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Middleton S, Dale S, McElduff B, Coughlan K, McInnes E, Mikulik R, Fischer T, Van der Merwe J, Cadilhac D, D’Este C, Levi C, Grimshaw JM, Grecu A, Quinn C, Cheung NW, Koláčná T, Medukhanova S, Sanjuan Menendez E, Salselas S, Messchendorp G, Cassier-Woidasky AK, Skrzypek-Czerko M, Slavat-Plana M, Antonella U, Pfeilschifter W. Translation of nurse-initiated protocols to manage fever, hyperglycaemia and swallowing following stroke across Europe (QASC Europe): A pre-test/post-test implementation study. Eur Stroke J 2022; 8:132-147. [PMID: 37021183 PMCID: PMC10069193 DOI: 10.1177/23969873221126027] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 08/24/2022] [Indexed: 11/16/2022] Open
Abstract
Introduction: Poor adoption of stroke guidelines is a problem internationally. The Quality in Acute Stroke Care (QASC) trial demonstrated significant reduction in death and disability with facilitated implementation of nurse-initiated Methods: This was a multi-country, multi-centre, pre-test/post-test study (2017–2021) comparing post implementation data with historically collected pre-implementation data. Hospital clinical champions, supported by the Angels Initiative conducted multidisciplinary workshops discussing pre-implementation medical record audit results, barriers and facilitators to FeSS Protocol implementation, developed action plans and provided education, with ongoing support co-ordinated remotely from Australia. Prospective audits were conducted 3-month after FeSS Protocol introduction. Pre-to-post analysis and country income classification comparisons were adjusted for clustering by hospital and country controlling for age/sex/stroke severity. Results: Data from 64 hospitals in 17 countries (3464 patients pre-implementation and 3257 patients post-implementation) showed improvement pre-to-post implementation in measurement recording of all three FeSS components, all p < 0.0001: fever elements (pre: 17%, post: 51%; absolute difference 33%, 95% CI 30%, 37%); hyperglycaemia elements (pre: 18%, post: 52%; absolute difference 34%; 95% CI 31%, 36%); swallowing elements (pre: 39%, post: 67%; absolute difference 29%, 95% CI 26%, 31%) and thus in overall FeSS Protocol adherence (pre: 3.4%, post: 35%; absolute difference 33%, 95% CI 24%, 42%). In exploratory analysis of FeSS adherence by countries’ economic status, high-income versus middle-income countries improved to a comparable extent. Discussion and conclusion: Our collaboration resulted in successful rapid implementation and scale-up of FeSS Protocols into countries with vastly different healthcare systems.
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Affiliation(s)
- Sandy Middleton
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Simeon Dale
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Benjamin McElduff
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Kelly Coughlan
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Elizabeth McInnes
- Nursing Research Institute, St Vincent’s Health Network Sydney, St Vincent’s Hospital Melbourne & Australian Catholic University, Sydney, NSW, Australia
- School of Nursing, Midwifery and Paramedicine, Australian Catholic University, Sydney, Australia
| | - Robert Mikulik
- International Clinical Research Centre, Neurology Department, St. Ann’s University Hospital and Masaryk University, Brno, Czech Republic
| | - Thomas Fischer
- Angels Initiative, Boehringer Ingelheim International GmbH, Hamburg, Germany
| | - Jan Van der Merwe
- Angels Initiative, Boehringer Ingelheim International GmbH, Hamburg, Germany
| | - Dominique Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, VIC, Australia
| | - Catherine D’Este
- National Centre for Epidemiology and Population Health (NCEPH), Australian National University, Canberra, Australia
- Sax Institute, Sydney, Australia
| | - Christopher Levi
- John Hunter Health and Innovation Precinct, HNE LHD, New Lambton, NSW, Australia
- Department of Medicine, University of Newcastle, Callaghan, NSW, Australia
| | - Jeremy M Grimshaw
- University of Ottawa, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Andreea Grecu
- International Clinical Research Centre, Neurology Department, St. Ann’s University Hospital and Masaryk University, Brno, Czech Republic
| | - Clare Quinn
- Prince of Wales Hospital, Randwick, Australia
| | - Ngai Wah Cheung
- Centre for Diabetes and Endocrinology Research, Westmead Hospital, University of Sydney, Sydney, NSW, Australia
| | | | | | | | | | | | | | | | - Merce Slavat-Plana
- Health Department, Agency for Health Quality and Assessment (AQuAS), CIBER Epidemiología y Salud Pública, CIBERESP, Stroke Programme, Barcelona, Spain
| | - Urso Antonella
- Hospital Network Area-Regional Health Department, Regione Lazio, Rome, Italy
| | - Waltraud Pfeilschifter
- Department of Neurology and Clinical Neurophysiology, Städtisches Klinikum Lüneburg, Lüneburg, Germany
- Department of Neurology, Goethe University, Frankfurt am Main, Germany
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"Lessons Learned" Preventing Recurrent Ischemic Strokes through Secondary Prevention Programs: A Systematic Review. J Clin Med 2021; 10:jcm10184209. [PMID: 34575320 PMCID: PMC8471819 DOI: 10.3390/jcm10184209] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 09/09/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022] Open
Abstract
