Implementation of a structured guideline-based program for the secondary prevention of ischemic stroke in China

Trends in guideline implementation: an updated scoping review

Background

Guidelines aim to support evidence-informed practice but are inconsistently used without implementation strategies. Our prior scoping review revealed that guideline implementation interventions were not selected and tailored based on processes known to enhance guideline uptake and impact. The purpose of this study was to update the prior scoping review.

Methods

We searched MEDLINE, EMBASE, AMED, CINAHL, Scopus, and the Cochrane Database of Systematic Reviews for studies published from 2014 to January 2021 that evaluated guideline implementation interventions. We screened studies in triplicate and extracted data in duplicate. We reported study and intervention characteristics and studies that achieved impact with summary statistics.

Results

We included 118 studies that implemented guidelines on 16 clinical topics. With regard to implementation planning, 21% of studies referred to theories or frameworks, 50% pre-identified implementation barriers, and 36% engaged stakeholders in selecting or tailoring interventions. Studies that employed frameworks (n=25) most often used the theoretical domains framework (28%) or social cognitive theory (28%). Those that pre-identified barriers (n=59) most often consulted literature (60%). Those that engaged stakeholders (n=42) most often consulted healthcare professionals (79%). Common interventions included educating professionals about guidelines (44%) and information systems/technology (41%). Most studies employed multi-faceted interventions (75%). A total of 97 (82%) studies achieved impact (improvements in one or more reported outcomes) including 10 (40% of 25) studies that employed frameworks, 28 (47.45% of 59) studies that pre-identified barriers, 22 (52.38% of 42) studies that engaged stakeholders, and 21 (70% of 30) studies that employed single interventions.

Conclusions

Compared to our prior review, this review found that more studies used processes to select and tailor interventions, and a wider array of types of interventions across the Mazza taxonomy. Given that most studies achieved impact, this might reinforce the need for implementation planning. However, even studies that did not plan implementation achieved impact. Similarly, even single interventions achieved impact. Thus, a future systematic review based on this data is warranted to establish if the use of frameworks, barrier identification, stakeholder engagement, and multi-faceted interventions are associated with impact.

Trial registration

The protocol was registered with Open Science Framework (https://osf.io/4nxpr) and published in JBI Evidence Synthesis.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01223-6.

The Impact of Standardized Health Education in Patients with Ischemic Stroke on Patient Management Satisfaction and Quality of Clinical Management Services

Aim

Ischemic stroke is a common brain disease, which seriously affects the quality of life of patients. The purpose of this study was to evaluate the impact of the application of standardized health education in ischemic stroke patients on patient management satisfaction and clinical management service quality.

Methods

220 patients with ischemic stroke were chosen for study target. The research objects were randomly divided into control group (n = 110) and education group (n = 110) by odd even number draw lots. The control group conducted conventional treatment; on the basis of the control group, the education group received standardized health education. The impact of the application of standardized health education in patients with ischemic stroke on patient management satisfaction and clinical management service quality was analyzed.

Results

The number of health error items in the two groups decreased significantly after 2 months and 3 months of treatment, contrast to before admission, and the number of health error items in the education group was lower than that in the control group, and the difference was statistically significant. After 3 months of treatment, the daily activity score increased and the neurological function score decreased in the two groups, and the daily activity score in the education group was higher than that in the control group, and the neurological function score was lower than that in the control group; the difference was statistically significant. The satisfaction scores of patients in the education group in different aspects such as staff working attitude, health management, diet management, and environmental management were higher than those in the control group, and the disparity was obvious.

Conclusion

The application of standardized health education in patients with ischemic stroke has certain clinical value.

Patient-Centered Outcomes in a Randomized Trial Investigating a Multimodal Prevention Program After Transient Ischemic Attack or Minor Stroke: The INSPiRE-TMS Trial

BACKGROUND

The INSPiRE-TMS trial (Intensified Secondary Prevention Intending a Reduction of Recurrent Events in Transient Ischemic Attack and Minor Stroke Patients) investigated effects of a multicomponent support program in patients with nondisabling stroke or transient ischemic attack. Although secondary prevention targets were achieved more frequently in the intensified care group, no significant differences were seen in rates of recurrent major vascular events. Here, we present the effects on prespecified patient-centered outcomes.

METHODS

In a multicenter trial, we randomized patients with modifiable risk factors either to the intensified or conventional care alone program. Intensified care was provided by stroke specialists and used feedback and motivational interviewing strategies (≥8 outpatient visits over 2 years) aiming to improve adherence to secondary prevention targets. We measured physical fitness, disability, cognitive function and health-related quality of life by stair-climbing test, modified Rankin Scale, Montreal Cognitive Assessment, and European Quality of Life 5 Dimension 3 Level during the first 3 years of follow-up.

RESULTS

Of 2072 patients (mean age: 67.4years, 34% female) assessed for the primary outcome, patient-centered outcomes were collected in 1,771 patients (877 intensified versus 894 conventional care group). Physical fitness improved more in the intensified care group (mean between-group difference in power (Watt): 24.5 after 1 year (95% CI, 5.5-43.5); 36.1 after 2 years (95% CI, 13.1-59.7) and 29.6 (95% CI, 2.0-57.3 after 3 years). At 1 year, there was a significant shift in ordinal regression analysis of modified Rankin Scale in favor of the intensified care group (common odds ratio, 1.23 [95% CI, 1.03-1.47]) but not after 2 (odds ratio, 1.17 [95% CI, 0.96-1.41]) or 3 years (odds ratio, 1.16 [95% CI, 0.95-1.43]) of follow-up. However, Montreal Cognitive Assessment and European Quality of Life 5 Dimension scores showed no improvement in the intensified intervention arm after 1, 2, or 3 years of follow-up.

CONCLUSIONS

Patients of the intensified care program group had slightly better results for physical fitness and modified Rankin Scale after 1 year, but none of the other patient-centered outcomes was significantly improved.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT01586702.

Longer term patient management following stroke: A systematic review

BACKGROUND

Tremendous progress in acute stroke therapy has improved short-term outcome but part of this achievement may be lost in the long run. Concepts for a better long-term management of stroke survivors are needed to address their unmet needs and to reduce the burden of post-stroke complications, residual deficits, and recurrent vascular events.

AIMS

This review summarizes current knowledge on post-hospital care and the scientific evidence supporting individual programs.

SUMMARY OF REVIEW

A systematic search of electronic databases according to PRISMA guidelines identified 10,374 articles, 77 of which met the inclusion criteria. One large randomised controlled trial on a multifaceted care program delivered by the multidisciplinary stroke team reduced recurrent vascular events and improved quality of life and functional outcome one year after the event, while a number of studies offer solutions for individual components of post-hospital disease management like patient education, counselling, and self-management or the management of post-stroke complications and residual deficits. A majority of studies, however, was small in size and limited by a short follow-up. Most initiatives with a narrow focus on risk factor control failed to lower the risk of recurrent events. The caregivers' central role in post-stroke patient management is broadly neglected in research.

CONCLUSIONS

Over the past years, first knowledge on how to best organize post-hospital care of stroke patients has emerged. Comprehensive and pragmatic programs operated by the multidisciplinary stroke team hold promise to reduce the long-term health burden of stroke. There is a clear need for further high-quality studies with both clinical endpoints and patient-reported outcomes to establish sustainable solutions in different settings and regions to improve life after stroke, a key priority of the Stroke Action Plan for Europe 2018-2030.

"Lessons Learned" Preventing Recurrent Ischemic Strokes through Secondary Prevention Programs: A Systematic Review

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.

Mediators, confounders and effectiveness of interventions for medication adherence after stroke

After a stroke, people are left with an increased risk of recurrence. One of the primary methods of prevention is the use of a range of medications, but adherence to these is often low. This article evaluates and summarises three systematic reviews that investigate possible underlying reasons for this and how to overcome these barriers.

Effect and efficacy of lifestyle interventions as secondary prevention

INTRODUCTION

Improvements in health behaviour are often recommended as part of secondary prevention in patients with stroke and transient ischaemic attack. However, there is a lack of knowledge as to how this is applied in clinical practice.

AIM

In this systematic review and meta-analysis, we examined the effect of counselling or educational intervention directed at individual or multiple behavioural risk factors on blood pressure and other reported outcomes.

