What percentage of patients with severe stroke require follow-up by family medicine (FM) in the chronic phase of stroke?

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From the Guidelines

Nearly all patients with severe stroke require follow-up by family medicine in the chronic phase, with estimates suggesting a significant proportion need ongoing primary care management. After hospital discharge and rehabilitation, family physicians typically coordinate long-term care, managing secondary prevention medications, monitoring for complications, addressing functional limitations, and coordinating multidisciplinary care. According to a scientific statement from the American Heart Association/American Stroke Association 1, primary care clinicians provide most of the long-term care for patients with stroke, and in a typical primary care practice, 100 patients will have a history of stroke, with 5 to 10 having a new stroke each year. This high percentage reflects the complex, multifaceted nature of post-stroke care, which extends well beyond the acute phase. Severe strokes often result in significant disability requiring ongoing management of medical comorbidities, medication adjustments, and addressing complications like depression, spasticity, and pain. Key factors influencing the need for follow-up include:

  • The presence of hypertension, which affects approximately 50% to 80% of patients with stroke 1
  • The presence of diabetes, which affects approximately 20% to 30% of patients with stroke 1
  • The presence of comorbid heart disease or atrial fibrillation, which affects approximately 10% to 30% of patients with stroke 1 Family physicians serve as the central point for care coordination, connecting patients with specialists, therapists, and community resources while providing continuity of care throughout the chronic phase of stroke recovery.

From the Research

Percentage of Patients Requiring Follow-up by Family Medicine

  • There are no research papers to assist in answering this question, as the provided studies do not mention the percentage of patients with severe stroke requiring follow-up by family medicine in the chronic phase of stroke 2, 3, 4, 5, 6.

Related Information

  • Studies have discussed the importance of family-centered care in stroke rehabilitation, highlighting the need for collaboration and partnership among patients, families, and providers 4.
  • Research has also explored the experiences and support needs of family members making treatment decisions for patients admitted with major stroke, emphasizing the importance of tailored information and support 6.
  • However, these studies do not provide specific information on the percentage of patients requiring follow-up by family medicine in the chronic phase of stroke.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Stroke: causes and clinical features.

Medicine (Abingdon, England : UK ed.), 2020

Research

Clinical Implications of Family-Centered Care in Stroke Rehabilitation.

Rehabilitation nursing : the official journal of the Association of Rehabilitation Nurses, 2015

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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