Recurrent ischemic strokes are a cause of significant healthcare burdens globally. Patients with uncontrolled vascular risk factors are more likely to develop recurrent ischemic strokes. This study aims to compile information gained from current secondary prevention programs. A pre-defined literature search strategy was applied to PubMed, SCOPUS, CINAHL, and Google Scholar databases, and studies from 1997 to 2020 were evaluated for quality, study aims, and outcomes. The search produced 1175 articles (1092 after duplicates were removed) and titles were screened; 55 titles were retained for the full-text analysis. Of the remaining studies, 31 were retained for assessment, five demonstrated long-term effectiveness, eight demonstrated short-term effectiveness, and 18 demonstrated no effectiveness. The successful studies utilized a variety of different techniques in the categories of physical fitness, education, and adherence to care plans to reduce the risk of recurrent strokes. The lessons we learned from the current prevention programs included (1) offer tailored care for underserved groups, (2) control blood pressure, (3) provide opportunities for medication dosage titration, (4) establish the care plan prior to discharge, (5) invest in supervised exercise programs, (6) remove barriers to accessing care in low resource settings, and (7) improve the transition of care.
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Lowe D, Ryan R, Schonfeld L, Merner B, Walsh L, Graham-Wisener L, Hill S. Effects of consumers and health providers working in partnership on health services planning, delivery and evaluation. Cochrane Database Syst Rev 2021; 9:CD013373. [PMID: 34523117 PMCID: PMC8440158 DOI: 10.1002/14651858.cd013373.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Health services have traditionally been developed to focus on specific diseases or medical specialties. Involving consumers as partners in planning, delivering and evaluating health services may lead to services that are person-centred and so better able to meet the needs of and provide care for individuals. Globally, governments recommend consumer involvement in healthcare decision-making at the systems level, as a strategy for promoting person-centred health services. However, the effects of this 'working in partnership' approach to healthcare decision-making are unclear. Working in partnership is defined here as collaborative relationships between at least one consumer and health provider, meeting jointly and regularly in formal group formats, to equally contribute to and collaborate on health service-related decision-making in real time. In this review, the terms 'consumer' and 'health provider' refer to partnership participants, and 'health service user' and 'health service provider' refer to trial participants. This review of effects of partnership interventions was undertaken concurrently with a Cochrane Qualitative Evidence Synthesis (QES) entitled Consumers and health providers working in partnership for the promotion of person-centred health services: a co-produced qualitative evidence synthesis. OBJECTIVES To assess the effects of consumers and health providers working in partnership, as an intervention to promote person-centred health services. SEARCH METHODS We searched the CENTRAL, MEDLINE, Embase, PsycINFO and CINAHL databases from 2000 to April 2019; PROQUEST Dissertations and Theses Global from 2016 to April 2019; and grey literature and online trial registries from 2000 until September 2019. SELECTION CRITERIA We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs of 'working in partnership' interventions meeting these three criteria: both consumer and provider participants meet; they meet jointly and regularly in formal group formats; and they make actual decisions that relate to the person-centredness of health service(s). DATA COLLECTION AND ANALYSIS Two review authors independently screened most titles and abstracts. One review author screened a subset of titles and abstracts (i.e. those identified through clinical trials registries searches, those classified by the Cochrane RCT Classifier as unlikely to be an RCT, and those identified through other sources). Two review authors independently screened all full texts of potentially eligible articles for inclusion. In case of disagreement, they consulted a third review author to reach consensus. One review author extracted data and assessed risk of bias for all included studies and a second review author independently cross-checked all data and assessments. Any discrepancies were resolved by discussion, or by consulting a third review author to reach consensus. Meta-analysis was not possible due to the small number of included trials and their heterogeneity; we synthesised results descriptively by comparison and outcome. We reported the following outcomes in GRADE 'Summary of findings' tables: health service alterations; the degree to which changed service reflects health service user priorities; health service users' ratings of health service performance; health service users' health service utilisation patterns; resources associated with the decision-making process; resources associated with implementing decisions; and adverse events. MAIN RESULTS We included five trials (one RCT and four cluster-RCTs), with 16,257 health service users and more than 469 health service providers as trial participants. For two trials, the aims of the partnerships were to directly improve the person-centredness of health services (via health service planning, and discharge co-ordination). In the remaining trials, the aims were indirect (training first-year medical doctors on patient safety) or broader in focus (which could include person-centredness of health services that targeted the public/community, households or health service delivery to improve maternal and neonatal mortality). Three trials were conducted in high income-countries, one was in a middle-income country and one was in a low-income country. Two studies evaluated