METHODS

PubMed, Embase, PsycInfo, CINAHL, Scopus and Web of Science were systematically searched. Meta-analyses were conducted on all outcome measures if appropriate. A qualitative analysis of the content of the interventions was conducted to review which elements the interventions consisted of.

RESULTS

Twenty-nine randomized controlled trials were identified. Fourteen reported effects on systolic blood pressure, and pooled results showed a significant beneficial effect (n = 2,222; -3.85 mmHg [95%CI -6.43; -1.28]). The effect was greatest in the four interventions which included supervised training (n = 174; -9.83 mmHg [95%CI -16.56; -3.09]).

CONCLUSION

Modifying health behaviour in stroke survivors might have a moderate beneficial effect on blood pressure, especially if the intervention includes supervised physical training.

STROKE-CARD care to prevent cardiovascular events and improve quality of life after acute ischaemic stroke or TIA: A randomised clinical trial

BACKGROUND

Patients with ischaemic stroke or transient ischaemic attack (TIA) are at high risk of recurrent stroke and other cardiovascular diseases and commonly suffer from reduced quality of life. We aimed to determine whether the disease management programme STROKE-CARD can prevent cardiovascular diseases and improve quality of life in these patients.

METHODS

In this pragmatic open-label two-centre randomised controlled trial with blinded outcome assessment, we randomly assigned patients with acute ischaemic stroke or TIA (ABCD² score ≥3) in a 2:1 ratio to receive STROKE-CARD care or standard care. STROKE-CARD care is a disease management programme by a multidisciplinary stroke team that comprises a standardised 3-month visit and access to a web-based patient portal targeting risk factor management, post-stroke complications, comorbidities and cardiovascular warning signs, rehabilitation demands, and patient education, counselling, and self-empowerment. Co-primary outcomes were analysed on an intention-to-treat basis and were: (i) major cardiovascular disease events defined as nonfatal ischaemic or haemorrhagic stroke, nonfatal myocardial infarction, or vascular death occurring between hospital discharge and 12 months; and (ii) health-related quality of life at 12 months quantified with the EuroQol-5-Dimensions-3-Levels (EQ-5D-3L) overall utility score. This trial is registered with ClinicalTrials.gov, number NCT02156778.

FINDINGS

Of 2149 patients enrolled between January 2014 and December 2017 (mean age 69 years, 41% female, 83% with ischaemic stroke, 17% with TIA), 1438 were assigned to STROKE-CARD care and 711 to standard care. Major cardiovascular disease events occurred in 78 patients in the STROKE-CARD care group (5.4%) and in 59 patients in the standard care group (8.3%) (hazard ratio, 0.63; 95% confidence interval: 0.45-0.88; P=0.007). STROKE-CARD care also led to a better EQ-5D-3L overall utility score at 12 months (P<0.001). Among pre-specified secondary outcomes, STROKE-CARD care improved all individual EQ-5D-3L dimensions and functional outcome on the modified Rankin Scale at 12 months. Post hoc explanatory analyses identified considerable demands for additional rehabilitation and refinement of preventive therapy regimes at the 3-month visit and high proportions of post-stroke complications and warning signs of imminent cardiovascular diseases within the first three months.

INTERPRETATION

The pragmatic and easily implementable STROKE-CARD care programme reduced cardiovascular risk and improved health-related quality of life and functional outcome in patients with acute ischaemic stroke or TIA.

FUNDING

Tirol Kliniken, Tyrolean Health Insurance Company, Tyrol Health Care Funds, Boehringer Ingelheim, Nstim Services, Sanofi, Bayer Healthcare.

Effect of pragmatic versus explanatory interventions on medication adherence in people with cardiometabolic conditions: a systematic review and meta-analysis

OBJECTIVE

To synthesise findings from randomised controlled trials (RCTs) of interventions aimed at increasing medication adherence in individuals with type 2 diabetes (T2DM) and/or cardiovascular disease (CVD). And, in a novel approach, to compare the intervention effect of studies which were categorised as being more pragmatic or more explanatory using the Pragmatic-Explanatory Continuum Indicator Summary-2 (PRECIS-2) tool, to identify whether study design affects outcomes. As explanatory trials are typically held under controlled conditions, findings from such trials may not be relatable to real-world clinical practice. In comparison, pragmatic trials are designed to replicate real-world conditions and therefore findings are more likely to represent those found if the intervention were to be implemented in routine care.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Ovid Medline, Ovid Embase, Web of Science and CINAHL from 1 January 2013 to 31 December 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

RCTs lasting ≥3 months (90 days), involving ≥200 patients in the analysis, with either established CVD and/or T2DM and which measured medication adherence. From 4403 citations, 103 proceeded to full text review. Studies published in any language other than English and conference abstracts were excluded.

MAIN OUTCOME MEASURE

Change in medication adherence.

RESULTS

Of 4403 records identified, 34 studies were considered eligible, of which 28, including 30 861 participants, contained comparable outcome data for inclusion in the meta-analysis. Overall interventions were associated with an increase in medication adherence (OR 1.57 (95% CI: 1.33 to 1.84), p<0.001; standardised mean difference 0.24 (95% CI: -0.10 to 0.59) p=0.101). The effectiveness of interventions did not differ significantly between studies considered pragmatic versus explanatory (p=0.598), but did differ by intervention type, with studies that included a multifaceted rather than a single-faceted intervention having a more significant effect (p=0.010). The analysis used random effect models and used the revised Cochrane Risk of Bias Tool to assess study quality.

CONCLUSIONS

In this meta-analysis, interventions were associated with a significant increase in medication adherence. Overall multifaceted interventions which included an element of education alongside regular patient contact or follow-up showed the most promise. Effectiveness of interventions between pragmatic and explanatory trials was comparable, suggesting that findings can be transferred from idealised to real-word conditions.

PROSPERO REGISTRATION NUMBER

CRD42017059460.

Stroke in China: advances and challenges in epidemiology, prevention, and management

With over 2 million new cases annually, stroke is associated with the highest disability-adjusted life-years lost of any disease in China. The burden is expected to increase further as a result of population ageing, an ongoing high prevalence of risk factors (eg, hypertension), and inadequate management. Despite improved access to overall health services, the availability of specialist stroke care is variable across the country, and especially uneven in rural areas. In-hospital outcomes have improved because of a greater availability of reperfusion therapies and supportive care, but adherence to secondary prevention strategies and long-term care are inadequate. Thrombolysis and stroke units are accepted as standards of care across the world, including in China, but bleeding-risk concerns and organisational challenges hamper widespread adoption of this care in China. Despite little supporting evidence, Chinese herbal products and neuroprotective drugs are widely used, and the increased availability of neuroimaging techniques also results in overdiagnosis and overtreatment of so-called silent stroke. Future efforts should focus on providing more balanced availability of specialised stroke services across the country, enhancing evidence-based practice, and encouraging greater translational research to improve outcome of patients with stroke.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Factors influencing health behaviour, blood pressure control, and disability in hypertensive ischaemic stroke patients after a comprehensive reminder intervention

AIMS

To test prospective pathways of a Comprehensive Reminder System based on the Health Belief Model (CRS-HBM), stroke knowledge, health belief in health behaviour, blood pressure (BP) control, and disability in hypertensive ischaemic stroke patients at 6-month postdischarge.

DESIGN

A nested cohort study design.

METHODS

Data were derived from a randomized controlled trial evaluating the effects of the intervention (N = 174, performed during February 2015 - March 2016). Data were collected by questionnaires and analysed in structural equation modelling in Mplus software.

RESULTS

The proposed model provided a good fit to the data. This model accounted for 51.5% of the variance in health behaviour, 34.1% in BP control, and 5.7% in modified Rankin Scale score at 6-month postdischarge. The CRS-HBM had: (a) direct positive effect (β = .391, p < .001) and indirect positive effects (β = .186, p = .002) on health behaviour; (b) direct positive effect (β = .356, p < .001) and indirect positive effects (β = .183, p = .009) on BP control; and (c) indirect negative effect (β = -.146, p = .008) on disability. Being female was linked to better health behaviour. Higher education predicted higher level of stroke knowledge and health belief.

CONCLUSIONS

The CRS-HBM can not only directly but also indirectly improve patients' health behaviours by improving their health knowledge or health belief. Better health behaviour can improve patients' BP control and reduce disability. Therefore, nurses need to pay more attention to not only patients' health knowledge but also their health belief when providing education.

