Effectiveness of Stroke Coordinated Care Interventions Delivered to Stroke Survivors in Low and Middle-Income Countries: A Systematic Review and Meta-Analysis

Abstract

Background: Stroke survivors receive complex care requiring navigation of multiple services and care providers. Considering this, stroke care is prone to care fragmentation and potentially poor outcomes in patients. Care coordination provides deliberate organisation of stroke care and services, ensuring that personnel and resources are interconnected through communication and relations. The goal is to ensure that care is comprehensive, meets the needs and preferences of patients and families, and ultimately, clinical expectations. This systematic review sought to identify components of stroke care coordination in low and middle-income countries (LMICs) and assess this intervention's impact on patients' clinical outcomes. Methods: Electronic databases, trial registries and non-database sources were searched; PubMed, LILACS, CINAHL via EBSCOhost, Scopus, Cochrane CENTRAL, WHO International Clinical Trials Registry Platform (ICTRP), Web of Science Core Collection and Preprint collection, ProQuest and Google Scholar. from 2000 to 31st December 2024, without language restriction. Hand searches for references for relevant studies were carried out. Title and abstract screening of unique records after deduplication were conducted using a study selection flow chart developed from the PICOS elements (P ─ patient, I ─ intervention, C ─ comparator, O ─ outcomes and S ─study). Full-texts of potentially relevant studies were retrieved and screened. Study selection, data extraction and risk of bias assessment were conducted independently by two reviewers. Risk of bias studies were assessed using the Risk of Bias in Randomised Trials (RoB 2) and the non randomised studies of intervention (ROBINS-I) tools. Disagreements between the reviewers on study selection, data extraction and risk of bias assessment were resolved through discussions. Risk ratio (RR) for binary outcomes and mean differences (MD) or standardised mean differences (SMD) for continuous outcomes were the effect measures for expressing the effectiveness of care-coordinated interventions. A random-effects model was used to pool effect estimates. Narrative syntheses were provided when meta-analysis was not plausible. Results: The research retrieved 9,715 studies, of which 16 met the inclusion criteria; 12 (75%) were conducted in Asia, two (12.5%) in Africa, and two (12.5%) in Southern America. Care coordinated interventions predominantly had multiple participants (100%), an interprofessional meeting channel of communications (93.8%) as components, with activities predominantly targeting patients' direct care and families. Stroke care coordinated interventions resulted in improved performance of activities of daily living (ADLs) (SMD = 0.92; CI= 0.37 – 1.48), cognitive functioning (SMD = 0.55; CI= 0.21 – 0.89), and quality of life (QoL) of stroke survivors (SMD= 1.00; CI= 0.21 – 1.78). The results indicated no difference in mortality rate, upper extremity motor function, lower extremity motor function, and depression levels between care coordination and standard care groups. Limited data did not support sub-analyses of moderators of care coordination interventions. Limited data did not allow meaningful comparisons of sub groups to detect potential differences in outcomes across stroke types, variation in care coordination components, and stroke severity. None of the studies included reported adverse events of stroke care-coordinated interventions. Conclusion: Stroke care-coordinated interventions in LMICs vary from one context to another. Current approaches result in improved independence and quality of life for stroke survivors. The evidence is, however, inconclusive on the moderating roles of clinical and intervention variables on stroke outcomes.