working in partnership interventions, compared to usual practice without partnership (Comparison 1); and three studies evaluated working in partnership as part of a multi-component intervention, compared to the same intervention without partnership (Comparison 2). No studies evaluated one form of working in partnership compared to another (Comparison 3). The effects of consumers and health providers working in partnership compared to usual practice without partnership are uncertain: only one of the two studies that assessed this comparison measured health service alteration outcomes, and data were not usable, as only intervention group data were reported. Additionally, none of the included studies evaluating this comparison measured the other primary or secondary outcomes we sought for the 'Summary of findings' table. We are also unsure about the effects of consumers and health providers working in partnership as part of a multi-component intervention compared to the same intervention without partnership. Very low-certainty evidence indicated there may be little or no difference on health service alterations or health service user health service performance ratings (two studies); or on health service user health service utilisation patterns and adverse events (one study each). No studies evaluating this comparison reported the degree to which health service alterations reflect health service user priorities, or resource use. Overall, our confidence in the findings about the effects of working in partnership interventions was very low due to indirectness, imprecision and publication bias, and serious concerns about risk of selection bias; performance bias, detection bias and reporting bias in most studies. AUTHORS' CONCLUSIONS The effects of consumers and providers working in partnership as an intervention, or as part of a multi-component intervention, are uncertain, due to a lack of high-quality evidence and/or due to a lack of studies. Further well-designed RCTs with a clear focus on assessing outcomes directly related to partnerships for patient-centred health services are needed in this area, which may also benefit from mixed-methods and qualitative research to build the evidence base.
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Affiliation(s)
- Dianne Lowe
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Rebecca Ryan
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Lina Schonfeld
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Bronwen Merner
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | - Louisa Walsh
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
| | | | - Sophie Hill
- Centre for Health Communication and Participation, School of Psychology and Public Health, La Trobe University, Bundoora, Australia
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Ganesh A, Ospel JM, Marko M, van Zwam WH, Roos YBWEM, Majoie CBLM, Goyal M. From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke. Front Neurol 2021; 12:713738. [PMID: 34381418 PMCID: PMC8350336 DOI: 10.3389/fneur.2021.713738] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond. Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT. Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability. Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.
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Affiliation(s)
- Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | | | - Martha Marko
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | | | | | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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5
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Chen Y, Zhong W, Gong X, Hu H, Yan S, Zhang X, Chen Z, Zhou Y, Lou M. Rationale and design of individualized quality improvement based on the Computer Analysing system to improve Stroke management quality Evaluation (CASE): a multicenter historically controlled study. Trials 2020; 21:677. [PMID: 32709249 PMCID: PMC7379356 DOI: 10.1186/s13063-020-04598-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 07/12/2020] [Indexed: 11/23/2022] Open
Abstract
Background Guideline-based medical care has been identified to improve outcomes in stroke. However, data acquisition and medical quality management during hospital stay still need to be improved in China. We have developed a computer-based medical data collecting system, together with automated calculation of key performance indicators (KPIs) and regular individualized education, and thus aim to explore whether it can improve the medical care quality of acute ischemic stroke (AIS) during hospital stay in stroke centers. Methods The individualized quality improvement based on the Computer Analysing system to improve Stroke management quality Evaluation (CASE) trial is a prospective, multicenter, historical control study among 30 stroke centers in China. In this trial, the data is directly extracted from the saved original medical record of each AIS patient during hospital stay, regardless of different Electronic Medical Record System (EMRS) in each center. Then, the automated calculation of KPIs and the regular education via teleconference per month allow the clinicians to examine the causes of non-compliance of guideline-based care and develop programs to decrease their frequency. Discussion We compare KPIs between pre-intervention stage and post-intervention stage (without or with education) among stroke centers. If proved effective, this approach might be generalized around China and even worldwide, where a unified EMRS is difficult to be applied and in-patient care needs to be improved. Trial registration ClinicalTrials.gov NCT03684629. Registered on 9 December 2018. Retrospectively registered.