IMPACT

The CRS-HBM intervention accounted for 51.5% of variance in health behaviour, 34.1% in BP control, and 5.7% in modified Rankin Scale score at 6-month postdischarge. This research can help nurses improve health education strategies in postdischarge and community contexts to achieve better health results.

The Efficacy of a Comprehensive Reminder System to Improve Health Behaviors and Blood Pressure Control in Hypertensive Ischemic Stroke Patients: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVE

The health behaviors of hypertensive stroke patients in China are not satisfactory. In this study, we tested the effect of a Health Belief Model Comprehensive Reminder System on health behaviors and blood pressure control in hypertensive ischemic stroke patients after occurrence and hospital discharge.

METHODS

A randomized, parallel-group, assessor-blinded experimental design yielded participation of 174 hospitalized hypertensive ischemic stroke patients. The intervention consisted of face-to-face and telephone health belief education, a patient calendar handbook, and weekly automated short-message services. Data were collected at baseline and 3 months after discharge.

RESULTS

Three months after discharge, the intervention group showed statistically, significantly better health behaviors for physical activity, nutrition, low-salt diet, and medication adherence. The intervention group also had statistically, significantly decreased systolic blood pressure and increased blood pressure control rate. Smoking and alcohol use behaviors were not affected.

CONCLUSION

At 3 months, use of the Comprehensive Reminder System based on the Health Belief Model, yielded improvement in most health behaviors and blood pressure control in hypertensive ischemic stroke patients. Continued implementation of this intervention protocol is warranted to determine the long-term effect. Smoking and alcohol use behaviors need to be targeted with a different intervention.

A support programme for secondary prevention in patients with transient ischaemic attack and minor stroke (INSPiRE-TMS): an open-label, randomised controlled trial

BACKGROUND

Patients with recent stroke or transient ischaemic attack are at high risk for a further vascular event, possibly leading to permanent disability or death. Although evidence-based treatments for secondary prevention are available, many patients do not achieve recommended behavioural modifications and pharmaceutical prevention targets in the long-term. We aimed to investigate whether a support programme for enhanced secondary prevention can reduce the frequency of recurrent vascular events.

METHODS

INSPiRE-TMS was an open-label, multicentre, international randomised controlled trial done at seven German hospitals with acute stroke units and a Danish stroke centre. Patients with non-disabling stroke or transient ischaemic attack within 2 weeks from study enrolment and at least one modifiable risk factor (ie, arterial hypertension, diabetes, atrial fibrillation, or smoking) were included. Computerised randomisation was used to allocate patients (1:1) either to the support programme in addition to conventional care or to conventional care alone. The support programme used feedback and motivational interviewing strategies with eight outpatient visits over 2 years aiming to improve adherence to secondary prevention targets. The primary outcome was the composite of major vascular events consisting of stroke, acute coronary syndrome, and vascular death, assessed in the intention-to-treat population (all patients who underwent randomisation, did not withdraw study participation, and had at least one follow-up). Outcomes were assessed at annual follow-ups using time-to-first-event analysis. All-cause death was monitored as a safety outcome. This trial is registered with ClinicalTrials.gov, NCT01586702.

FINDINGS

From Aug 22, 2011, to Oct 30, 2017, we enrolled 2098 patients. Of those, 1048 (50·0%) were randomly assigned to the support programme group and 1050 (50·0%) patients were assigned to the conventional care group. 1030 (98·3%) patients in the support group and 1042 (99·2%) patients in the conventional care group were included in the intention-to-treat analysis. The mean age of analysed participants was 67·4 years and 700 (34%) were women. After a mean follow-up of 3·6 years, the primary outcome of major vascular events had occurred in 163 (15·8%) of 1030 patients of the support programme group and in 175 (16·8%) of 1042 patients of the conventional care group (hazard ratio [HR] 0·92, 95% CI 0·75-1·14). Total major vascular event numbers were 209 for the support programme group and 225 for the conventional care group (incidence rate ratio 0·93, 95% CI 0·77-1·12; p=0·46) and all-cause death occurred in 73 (7·1%) patients in the support programme group and 85 (8·2%) patients in the conventional care group (HR 0·85, 0·62-1·17). More patients in the support programme group achieved secondary prevention targets (eg, in 1-year-follow-up 52% vs 42% [p<0·0001] for blood pressure, 62% vs 54% [p=0·0010] for LDL, 33% vs 19% [p<0·0001] for physical activity, and 51% vs 34% [p=0·0010] for smoking cessation).

INTERPRETATION

Provision of an intensified secondary prevention programme in patients with non-disabling stroke or transient ischaemic attack was associated with improved achievement of secondary prevention targets but did not lead to a significantly lower rate of major vascular events. Further research is needed to investigate the effects of support programmes in selected patients who do not achieve secondary prevention targets soon after discharge.

FUNDING

German Federal Ministry of Education and Research, Pfizer, and German Stroke Foundation.

Cardiovascular surgery experience does not significantly improve patients' response to stroke

OBJECTIVES

Patients with a history of cardiovascular surgery are at risk of stroke, and immediately calling emergency medical services (EMS) after stroke onset is crucial to receiving effective reperfusion therapy. We aimed to determine the effect of a history of cardiovascular surgery on patients' ability to recognize stroke and intent to call EMS.

METHODS

We performed a cross-sectional community-based study from January 2017 to May 2017. A total population of 186,167 individuals, recruited from 69 administrative areas across China, was analyzed. Different multivariable logistic regression models were performed to identify the associations between cardiovascular surgical history and stroke recognition or intent to call EMS, respectively.

RESULTS

0.1% of the total population had a history of cardiovascular surgery. In the surgery group, the estimated stroke recognition rate (SRR) and correct action rate (CAR) were 84.9% and 74.7%, respectively. The prevalence of cardiovascular risk factors was significantly higher in the surgery group. Cardiovascular surgical history was not associated with recognition of stroke across different models. The surgery group was more likely to call EMS, but the difference was not significant after full adjustment (OR: 1.40, 95% CI: 0.99-1.98, p = .0572).

CONCLUSIONS

Cardiovascular surgical history does not influence patients' likelihood of calling EMS more often at stroke onset. Patients receiving cardiovascular surgeries should be counseled regarding stroke recognition, proper response to stroke, and the importance of controlling risk factors.

Rationale and design of Patient-centered Retrospective Observation of Guideline-Recommended Execution for Stroke Sufferers in China: China PROGRESS

Background

In 2009, China launched ambitious healthcare reform plans to provide affordable and equitable basic healthcare for all patients, including the substantial number of patients who had a stroke. However, little is known about the pattern of evidence-based stroke care and outcomes across hospitals, regions and time during the last decade.

Aims

The Patient-centered Retrospective Observation of Guideline-Recommended Execution for Stroke Sufferers in China (China PROGRESS) Study aims to use findings from a representative sample of Chinese hospitals over the last decade to improve future stroke care for patients hospitalised with ischaemic stroke (IS) or transient ischaemic attack (TIA).

Design

The China PROGRESS Study will use a two-stage cluster sampling method to identify over 32000 patient records from 208 hospitals across the Eastern, Central and Western geographical regions in China. To assess the temporal trends in patient characteristics, treatment and outcomes, study investigators will select records from 2005, 2010 and 2015. A double data reading/entry system will be developed to conduct this assessment. A central coordinating centre will monitor case ascertainment, data abstraction and data management. Analyses will examine patient characteristics, testing patterns, in-hospital treatment and outcomes, and variations across regions and across time.

Conclusions

The China PROGRESS Study is the first nationally representative study that aims to better understand care quality and outcomes for patients with IS or TIA before and after the national healthcare reform in China. This initiative will translate findings into clinical practices that improve care quality for patients who had a stroke and policy recommendations that allow these changes to be implemented widely.

Ethics approval

This study has also been approved by the central institutional review board (IRB) at Beijing Tiantan Hospital.

