exercise increased from 2% to 38%. While effective, it was time-consuming and an automated screening model (ASM) was developed. Using the ASM, we searched EMRs to identify rural Veterans meeting health criteria for safe for TD-PAC. 674 flyers with invitations to receive individualized TD-PAC were mailed to Veterans associated with 6 Gerofit programs across the country. Response rates varied between 4 to 31% and different models of TD-PAC are being delivered. Implications: ASM may provide a way to deliver age appropriate PA materials for large numbers of Veterans throughout the country