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Affiliation(s)
- Yi Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88# Jiefang Road, Hangzhou, 310009, China
| | - Wansi Zhong
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88# Jiefang Road, Hangzhou, 310009, China
| | - Xiaoxian Gong
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88# Jiefang Road, Hangzhou, 310009, China
| | - Haitao Hu
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88# Jiefang Road, Hangzhou, 310009, China
| | - Shenqiang Yan
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88# Jiefang Road, Hangzhou, 310009, China
| | - Xuting Zhang
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88# Jiefang Road, Hangzhou, 310009, China
| | - Zhicai Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88# Jiefang Road, Hangzhou, 310009, China
| | - Ying Zhou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88# Jiefang Road, Hangzhou, 310009, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University School of Medicine, 88# Jiefang Road, Hangzhou, 310009, China.
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Rudd AG, Bladin C, Carli P, De Silva DA, Field TS, Jauch EC, Kudenchuk P, Kurz MW, Lærdal T, Ong M, Panagos P, Ranta A, Rutan C, Sayre MR, Schonau L, Shin SD, Waters D, Lippert F. Utstein recommendation for emergency stroke care. Int J Stroke 2020; 15:555-564. [PMID: 32223543 PMCID: PMC7672780 DOI: 10.1177/1747493020915135] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Background Recent advances in treatment for stroke give new possibilities for optimizing
outcomes. To deliver these prehospital care needs to become more
efficient. Aim To develop a framework to support improved delivery of prehospital care. The
recommendations are aimed at clinicians involved in prehospital and
emergency health systems who will often not be stroke specialists but need
clear guidance as to how to develop and deliver safe and effective care for
acute stroke patients. Methods Building on the successful implementation program from the Global
Resuscitation Alliance and the Resuscitation Academy, the Utstein
methodology was used to define a generic chain of survival for Emergency
Stroke Care by assembling international expertise in Stroke and Emergency
Medical Services (EMS). Ten programs were identified for Acute Stroke Care
to improve survival and outcomes, with recommendations for implementation of
best practice. Conclusions Efficient prehospital systems for acute stroke will be improved through
public awareness, optimized prehospital triage and timely diagnostics, and
quick and equitable access to acute treatments. Documentation, use of
metrics and transparency will help to build a culture of excellence and
accountability.
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Affiliation(s)
- A G Rudd
- NHS England and King's College, London, England
| | - C Bladin
- Eastern Health Monash University, Melbourne, Australia
| | - P Carli
- Emergency Medical Services, Paris, France
| | - D A De Silva
- National Neuroscience Institute, Singapore General Hospital, Singapore
| | - T S Field
- University of British Columbia, Vancouver, Canada
| | - E C Jauch
- Mission Health System, Asheville, USA
| | - P Kudenchuk
- University of Washington School of Medicine, Seattle, WA, USA
| | - M W Kurz
- Stavanger University Hospital, Stavanger, Norway
| | - T Lærdal
- The Laerdal Foundation, Stavanger, Norway
| | - Meh Ong
- Singapore General Hospital and Duke-NUS Medical School, Singapore, Singapore
| | - P Panagos
- Washington University School of Medicine, St. Louis, MO, USA
| | - A Ranta
- University of Otago, Dunedin, New Zealand
| | - C Rutan
- American Heart Association, Dallas, TX, USA
| | | | - L Schonau
- Danish Resuscitation Council, Copenhagen, Denmark
| | - S D Shin
- Seoul National University College of Medicine, Seoul, South Korea
| | - D Waters
- Ambulance New Zealand, Wellington, New Zealand
| | - F Lippert
- Copenhagen Emergency Medical Services, Copenhagen, Denmark
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7
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Yang W, Yang J, Xiong X, Weng X, Wu W. Effect of Statins on Patients with Acute Ischemic Stroke Infection based on Intelligent Data Acquisition of Computed Tomography Image information (Preprint). JMIR Med Inform 2020. [DOI: 10.2196/18571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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8