Consecutive Slides on Axial View Is More Effective Than Transversal Diameter to Differentiate Mechanisms of Single Subcortical Infarctions in the Lenticulostriate Artery Territory

Objective: Lipohyalinosis or atherosclerosis might be responsible for single subcortical infarctions (SSIs); however, ways of differentiating between the two clinically remain uncertain. We aimed to investigate whether consecutive slides on axial view or transversal diameter is more effective to differentiate mechanisms by comparing their relationships with white matter hyperintensities (WMHs). Methods: All the participants from the Standard Medical Management in Secondary Prevention of Ischemic stroke in China (SMART) cohort who had SSIs in the lenticulostriate artery territory were included and categorized according to consecutive slides on axial view (≥4 consecutive slices or not) and transversal diameter (≥15 mm or not). The associations between the severity of WMHs and the different categories were analyzed. Results: Among the 3,821 patients of the SMART study, 281 had diffusion-weighted image-proven SSIs in the lenticulostriate artery territory. When classified by consecutive slides on axial view, SSIs on ≥4 slices were significantly associated with the severity of the WMHs, both in deep WMH (DWMH) (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.11-0.97; p = 0.04) and periventricular hyperintensity (PVH) (OR, 0.37; 95% CI, 0.17-0.78; p = 0.01). No such association was found on the basis of the transversal diameter (p > 0.1). Conclusion: Consecutive slides on axial view (≥4 consecutive slices) might be more effective than transversal diameter to identify the atherosclerotic mechanisms of SSIs in the lenticulostriate artery territory. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT00664846.

Adherence to Guidelines at a Stroke Prevention Clinic: A Follow-up Study

Background

In 2010, we published our stroke prevention clinic’s performance as compared to Canadian stroke prevention guidelines. We now compare our clinic’s adherence with guidelines to our previous results, following the implementation of an electronic documentation form.

Methods

All new patients referred to our clinic (McGill University Health Center) for recent transient ischemic attack (TIA) or ischemic stroke between 2014 and 2017 were included. We compared adherence to guidelines to our previous report (N=408 patients for period 2008–2010) regarding vascular risk management and treatment.

Results

Three hundred and ninety-two patients were included, of which 36% had a TIA and 64% had an ischemic stroke, with a mean age of 70 years and 43% female. Although the more recent cohort has shown a higher proportion of cardioembolic stroke compared to previous (19.1% vs. 14.7%) following new guidelines regarding prolonged cardiac monitoring, increased popularity in CT angiography has not translated into greater proportion of large-artery stroke subtype (26.3% vs. 26.2%). Blood pressure (BP) targets were achieved in 83% compared with 70% in our previous report (p<0.01). Attainment of low-density lipoprotein cholesterol target was also improved in our recent study (66% vs. 46%, p<0.01). No significant difference was found in the consistency of antithrombotic use (97.7% vs. 99.8%, p=0.08). However, there was a decline in smoking cessation (35% vs. 73%, p=0.02). Overall, optimal therapy status was better attained in the present cohort compared to the previous one (52% vs. 22%, p<0.01). The male sex was associated with better attainment of optimal therapy status (odds ratio, 1.61; 95% confidence interval, 1.04–2.51). The number of follow-up visits and the length of follow-up were not associated with attainment of stroke prevention targets.

Conclusions

Our study shows improvement in attainment of therapeutic goals as recommended by Canadian stroke prevention guidelines, possibly attributed in part to the implementation of electronic medical recording in our clinic. Areas for improvement include smoking cessation counseling and diabetes screening.

Association between PPARG genetic polymorphisms and ischemic stroke risk in a northern Chinese Han population: a case-control study

Two common polymorphisms of the peroxisome proliferator-activated receptor gamma (PPARG) gene, rs1801282 and rs3856806, may be important candidate gene loci affecting the susceptibility to ischemic stroke. This case-control study sought to identify the relationship between these two single-nucleotide polymorphisms and ischemic stroke risk in a northern Chinese Han population. A total of 910 ischemic stroke participants were recruited from the First Hospital of China Medical University, Shenyang, China as a case group, of whom 895 completed the study. The 883 healthy controls were recruited from the Health Check Center of the First Hospital of China Medical University, Shenyang, China. All participants or family members provided informed consent. The study protocol was approved by the Ethics Committee of the First Hospital of China Medical University, China on February 20, 2012 (approval No. 2012-38-1). The protocol was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR-COC-17013559). Plasma genomic DNA was extracted from all participants and analyzed for rs1801282 and rs3856806 single nucleotide polymorphisms using a SNaPshot Multiplex sequencing assay. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated using unconditional logistic regression to estimate the association between ischemic stroke and a particular genotype. Results demonstrated that the G allele frequency of the PPARG gene rs1801282 locus was significantly higher in the case group than in the control group (P < 0.001). Individuals carrying the G allele had a 1.844 fold increased risk of ischemic stroke (OR = 1.844, 95% CI: 1.286-2.645, P < 0.001). Individuals carrying the rs3856806 T allele had a 1.366 fold increased risk of ischemic stroke (OR = 1.366, 95% CI: 1.077-1.733, P = 0.010). The distribution frequencies of the PPARG gene haplotypes rs1801282-rs3856806 in the control and case groups were determined. The frequency of distribution in the G-T haplotype case group was significantly higher than that in the control group. The risk of ischemic stroke increased to 2.953 times in individuals carrying the G-T haplotype (OR = 2.953, 95% CI: 2.082-4.190, P < 0.001). The rs1801282 G allele and rs3856806 T allele had a multiplicative interaction (OR = 3.404, 95% CI: 1.631-7.102, P < 0.001) and additive interaction (RERI = 41.705, 95% CI: 14.586-68.824, AP = 0.860; 95% CI: 0.779-0.940; S = 8.170, 95% CI: 3.772-17.697) on ischemic stroke risk, showing a synergistic effect. Of all ischemic stroke cases, 86% were attributed to the interaction of the G allele of rs1801282 and the T allele of rs3856806. The effect of the PPARG rs1801282 G allele on ischemic stroke risk was enhanced in the presence of the rs3856806 T allele (OR = 8.001 vs. 1.844). The effect of the rs3856806 T allele on ischemic stroke risk was also enhanced in the presence of the rs1801282 G allele (OR = 2.546 vs. 1.366). Our results confirmed that the G allele of the PPARG gene rs1801282 locus and the T allele of the rs3856806 locus may be independent risk factors for ischemic stroke in the Han population of northern China, with a synergistic effect between the two alleles.

Pragmatic trial of multifaceted intervention (STROKE-CARD care) to reduce cardiovascular risk and improve quality-of-life after ischaemic stroke and transient ischaemic attack -study protocol

BACKGROUND

Patients with ischaemic stroke or transient ischaemic attack (TIA) are at high risk of future cardiovascular events. Despite compelling evidence about the efficacy of secondary prevention, a substantial gap exists between risk factor management in real life and that recommended by international guidelines. Moreover, stroke is a leading cause of disability and morbidity which partly emerges from post-stroke complications.

METHODS/DESIGN

We designed a block-randomised (2:1 ratio) open pragmatic trial [NCT02156778] with blinded outcome assessment comparing STROKE-CARD to usual post-stroke-patient care. STROKE-CARD is a multifaceted post-stroke disease management program with the objective of reducing recurrent cardiovascular events and improving quality of life in ischaemic stroke and TIA-patients. It combines intensified multi-domain secondary prevention, systematic detection and treatment of post-stroke complications, and patient self-empowerment. Enrolment of 2160 patients with acute ischaemic stroke or TIA (ABCD2-Score ≥ 3) is planned at two study centres in Austria. The co-primary efficacy endpoints are (i) the composite of major recurrent cardiovascular events (nonfatal stroke, nonfatal myocardial infarction, and vascular death) occurring within 12 months after the index event and (ii) one-year health-related quality-of-life measured with the European Quality of Life-5 Dimensions (EQ-5D-3 L) questionaire. Secondary endpoints include all-cause mortality, functional outcome, and target-level achievement in risk factor management.

DISCUSSION

This trial will provide evidence on whether the pragmatic post-stroke intervention program STROKE-CARD can help prevent cardiovascular events and improve quality-of-life within the setting of a high-quality acute stroke care system. In case of success, STROKE-CARD may be implemented in daily clinical routine and serve as a model for other disease management initiatives.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02156778 . (June 5, 2014, retrospectively registered).

Atherosclerosis Might Be Responsible for Branch Artery Disease: Evidence From White Matter Hyperintensity Burden in Acute Isolated Pontine Infarction

Objective: To investigate an MRI-based etiological classification for acute isolated pontine infarcts and to assess differences in vascular risk factors, clinical characteristics and WMH burden among the etiological subtypes.

