Evaluation of Telerehabilitation for Stroke Survivors in a Community Hospital Network

Thesis Abstract

Telerehabilitation offers a scalable solution to bridge rehabilitation gaps for stroke survivors within fragmented community hospital networks, yet evidence on its effectiveness, implementation determinants, and sustainability in real-world networks remains limited. This study addresses the problem of inequitable access to post-stroke rehabilitation services and inconsistent rehabilitation outcomes across a network of community hospitals by evaluating a structured telerehabilitation program integrated with conventional in-person therapy. The aim is to determine the effectiveness, feasibility, and determinants of adoption of telerehabilitation for stroke survivors across the network, with specific objectives to (1) compare functional outcomes between telerehabilitation and standard care at 12 weeks and 26 weeks, (2) assess patient, provider, and organizational factors influencing adherence and satisfaction, (3) examine cost-effectiveness from the health-system perspective, and (4) develop a scalable implementation framework for broader adoption. A mixed-methods design will be employed, combining a pragmatic quasi-experimental approach for effectiveness and a concurrent qualitative study for contextual understanding. The population comprises adult stroke survivors (n?320) enrolled across eight community hospital sites within the network, who meet inclusion criteria of mild-to-moderate impairment (Modified Rankin Scale 2–4) and access to needed telecommunication infrastructure. A cohort of 320 participants will be allocated to either telerehabilitation plus usual care (n?160) or usual care alone (n?160) using site-based assignment to preserve real-world conditions. Data collection will utilize standardized instruments the Fugl-Meyer Assessment for upper and lower extremity function, the Barthel Index for activities of daily living, the Montreal Cognitive Assessment for cognitive screening, and the Stroke-Specific Quality of Life Scale. Secondary measures include the Timed Up and Go test, Hospital Anxiety and Depression Scale, and adherence metrics recorded via the telerehabilitation platform. Data collection points are baseline, 12 weeks, and 26 weeks. Economic evaluation will adopt a micro-costing approach, capturing direct medical costs, patient costs, and equipment expenses, with incremental cost-effectiveness analysis expressed as cost per quality-adjusted life year gained. Quantitative analysis will employ intention-to-treat principles. Primary outcomes will be analyzed using mixed-effects linear models to account for repeated measures and clustering by site, with fixed effects for group, time, and group-by-time interaction. Secondary outcomes will be analyzed using generalized estimating equations for binary and ordinal outcomes. A cost-effectiveness analysis will compute incremental cost-effectiveness ratios, with sensitivity analyses conducted via probabilistic methods. Subgroup analyses will explore differential effects by age, sex, baseline impairment, and distance to hospital. The qualitative component will use purposive sampling to interview stroke survivors, family caregivers, therapists, and administrators (n?40) to explore perceived barriers, facilitators, and contextual factors influencing implementation. Thematic analysis will be conducted using a quasi-ethnographic coding framework, and triangulation will integrate qualitative insights with quantitative findings to interpret heterogeneity in results and inform an implementation framework. The theoretical underpinnings will integrate the Technology Acceptance Model to explain adoption decisions, and the Consolidated Framework for Implementation Research to structure determinants and outcomes. Expected findings include superior or non-inferior functional gains in the telerehabilitation group at 12 and 26 weeks, with improvements in ADLs and stroke-specific quality of life, and acceptable adherence and high satisfaction among patients and providers. The economic evaluation is anticipated to show favorable incremental cost-effectiveness in urban and rural sites with scalable telecommunication costs and reduced transportation burdens. The study will contribute to knowledge by providing robust, multi-site evidence on the clinical effectiveness, economic value, and implementation feasibility of telerehabilitation for stroke within community hospital networks, guiding policy and payer decisions. It will propose an implementation framework detailing governance, workflow integration, data governance, training, and ongoing support to sustain telerehabilitation beyond the study period. The principal conclusion is that telerehabilitation, when integrated with standard care, can achieve clinically meaningful improvements in function and quality of life at a reasonable incremental cost, with adoption shaped by organizational readiness and stakeholder engagement; recommendations include prioritizing interoperable digital platforms, targeted patient selection criteria, standardized therapist protocols, and ongoing monitoring dashboards to optimize outcomes and sustainability across community hospital networks.