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Machline-Carrion MJ, Santucci EV, Damiani LP, Bahit MC, Málaga G, Pontes-Neto OM, Martins SCO, Zétola VF, Normilio-Silva K, Rodrigues de Freitas G, Gorgulho A, De Salles A, Pacheco da Silva BG, Santos JY, de Andrade Jesuíno I, Bueno PRT, Cavalcanti AB, Guimarães HP, Xian Y, Bettger JP, Lopes RD, Peterson ED, Berwanger O. Effect of a Quality Improvement Intervention on Adherence to Therapies for Patients With Acute Ischemic Stroke and Transient Ischemic Attack: A Cluster Randomized Clinical Trial. JAMA Neurol 2019; 76:932-941. [PMID: 31058947 DOI: 10.1001/jamaneurol.2019.1012] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Translating evidence into clinical practice in the management of acute ischemic stroke (AIS) and transient ischemic attack (TIA) is challenging, especially in low- and middle-income countries. Objective To assess the effect of a multifaceted quality improvement intervention on adherence to evidence-based therapies for care of patients with AIS and TIA. Design, Setting and Participants This 2-arm cluster-randomized clinical trial assessed 45 hospitals and 2336 patients with AIS and TIA for eligibility before randomization. Eligible hospitals were able to provide care for patients with AIS and TIA in Brazil, Argentina, and Peru. Recruitment started September 12, 2016, and ended February 26, 2018; follow-up ended June 29, 2018. Data were analyzed using the intention-to-treat principle. Interventions The multifaceted quality improvement intervention included case management, reminders, a roadmap and checklist for the therapeutic plan, educational materials, and periodic audit and feedback reports to each intervention cluster. Main Outcomes and Measures The primary outcome was a composite adherence score for AIS and TIA performance measures. Secondary outcomes included an all-or-none composite end point of performance measures, the individual process measure components of the composite end points, and clinical outcomes at 90 days after admission (stroke recurrence, death, and disability measured by the modified Rankin scale). Results A total of 36 hospitals and 1624 patients underwent randomization. Nineteen hospitals were randomized to the quality improvement intervention and 17 to routine care. The overall mean (SD) age of patients enrolled in the study was 69.4 (13.5) years, and 913 (56.2%) were men. Overall mean (SD) composite adherence score for the 10 performance measures in the intervention group hospitals compared with control group hospitals was 85.3% (20.1%) vs 77.8% (18.4%) (mean difference, 4.2%; 95% CI, -3.8% to 12.2%). As a secondary end point, 402 of 817 patients (49.2%) at intervention hospitals received all the therapies that they were eligible for vs 203 of 807 (25.2%) in the control hospitals (odds ratio, 2.59; 95% CI, 1.22-5.53; P = .01). Conclusions and Relevance A multifaceted quality improvement intervention did not result in a significant increase in composite adherence score for evidence-based therapies in patients with AIS or TIA. However, when using an all-or-none approach, the intervention resulted in improved adherence to evidence-based therapies. Trial Registration ClinicalTrials.gov identifier: NCT02223273.
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Affiliation(s)
| | | | | | - M Cecilia Bahit
- Fundacion Instituto de Neurología Cognitiva Rosario, Grupo Argentino Colaborativo en Investigación Clínica, Rosario, Argentina
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ying Xian
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Janet Prvu Bettger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina.,Brazilian Clinical Research Institute, São Paulo, Brazil
| | - Eric D Peterson
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
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9
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Wajngarten M, Silva GS. Hypertension and Stroke: Update on Treatment. Eur Cardiol 2019; 14:111-115. [PMID: 31360232 PMCID: PMC6659031 DOI: 10.15420/ecr.2019.11.1] [Citation(s) in RCA: 112] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 05/14/2019] [Indexed: 12/16/2022] Open
Abstract
Stroke is the second most common cause of mortality worldwide and the third most common cause of disability. Hypertension is the most prevalent risk factor for stroke. Stroke causes and haemodynamic consequences are heterogeneous which makes the management of blood pressure in stroke patients complex requiring an accurate diagnosis and precise definition of therapeutic goals. In this article, the authors provide an updated review on the management of arterial hypertension to prevent the first episode and the recurrence. They also present a discussion on blood pressure management in hypertensive urgencies and emergencies, especially in the acute phase of hypertensive encephalopathy, ischaemic stroke and haemorrhagic stroke.
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Affiliation(s)
| | - Gisele Sampaio Silva
- Neurology and Neurosurgery Department, Federal University of São PauloBrazil
- Academic Research Organization, Hospital Israelita Albert EinsteinSão Paulo, Brazil
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