Methods: All participants from SMART cohort with DWI-proven acute isolated pontine infarcts (AIPI) were included and categorized into 3 groups: large-artery-occlusive disease (LAOD), basilar artery branch disease (BAD), and small vessel disease (SVD), according to basilar artery atherosclerosis severity and lesion extent of the transverse axial plane. The vascular risk factors and 6-month functional outcome was analyzed among 3 groups.

Results: Of the 1129 patients enrolled, 175 had AIPI. BAD was the most frequent subtype of AIPI (46.3%), followed by SVD (36.0%) and LAOD (17.7%). Neurological impairment on admission was more severe in the LAOD group, followed by BAD. The BAD group had greater frequencies of female sex, hypertension, diabetes mellitus compared to the SVD group (P < 0.05). NIHSS on admission were significantly higher in the BAD group as compared with the SVD group (P < 0.001), but no difference was found between BAD and LAOD group. Poor outcome (mRS≥3) was found in only 13.7% of patients at 6-month post-stroke and there was no difference among 3 groups. WMH severity was significant higher in the SVD group compared to the BAD group for the deep subcortical region; however, there was no difference for the periventricualr region. There was no significant difference in either DWMH or PVWMH severity between the BAD and LAOD groups.

Conclusion: BAD is the most frequent etiology of AIPI followed by SVD and LAOD. WMH burden, vascular risk factors and clinical characteristics in BAD group were more similar to the LAOD group, rather than to the SVD group, suggesting the atherothrombotic nature of BAD.

Lesion Topography and Its Correlation With Etiology in Medullary Infarction: Analysis From a Multi-Center Stroke Study in China

Objectives: The lesion topography of medullary infarction (MI) is heterogeneous and its correlation with stroke etiology remains elusive. We aim to clarify the lesion pattern of MI and to assess its correlation with stroke etiology.

Material and Methods: Of 1129 subjects with available DWI in SMART study (a multi-center trial concerning secondary stroke prevention in China) between April 2008 and December 2010, 43 patients with DWI confirmed MI (3.8%) were retrospectively evaluated. Lesions were categorized as lateral and medial medullary infarction (LMI and MMI, 33 and 10 subjects respectively) at 3 levels rostro-caudally and correlated with the stroke etiology. Clinical profiles and long-term prognosis were analyzed.

Results: Large artery atherosclerosis, small vessel occlusion, cardiogenic embolism and artery dissection accounted for 29, 11, 1, and 2 infarcts, respectively. Large artery disease was the most common cause in LMI (24 of 33, 72.7%) whereas small vessel occlusion was not uncommon in MMI (5 of 10, 50.0%). Though the difference of infarct pattern between large artery atherosclerosis and small vessel occlusion was insignificant, two distinct lesion patterns were considered to be relevant: (1) Rostral MMI with continuous medial pontine infarctions were more likely attributed to small vessel occlusion than large artery atherosclerosis. Kameda et al. (2) MMI with ventral to dorsal extension were more often caused by large artery disease than small vessel occlusion. Median NIHSS at admission was 4. During a median follow-up of 17 months, 2 patients died and 2 experienced recurrent ischemic events, 39 of 41 subjects (95.1%) were functional independent (mRS 0–2).

Conclusions: This multi-center study demonstrates that MI has distinct lesion pattern depending on various stroke etiologies and mechanisms. Future investigations with larger sample size should establish the lesion pattern of MI and validate its correlation with the stroke etiology and mechanisms, which might improve stroke management.

System-integrated technology-enabled model of care to improve the health of stroke patients in rural China: protocol for SINEMA-a cluster-randomized controlled trial

BACKGROUND

Despite the significant burden of stroke in rural China, secondary prevention of stroke is suboptimal. This study aims to develop a SINEMA for the secondary prevention of stroke in rural China and to evaluate the effectiveness of the model compared with usual care.

METHODS

The SINEMA model is being implemented and evaluated through a 1-year cluster-randomized controlled trial in Nanhe County, Hebei Province in China. Fifty villages from 5 townships are randomized in a 1:1 ratio to either the intervention or the control arm (usual care) with a target to enroll 25 stroke survivors per village. Village doctors in the intervention arm (1) receive systematic cascade training by stroke specialists on clinical guidelines, essential medicines and behavior change; (2) conduct monthly follow-up visits with the support of a mobile phone application designed for this study; (3) participate in virtual group activities with other village doctors; 4) receive performance feedback and payment. Stroke survivors participate in a health education and project briefing session, receive monthly follow-up visits by village doctors and receive a voice message call daily as reminders for medication use and physical activities. Baseline and 1-year follow-up survey will be conducted in all villages by trained staff who are blinded of the randomized allocation of villages. The primary outcome will be systolic blood pressure and the secondary outcomes will include diastolic blood pressure, medication adherence, mobility, physical activity level and quality of life. Process and economic evaluation will also be conducted.

DISCUSSION

This study is one of very few that aim to promote secondary prevention of stroke in resource-constrained settings and the first to incorporate mobile technologies for both healthcare providers and patients in China. The SINEMA model is innovative as it builds the capacity of primary healthcare workers in the rural area, uses mobile health technologies at the point of care, and addresses critical health needs for a vulnerable community-dwelling patient group. The findings of the study will provide translational evidence for other resource-constrained settings in developing strategies for the secondary prevention of stroke.

Interventions for improving modifiable risk factor control in the secondary prevention of stroke

BACKGROUND

People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Stroke services need to be configured to maximise the adoption of evidence-based strategies for secondary stroke prevention. Smoking-related interventions were examined in a separate review so were not considered in this review. This is an update of our 2014 review.

OBJECTIVES

To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2017), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2017), CENTRAL (the Cochrane Library 2017, issue 3), MEDLINE (1950 to April 2017), Embase (1981 to April 2017) and 10 additional databases including clinical trials registers. We located further studies by searching reference lists of articles and contacting authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention.

DATA COLLECTION AND ANALYSIS

Four review authors selected studies for inclusion and independently extracted data. The quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach (GRADEpro GDT).Three review authors assessed the risk of bias for the included studies. We sought missing data from trialists.The results are presented in 'Summary of findings' tables.

MAIN RESULTS

The updated review included 16 new studies involving 25,819 participants, resulting in a total of 42 studies including 33,840 participants. We used the Cochrane risk of bias tool and assessed three studies at high risk of bias; the remainder were considered to have a low risk of bias. We included 26 studies that predominantly evaluated organisational interventions and 16 that evaluated educational and behavioural interventions for participants. We pooled results where appropriate, although some clinical and methodological heterogeneity was present.Educational and behavioural interventions showed no clear differences on any of the review outcomes, which include mean systolic and diastolic blood pressure, mean body mass index, achievement of HbA1c target, lipid profile, mean HbA1c level, medication adherence, or recurrent cardiovascular events. There was moderate-quality evidence that organisational interventions resulted in improved blood pressure control, in particular an improvement in achieving target blood pressure (odds ratio (OR) 1.44, 95% confidence interval (CI) 1.09 to1.90; 13 studies; 23,631 participants). However, there were no significant changes in mean systolic blood pressure (mean difference (MD), -1.58 mmHg 95% CI -4.66 to 1.51; 16 studies; 17,490 participants) and mean diastolic blood pressure (MD -0.91 mmHg 95% CI -2.75 to 0.93; 14 studies; 17,178 participants). There were no significant changes in the remaining review outcomes.

AUTHORS' CONCLUSIONS

We found that organisational interventions may be associated with an improvement in achieving blood pressure target but we did not find any clear evidence that these interventions improve other modifiable risk factors (lipid profile, HbA1c, medication adherence) or reduce the incidence of recurrent cardiovascular events. Interventions, including patient education alone, did not lead to improvements in modifiable risk factor control or the prevention of recurrent cardiovascular events.

Interventions to improve medication adherence among Chinese patients with hypertension: a systematic review and meta-analysis of randomized controlled trails

OBJECTIVE

A systematic review and meta-analysis of randomized controlled trials (RCTs) were performed to understand the effectiveness of medication adherence (MA) interventions among Chinese patients with hypertension.

METHODS

A literature search was conducted with three English databases (PubMed, Web of Science and Embase) and three Chinese databases (China National Knowledge Infrastructure, Wanfang and VIP Database for Chinese Technical Periodicals) for the period from 1970 to October 2017. Only both RCTs with a minimum of 10 participants in each intervention group and Chinese patients with hypertension as participants were included. A random-effects model was applied to calculate pooled effect sizes with 95% CI. Subgroup analysis was conducted to identify potential sources of heterogeneity from duration of intervention, type of intervener, methods of intervention and sites of intervention. Funnel plots and Egger's test were used to evaluate for publication bias.

