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Parcours post-avc, mesure des sequelles post-avc et lien entre parcours et sequelles à un an : enjeux conceptuels et méthodologiques, résultats d’une cohorte rétrospective, perspectives de recherche

Abstract : The downstream pathways of stroke patients are highly heterogeneous and have many inefficiencies due to defects in the offer of care and inequalities in access to care. Knowledge of post-stroke downstream pathways and the link between downstream pathways and functional outcome is not sufficient to plan the offer of care necessary to implement an effective pathway that meets all patients' needs. The objective of our study was twofold: 1) to analyze the downstream pathways of stroke patients, by constructing a typology of downstream pathways and analyzing inequalities in care and 2) to identify the downstream pathway components associated with the one-year functional outcome of stroke patients. The study design was a multicenter retrospective cohort of stroke patients included in the Aquitaine Stroke Observatory (ObA2) between October and December 2013 and followed up to 1 year after the acute episode. The database consisted of data collected in ObA2 (socio-demographic and clinical characteristics of patients, pre-hospital and hospital pathways) linked to those of the Information System Medicalization Program. The typology of downstream pathways was based on factorial analyses and data-visualization methods (exploratory approach). The characteristics of the typical downstream pathways identified by the exploratory approach were described and compared (descriptive approach) and compared with those of eference pathways (normative approach). Functional outcome was measured by two criteria: 1) functional status measured by the rankin score - mRS at 1 year and 2) functional evolution, measured by the difference between mRS at 1 year and mRS at the time of the acute episode (adverse if difference >2 vs. favourable if difference 2). The analysis of factors associated with functional status was based on a logistic regression model (mRS >2 vs 2) stratified on the output mRS. The analysis of the factors associated with functional evolution was based on an adapted polytomical regression model (functional evolution indicator in three categories: stable, aggravation, recovery). Four typical pathways were identified, based on stroke type and orientation at the end of primary hospitalization: 1) ischemic stroke returning home, 2) ischemic stroke oriented to specialized rehabilitation, 3) hemorrhagic stroke oriented to specialized rehabilitation and 4) various. The comparative analysis of the standard pathways showed the decisive role of the patient's functional state during primary hospitalization on the sequences of the downstream pathways. The normative approach showed that more than half of patients with multiple disabilities were not admitted to specialized rehabilitation; this lack of access to rehabilitation was more pronounced among patients living at a distance from the place of care and the elderly. Our explanatory analysis identified that admission to rehabilitation was associated with an improvement in functional outcome at one year. Our study made it possible to improve knowledge of post-stroke downstream pathways and identified an overall lack of access to rehabilitation, which is more pronounced among people living at a distance from the place of care and the elderly. This lack of access to care is a major loss of opportunity to functional outcome for stroke patients. We provide useful information to guide a policy for the management of stroke patients in the downstream phase, and make proposals to this end. However, due to its methodological and structural limitations, our study cannot meet all the requirements in terms of information on downstream stroke pathways. We propose an alternative study, more methodologically robust, which will allow us to go further in the knowledge of downstream poststroke pathways.
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Sophie Broussy-Boudeau. Parcours post-avc, mesure des sequelles post-avc et lien entre parcours et sequelles à un an : enjeux conceptuels et méthodologiques, résultats d’une cohorte rétrospective, perspectives de recherche. Médecine humaine et pathologie. Université de Bordeaux, 2019. Français. ⟨NNT : 2019BORD0414⟩. ⟨tel-02900289⟩

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