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Stroke Case- and Care-Management in East Westphalia-Lippe (OWL), Germany. The STROKE OWL-Project"


Georg R Galle

Stiftung Deutsche Schlaganfall-Hilfe, DE
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Patients with stroke are at a high risk of recurrent stroke and rehospitalisation. The STROKE OWL trial investigates whether secondary strokes are preventable with a cross-sectoral post-stroke case and care management programme. As secondary endpoints patient related outcomes like quality of life are assessed. STROKE OWL is funded by the Innovation Fund of the German Federal Joint Committee (G-BA).


It is planned to enrol 1.600 patients with stroke and transient ischaemic attack (TIA) in East Westphalia-Lippe (OWL) between June 2018 and March 2020. 17 Stroke Case-Managers (Stroke Navigators) are currently recruiting. They support the patients over 12 months. The intake of patients happens at the Stroke Unit. 7 acute clinics in OWL with a certified Stroke Unit participate.

The primary data are collected in a digital patient file (“Lotsen-App”) which was developed by OFFIS – Institute for Information Technology. Control group data are provided by cooperating health insurance companies. The study design (quasi-experimental research design with control group) has been developed by the University of Bielefeld, Faculty of Public Health. Primary data collected within the 12 months intervention include i.a. medical, life style and patient related data.


Patient recruitment started in June 2018 and will end in March 2020 with a 1-year follow-up. Until end of September 2019, 1.045 patients (458 female) have been enrolled into the study. Included are patients after stroke of the ICD codes I60 - I64 (most with main diagnosis I63: 810) and G45 (145). The mean age is 70 years.


The preliminary process evaluation shows so far that the stroke navigators are working according to the predefined patient oriented pathways and that the complex intervention follows the case management process. The stroke navigator works at the interfaces between acute care, rehabilitation and the outpatient sector. He informs the patient and his relatives, documents the treatment and coordinates the measures in secondary prevention. Further project evaluation will answer the central study questions if a stroke case management supports patients to define individual targets for secondary prevention and the achievement of these targets and improve the quality of life.


STROKE OWL is a case management based model for integrated care after stroke and therefore a promising approach to reduce the risk of recurrent stroke and to improve the quality of care for stroke survivors.

Primary results will be reported in September 2021.

Lessons Learned:

The high complexity of the intervention and the need for coordination with a large number of partners involved made an extension of the preparation time for establishing the project framework, study protocols and documents necessary.


The study aims to be representative for a broad spectrum of patients after stroke (modified ranking 0- 4), but limited influence on enrolment due to patients choice or further medical exclusion criteria may complicate representivity. 

Suggestions for future research:

From a health economic perspective and the background of varying degrees of stroke severity and associated need for care and support the development of tailored and demand-specific models make sense.

How to Cite: Galle GR. Stroke Case- and Care-Management in East Westphalia-Lippe (OWL), Germany. The STROKE OWL-Project\". International Journal of Integrated Care. 2021;21(S1):268. DOI:
Published on 01 Sep 2021.


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