KEY FINDINGS

A total of 48 studies met criteria for the meta-analysis, including 14 568 participants, testing 57 independent comparisons. Overall, the effect size revealed that interventions significantly improved MA (pooled relative risk = 1.59, 95% CI: 1.43 to 1.78; pooled Cohen's d = 1.42, 95% CI: 0.976 to 1.876). Interventions were found to significantly reduce blood pressure (BP) (systolic BP: Cohen's d = -0.85, 95% CI: -1.11 to -0.60 and diastolic BP: Cohen's d = -0.73, 95% CI: -1.00 to -0.46). Longer duration of intervention gave better effectiveness. Physician as interventionist, regular follow-up visits and interventions conducted at a hospital were associated with better effectiveness.

CONCLUSION

Adherence interventions improve MA and reduce uncontrolled BP among Chinese patients with hypertension. In the future, investigators should adopt a skill set to address the problem of poor MA.

Pulse Pressure Within 3 Months After Ischemic Stroke Is Associated With Long-Term Stroke Outcomes

BACKGROUND

Pulse pressure (PP) is a surrogate marker of arterial stiffness. Studies on baseline PP and long-term outcomes in patients with stroke are limited. We aimed to evaluate whether PP within 3 months after ischemic stroke was associated with long-term stroke outcomes.

METHODS

A total of 4,195 patients (61.2 ± 11.6 years, 68.4% men) with first-ever ischemic stroke in 3 months had baseline blood pressure (BP) measured. Study end-points were the combined end-points (recurrent vascular events and all-cause mortality) and recurrent stroke.

RESULTS

In the group <60 years of age, the BP components of systolic BP (SBP), diastolic BP (DBP), mean arterial pressure (MAP), or PP did not significantly correlate with long-term stroke outcomes. In the group ≥60 years of age, PP was significantly associated with combined end-points (hazards ratio [HR] = 1.35; 95% confidence interval [CI], 1.18-1.54) and recurrent stroke (HR = 1.46; 95% CI, 1.24-1.72). Combination of SBP and PP, DBP and PP, or MAP and PP, respectively, showed no incremental value of SBP, DBP, or MAP in predicting long-term stroke outcomes.

CONCLUSIONS

PP was significantly associated with long-term stroke outcomes, and this association was prominent in patients with stroke older than 60 years of age.

Educational and behavioural interventions for anticoagulant therapy in patients with atrial fibrillation

BACKGROUND

Current guidelines recommend oral anticoagulation therapy for patients with atrial fibrillation (AF) with one or more risk factors for stroke; however, anticoagulation control (time in therapeutic range (TTR)) with vitamin K antagonists (VKAs) is dependent on many factors. Educational and behavioural interventions may impact patients' ability to maintain their international normalised ratio (INR) control. This is an updated version of the original review first published in 2013.

OBJECTIVES

To evaluate the effects of educational and behavioural interventions for oral anticoagulation therapy (OAT) on TTR in patients with AF.

SEARCH METHODS

We updated searches from the previous review by searching the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effects (DARE) in The Cochrane Library (January 2016, Issue 1), MEDLINE Ovid (1949 to February week 1 2016), EMBASE Classic + EMBASE Ovid (1980 to Week 7 2016), PsycINFO Ovid (1806 to Week 1 February 2016) and CINAHL Plus with Full Text EBSCO (1937 to 16/02/2016). We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials evaluating the effect of any educational and behavioural intervention compared with usual care, no intervention, or intervention in combination with other self-management techniques among adults with AF who were eligible for, or currently receiving, OAT.

DATA COLLECTION AND ANALYSIS

Two of the review authors independently selected studies and extracted data. Risk of bias was assessed using the Cochrane 'Risk of bias' tool. We included outcome data on TTR, decision conflict (patient's uncertainty in making health-related decisions), percentage of INRs in the therapeutic range, major bleeding, stroke and thromboembolic events, patient knowledge, patient satisfaction, quality of life (QoL), beliefs about medication, illness perceptions, and anxiety and depression. We pooled data for three outcomes - TTR, anxiety and depression, and decision conflict - and reported mean differences (MD). Where insufficient data were present to conduct a meta-analysis, we reported effect sizes and confidence intervals (CI) from the included studies. We evaluated the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework.

MAIN RESULTS

Eleven trials with a total of 2246 AF patients (ranging from 14 to 712 by study) were included within the review. Studies included education, decision aids, and self-monitoring plus education interventions. The effect of self-monitoring plus education on TTR was uncertain compared with usual care (MD 6.31, 95% CI -5.63 to 18.25, I2 = 0%, 2 trials, 69 participants, very low-quality evidence). We found small but positive effects of education on anxiety (MD -0.62, 95% CI -1.21 to -0.04, I2 = 0%, 2 trials, 587 participants, low-quality evidence) and depression (MD -0.74, 95% CI -1.34 to -0.14, I2 = 0%, 2 trials, 587 participants, low-quality evidence) compared with usual care. The effect of decision aids on decision conflict favoured usual care (MD -0.1, 95% CI -0.17 to -0.02, I2 = 0%, 2 trials, 721 participants, low-quality evidence).

AUTHORS' CONCLUSIONS

This review demonstrates that there is insufficient evidence to draw definitive conclusions regarding the impact of educational or behavioural interventions on TTR in AF patients receiving OAT. Thus, more trials are needed to examine the impact of interventions on anticoagulation control in AF patients and the mechanisms by which they are successful. It is also important to explore the psychological implications for patients suffering from this long-term chronic condition.

Statin Adherence and the Risk of Stroke: A Dose-Response Meta-Analysis

BACKGROUND

Statins are one of the most common medications for stroke prevention. Increasing evidence indicates that the effect of statins against stroke may depend on the optimal adherence of the patients to the long-term therapies. However, the magnitude of the association between statin adherence and the risk of stroke has not been determined.

OBJECTIVE

We conducted a dose-response meta-analysis to investigate the association between statin adherence and the risk of stroke.

METHODS

The Medline and Embase databases were systematically searched to identify relevant observational studies that evaluated the association between statin adherence and stroke risk. Statin adherence was primarily quantified by the proportion of days covered by prescribed statins. Studies in which relative risks (RRs) with 95% confidence intervals (CIs) for the association between statin adherence and stroke risk were reported or could be estimated were included in this meta-analysis.

RESULTS

A total of 15 studies with 710,504 participants were included. The pooled RR of total stroke for the categories with the highest compared with the lowest adherence to statins was 0.72 (95% CI 0.65-0.79). Stratified by stroke subtype, the pooled RR for ischemic stroke (IS) was 0.83 (95% CI 0.74-0.92) and for hemorrhagic stroke was 0.75 (95% CI 0.51-1.09). The dose-response analysis indicated that an improvement in statin adherence of 20% was associated with an 8% lower risk of total stroke (RR 0.92; 95% CI 0.89-0.94). In the subgroup analysis for IS, an improvement in statin adherence of 20% was associated with a 7% lower risk of IS (RR 0.93; 95% CI 0.88-0.99).

CONCLUSION

Improved adherence to statins was associated with a lower risk of stroke, particularly of IS.

Patient-Centered Interventions to Improve Adherence to Statins: A Narrative Synthesis of Systematically Identified Studies

Poor adherence to statins increases cardiovascular disease risk. We systematically identified 32 controlled studies that assessed patient-centered interventions designed to improve statin adherence. The limited number of studies and variation in study characteristics precluded strict quality criteria or meta-analysis. Cognitive education or behavioural counselling delivered face-to-face multiple times consistently improved statin adherence compared with control groups (7/8 and 3/3 studies, respectively). None of four studies using medication reminders and/or adherence feedback alone reported significantly improved statin adherence. Single interventions that improved statin adherence but were not conducted face-to-face included cognitive education in the form of genetic test results (two studies) and cognitive education via a website (one study). Similar mean adherence measures were reported for 17 intervention arms and were thus compared in a sub-analysis: 8 showed significantly improved statin adherence, but effect sizes were modest (+7 to +22 % points). In three of these studies, statin adherence improved despite already being high in the control group (82-89 vs. 57-69 % in the other studies). These three studies were the only studies in this sub-analysis to include cognitive education delivered face-to-face multiple times (plus other interventions). In summary, the most consistently effective interventions for improving adherence to statins have modest effects and are resource-intensive. Research is needed to determine whether modern communications, particularly mobile health platforms (recently shown to improve medication adherence in other chronic diseases), can replicate or even enhance the successful elements of these interventions while using less time and fewer resources.

