What does this research mean for the field?

A centralized multidisciplinary outpatient stroke clinic significantly reduces the median time to achieve outpatient LDL <70 mg/dL and systolic BP <130 mmHg in post-hospitalization stroke patients. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

What question did this study set out to answer?

The aim was to assess the impact of a centralized multidisciplinary stroke clinic on post-stroke care outcomes.

February 2, 2026

Abstract WP095: Centralized Post-Hospitalization Stroke Care through a Multidisciplinary Stroke Clinic: A Solution for a Large Healthcare System

Q: What are the key findings of this study?

Post-implementation, median time to achieve outpatient LDL <70 mg/dL decreased from 98 days to 67 days (p=0.001) and systolic BP <130 mmHg from 154 to 108 days (p=0.002).

Q: What question did this study set out to answer?

The aim was to assess the impact of a centralized multidisciplinary stroke clinic on post-stroke care outcomes.

Key Result

Post-implementation, median time to achieve outpatient LDL <70 mg/dL decreased from 98 days to 67 days (p=0.001) and systolic BP <130 mmHg from 154 to 108 days (p=0.002).

Key Points

The aim was to assess the impact of a centralized multidisciplinary stroke clinic on post-stroke care outcomes.
Retrospective analysis of patients with ischemic stroke, ICH, SAH, or TIA from six stroke centers.
Comparison of clinical outcomes before and after implementing the multidisciplinary model.
Evaluation of time to achieve outpatient LDL <70 mg/dL and systolic BP <130 mmHg.
2451 patients were seen in the stroke clinic post-discharge.
Increased attendance at the stroke clinic within 90 days: 31% to 40% for CSC and 22% to 29% for system-wide hospitals.
Decreased median time to LDL <70 mg/dL: from 98 days to 67 days.
Decreased time to achieve systolic BP <130 mmHg: from 154 days to 108 days.

Structured PICO

Does a structured multidisciplinary stroke clinic care model improve the time to achieve risk factor control and access to specialty services in patients discharged after a stroke or TIA?

Population

2,451 patients with ischemic stroke, intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), or transient ischemic attack (TIA) discharged from six Emory Healthcare stroke centers (mean age 64±15 years, 59% black, 51% female, 83% ischemic stroke).

Intervention

Structured multidisciplinary stroke clinic care model led by stroke prevention and rehabilitation physicians supported by physical therapy, neuropsychology, and geriatric medicine (post-implementation period).

Comparator

Centralized stroke clinic care prior to the implementation of the structured multidisciplinary model (pre-implementation period).

Outcome

Time from discharge to achieving outpatient LDL <70 mg/dL and SBP <130 mmHg, neuropsychology, and rehabilitation evaluation.surrogate

A centralized multidisciplinary stroke clinic significantly accelerates the achievement of guideline-directed LDL and blood pressure targets following hospital discharge.

Main Result

Absolute Event Rate: 0% vs 0%

Abstract

Background: Emory Healthcare implemented a structured, multidisciplinary stroke clinic system led by stroke prevention and rehabilitation physicians supported by physical therapy, neuropsychology and geriatric medicine. This model is designed to enhance post-stroke care through improved risk factor control, access to specialty services, and reduced recurrence.This study evaluated the impact of a comprehensive multidisciplinary stroke systems-of-care model in a real-world setting. Methods: We retrospectively analyzed patients with ischemic stroke, ICH, SAH, or TIA discharged from six Emory Healthcare stroke centers and seen in a centralized stroke clinic before (October 1, 2022–December 31, 2023) and after (January 1, 2024–April 30, 2025) implementing a structured multidisciplinary care model. Clinical outcomes include time from discharge to outpatient LDL<70 mg/dL and SBP <130 mmHg), neuropsychology, and rehabilitation evaluation are reported for discharges from the Comprehensive Stroke Center (CSC) and systemwide. Results: During the study period, 2451 patients (mean age 64±15 years, 59% black, 51% female, 83% ischemic stroke) were seen in the stroke clinic after hospital discharge. There was a significant increase in hospital-discharged patients seen within 90 days after implementation among CSC (Pre 31% vs Post 40%, p<0.001) and systemwide hospitals (Pre 22%, Post 29%, p <0.001). There was no significant difference in 90-day system ED revisits (Pre 16%, Post 15%, p=0.47), 90-day system readmissions (Pre 17% vs Post 19%, p=0.21) or mortality (Pre 0.8%, Post 1.9%, p=0.07). Median time from discharge to achieving outpatient LDL <70 mg/dL significantly decreased Pre 98 days [IQR: 41-221 vs. Post 67 days (IQR: 51-134), p=0.001] as did time to achieving systolic BP <130 mmHg 154 days (IQR: 56-368) vs 108 days (IQR: 35-179), p=0.002. Post-implementation 372 patients underwent neuropsychology testing. Also, rehabilitation evaluation and referrals increased by 42%. During the study period Emory Clinic ranked among the top 5 national enrollers for two NIH StrokeNet prevention trials. Conclusion: A centralized multidisciplinary outpatient stroke clinic represents an effective systems-based approach to achieving rapid risk factors control while providing cognitive and rehabilitation resources for discharged patients in a structured environment. This stroke clinic model can achieve high enrollment targets for stroke prevention and rehabilitation clinical trials.