2014 Chinese guidelines for secondary prevention of ischemic stroke and transient ischemic attack

Ischemic stroke and transient ischemic attack (TIA) are the most common cerebrovascular disorder and leading cause of death in China. The Effective secondary prevention is the vital strategy for reducing stroke recurrence. The aim of this guideline is to provide the most updated evidence-based recommendation to clinical physicians from the prior version. Control of risk factors, intervention for vascular stenosis/occlusion, antithrombotic therapy for cardioembolism, and antiplatelet therapy for noncardioembolic stroke are all recommended, and the prevention of recurrent stroke in a variety of uncommon causes and subtype provided as well. We modified the level of evidence and recommendation according to part of results from domestic RCT in order to facility the clinical practice.

A Systematic Review of Randomized Controlled Trials of Medication Adherence Interventions in Adult Stroke Survivors

BACKGROUND

Stroke survivors are at an increased risk for recurrent stroke. Despite recommendations to avoid recurrence from the American Heart Association/American Stroke Association, medication adherence (MA) in persons with chronic conditions such as stroke is only 50%.

PURPOSE

The aim of this study was to synthesize randomized controlled trial intervention studies designed to increase MA in adult stroke survivors.

SEARCH METHODS

The Cumulative Index of Nursing and Allied Health Literature, PsycINFO, PubMed, and Excerpta Medica database from January 1, 2009, to December 31, 2015, were searched.

STUDY SELECTION

This study reviewed randomized controlled trials evaluating MA interventions in stroke survivors.

DATA EXTRACTION

Two reviewers independently assessed all full-text articles, and those not meeting the inclusion criteria by both researchers were excluded.

RESULTS

This review included 18 studies involving 10 292 participants. Overall, the strength of the included studies was strong. Statistically significant results were reported in 5 of the 18 (28%) studies. Of these, 3 used cognitive/behavioral interventions to increase MA, whereas 2 studies used an educational-based intervention.

CONCLUSIONS

Despite some isolated success, most MA interventions in stroke survivors do not show statistically significant improvement. Future MA research must address the lack of consistent use of objective measurement tools and focus on the long-term benefits of MA interventions.

A systematic review of interventions to improve adherence to statin medication: What do we know about what works?

Suboptimal adherence to statin medication is common and leads to serious negative health consequences but may respond to intervention. This review evaluated the effectiveness of interventions intended to improve adherence to statin medication. Data sources included peer-reviewed publications from Cochrane Register of Randomized Controlled Trials (RCTs), PubMed, CINAHL, and EMBase indexed between 01 October 2008 and 18 October 2015 and studies from reference lists and technical experts. RCTs that evaluated an intervention targeting adherence to self-administered statin medication for primary or secondary prevention were eligible. Two investigators independently reviewed trials, extracted data, and evaluated risk of bias. Twenty-nine RCTs reporting on 39,769 patients met inclusion. Identified RCTs exhibited methodological weaknesses: all but one failed to set inclusion parameters for medication adherence; nearly half lacked sufficient power to detect meaningful effects; and the majority had a risk of bias. Interventions were categorized into five classes (simplification of regimen, prescription cost coverage, reminders, education and information, and multi-faceted) and effects were pooled within each class. Prescription cost coverage, Hedges' g=0.15, 95%CI [0.11:0.21], simplification of drug regimen, Hedges' g=0.38, 95%CI [0.22:0.55], the provision of education, Hedges' g=0.19, 95%CI [0.01:0.37], and the use of multi-faceted interventions, Hedges' g=0.16, 95%CI [0.05:0.27], had small positive effects on statin adherence relative to usual care and reminders were promising, Hedges' g=0.0.27, 95%CI [-0.05:0.60]. In conclusion, there are some successful interventions to improve adherence to statin medication but the effects are small and additional methodologically rigorous trials are needed.

Amniotic Fluid Embolism: Using the Medical Staff Process to Facilitate Streamlined Care

Amniotic fluid embolism (AFE) is a catastrophic consequence of labor and delivery that often results in maternal and neonatal death. These poor outcomes are related largely to the rarity of the event in a population overwhelmingly biased by overall good health. Despite the presence of national AFE registries, there are no published algorithmic approaches to its management, to our knowledge. The purpose of this article is to share a care pathway developed by a multidisciplinary group at a community teaching hospital. Post hoc analysis of a complicated case of AFE resulted in development of this pathway, which addresses many of the major consequences of AFE. We offer this algorithm as a template for use by any institution willing to implement a clinical pathway to treat AFE. It is accompanied by the remarkable case outcome that prompted its development.

Elevated Fasting Blood Glucose Is Predictive of Poor Outcome in Non-Diabetic Stroke Patients: A Sub-Group Analysis of SMART

BACKGROUND

Although increasing evidence suggests that hyperglycemia following acute stroke adversely affects clinical outcome, whether the association between glycaemia and functional outcome varies between stroke patients with\without pre-diagnosed diabetes remains controversial. We aimed to investigate the relationship between the fasting blood glucose (FBG) and the 6-month functional outcome in a subgroup of SMART cohort and further to assess whether this association varied based on the status of pre-diagnosed diabetes.

METHODS

Data of 2862 patients with acute ischemic stroke (629 with pre-diagnosed diabetics) enrolled from SMART cohort were analyzed. Functional outcome at 6-month post-stroke was measured by modified Rankin Scale (mRS) and categorized as favorable (mRS:0-2) or poor (mRS:3-5). Binary logistic regression model, adjusting for age, gender, educational level, history of hypertension and stroke, baseline NIHSS and treatment group, was used in the whole cohort to evaluate the association between admission FBG and functional outcome. Stratified logistic regression analyses were further performed based on the presence/absence of pre-diabetes history.

RESULTS

In the whole cohort, multivariable logistical regression showed that poor functional outcome was associated with elevated FBG (OR1.21 (95%CI 1.07-1.37), p = 0.002), older age (OR1.64 (95% CI1.38-1.94), p<0.001), higher NIHSS (OR2.90 (95%CI 2.52-3.33), p<0.001) and hypertension (OR1.42 (95%CI 1.13-1.98), p = 0.04). Stratified logistical regression analysis showed that the association between FBG and functional outcome remained significant only in patients without pre-diagnosed diabetes (OR1.26 (95%CI 1.03-1.55), p = 0.023), but not in those with premorbid diagnosis of diabetes (p = 0.885).

CONCLUSION

The present results demonstrate a significant association between elevated FBG after stroke and poor functional outcome in patients without pre-diagnosed diabetes, but not in diabetics. This finding confirms the importance of glycemic control during acute phase of ischemic stroke especially in patients without pre-diagnosed diabetes. Further investigation for developing optimal strategies to control blood glucose level in hyperglycemic setting is therefore of great importance.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00664846.

Effectiveness of Goal-Setting Telephone Follow-Up on Health Behaviors of Patients with Ischemic Stroke: A Randomized Controlled Trial

BACKGROUND

Adopting healthy behaviors is critical for secondary stroke prevention, but many patients fail to follow national guidelines regarding diet, exercise, and abstinence from risk factors. Compliance often decreases with time after hospital discharge, yet few studies have examined programs promoting long-term adherence to health behaviors. Goal setting and telephone follow-up have been proven to be effective in other areas of medicine, so this study evaluated the effectiveness of a guideline-based, goal-setting telephone follow-up program for patients with ischemic stroke.

METHODS

This was a multicenter, assessor-blinded, parallel-group, randomized controlled trial. Ninety-one stroke patients were randomized to either a control group or an intervention group. Intervention consisted of predischarge education and 3 goal-setting follow-up sessions conducted by phone. Data were collected at baseline and during the third and sixth months after hospital discharge.

RESULTS

Six months after discharge, patients in the intervention group exhibited significantly higher medication adherence than patients in the control group. There were no statistically significant differences in physical activity, nutrition, low-salt diet adherence, blood pressure monitoring, smoking abstinence, unhealthy use of alcohol, and modified Rankin Scale (mRS) scores between the 2 groups.

CONCLUSIONS

Goal-setting telephone follow-up intervention for ischemic stroke patients is feasible and leads to improved medication adherence. However, the lack of group differences in other health behavior subcategories and in themRS score indicates a need for more effective intervention strategies to help patients reach guideline-recommended targets.

Quality Improvement for Cardiovascular Disease Care in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

The majority of global cardiovascular disease (CVD) burden falls on people living in low- and middle-income countries (LMICs). In order to reduce preventable CVD mortality and morbidity, LMIC health systems and health care providers need to improve the delivery and quality of CVD care.

OBJECTIVES

As part of the Disease Control Priorities Three (DCP3) Study efforts addressing quality improvement, we reviewed and summarized currently available evidence on interventions to improve quality of clinic-based CVD prevention and management in LMICs.

METHODS

We conducted a narrative review of published comparative clinical trials that evaluated efficacy or effectiveness of clinic-based CVD prevention and management quality improvement interventions in LMICs. Conditions selected a priori included hypertension, diabetes, hyperlipidemia, coronary artery disease, stroke, rheumatic heart disease, and congestive heart failure. MEDLINE and EMBASE electronic databases were systematically searched. Studies were categorized as occurring at the system or patient/provider level and as treating the acute or chronic phase of CVD.

RESULTS

From 847 articles identified in the electronic search, 49 met full inclusion criteria and were selected for review. Selected studies were performed in 19 different LMICs. There were 10 studies of system level quality improvement interventions, 38 studies of patient/provider interventions, and one study that fit both criteria. At the patient/provider level, regardless of the specific intervention, intensified, team-based care generally led to improved medication adherence and hypertension control. At the system level, studies provided evidence that introduction of universal health insurance coverage improved hypertension and diabetes control. Studies of system and patient/provider level acute coronary syndrome quality improvement interventions yielded inconclusive results. The duration of most studies was less than 12 months.

CONCLUSIONS

The results of this review suggest that CVD care quality improvement can be successfully implemented in LMICs. Most studies focused on chronic CVD conditions; more acute CVD care quality improvement studies are needed. Longer term interventions and follow-up will be needed in order to assess the sustainability of quality improvement efforts in LMICs.

A guideline-based program may improve the outcome of stroke among illiterate patients

BACKGROUND

Education level is considered as an important factor for post-stroke functional outcome. Our previous study confirms the feasibility of SMART program to improve adherence of secondary stroke prevention in China.

AIMS

We aim to investigate whether this program can influence the impact of educational level on post-stroke functional outcome in this sub-group analysis of SMART study.

METHODS

We enrolled 3722 patients with acute ischemic stroke from multicenter (n = 47) SMART cohort. Patient's educational level was categorized as three: illiterate, 6th grade or lower, and 7th grade or higher. Functional outcome at six-month post-stroke was assessed by Modified Rankin Scale (mRS) and categorized as favorable (mRS: 0-2) or poor (mRS: 3-5). Binary logistic model, adjusting for age, gender, stroke history, hypertension, diabetes, hyperlipidemia, educational level, and NIHSS was performed, respectively, in SMART group and usual care group to evaluate the effect of the SMART program on stroke functional outcome among different educated patients.

RESULTS

In both groups, logistic regression analysis showed that poor functional outcome was independently associated with older age [OR(95% CI):1.81(1.41-2.33), p < 0.001(SMART); OR (95% CI):1.38 (1.09-1.73), p = 0.007(usual care)], higher baseline NIHSS [OR (95% CI): 2.90 (2.38-3.53), p < 0.001(SMART); OR (95% CI): 2.82 (2.32-3.44), p < 0.001(usual care)], and diabetes [OR(95% CI):1.88 (1.18-3.00), p = 0.008(SMART); OR (95%CI):1.68 (1.03-2.73), p = 0.037(usual care)]. Compared to illiterate, higher educational levels were independently associated with favorable outcome in usual care group [OR (95% CI): 0.43 (0.20-0.93), p = 0.032 (6th grade or lower) and OR (95% CI): 0.40 (0.19-0.84), p = 0.016 (7th Grade or higher)], but not in SMART group (p = 0.806 and p = 0.889, respectively).

CONCLUSIONS

This study demonstrates that implementation of SMART program may improve post-stroke functional outcome among illiterate. This suggests special attention should be paid to illiterate patients with intensive education in order to improve post-stroke disability.

Community physicians' knowledge of secondary prevention after ischemic stroke: a questionnaire survey in Shanxi Province, China

BACKGROUND

This cross-sectional, questionnaire-based survey, conducted in Shanxi Province, China, evaluated the knowledge of community physicians of secondary prevention of ischemic stroke and transient ischemic attacks (TIAs).

METHODS

A total of 1910 physicians practicing at 832 community-based clinics, hospitals and other care centers in 11 prefectures of Shanxi Province completed the questionnaires between 1 July and 30 September 2013.

RESULTS

Over 90 % of participants were aware of the most common risk factors for stroke, but lifestyle-related factors were seen as of low or medium importance for secondary prevention. Only about 50 % of physicians were aware of the existence of commonly used stroke scales, and fewer said that they would use those scales in their clinical practice. There were slight differences in the responses to some of the questions on risk factors and stroke scales were associated with the physicians' gender, academic qualifications, practice duration and location. Less than half of the participants were aware of the secondary prevention recommendations included in the most recent guidelines.

CONCLUSION

The survey revealed a huge gap in knowledge of current guidelines for secondary prevention of ischemic stroke and TIA among the physicians surveyed. Continuing education and training of community physicians, administered as a public health program, is needed to improve the healthcare of ischemic stroke and TIA patients.

Fixed-Dose Combination Treatment After Stroke for Secondary Prevention in China

Background and Purpose—

There is evidence and international consensus on the advantages and potential of a polypill for established cardiovascular disease patients to improve adherence in the secondary prevention of cardiovascular disease. This study aimed to estimate the numbers of stroke patients who would be eligible for the polypill strategy in China, and the suitable composition of a polypill, based on data of the China National Stroke Prevention Project.

Methods—

A total of 717 620 residents aged ≥40 years from 6 Chinese representative provinces were screened for prevalent stroke from 2011 to 2012 with an 84.4% response rate. Participants with a history of stroke received further investigation of risk factors and treatments. The potential need for treatment was classified according to the guidelines. Rates were standardized using the population composition of the Sixth National Population Census of China.

Results—

The standardized prevalence rate of stroke was 1.9%. Up to 93.1% of stroke patients were eligible for a polypill containing at least 2 types of medications, with 75.3% eligible for a statin and antiplatelet agent and 70.6% for antihypertensive and antiplatelet medications. Considering 3 therapies, 54% were eligible for antihypertensive, statin, and antiplatelet medications. The current treatment rate with all required combinations of separate pills was only 6.9%.

Conclusions—

A huge number of stroke patients in China require preventive therapy and would be eligible for a polypill. This study indicates that it would be reasonable to consider and assess the value of a polypill strategy to improve secondary prevention of stroke in China.

Multimodal secondary prevention behavioral interventions for TIA and stroke: a systematic review and meta-analysis

Background

Guidelines recommend implementation of multimodal interventions to help prevent recurrent TIA/stroke. We undertook a systematic review to assess the effectiveness of behavioral secondary prevention interventions.

Strategy

Searches were conducted in 14 databases, including MEDLINE (1980-January 2014). We included randomized controlled trials (RCTs) testing multimodal interventions against usual care/modified usual care. All review processes were conducted in accordance with Cochrane guidelines.

Results

Twenty-three papers reporting 20 RCTs (6,373 participants) of a range of multimodal behavioral interventions were included. Methodological quality was generally low. Meta-analyses were possible for physiological, lifestyle, psychosocial and mortality/recurrence outcomes. Note: all reported confidence intervals are 95%. Systolic blood pressure was reduced by 4.21 mmHg (mean) (−6.24 to −2.18, P = 0.01 I² = 58%, 1,407 participants); diastolic blood pressure by 2.03 mmHg (mean) (−3.19 to −0.87, P = 0.004, I² = 52%, 1,407 participants). No significant changes were found for HDL, LDL, total cholesterol, fasting blood glucose, high sensitivity-CR, BMI, weight or waist:hip ratio, although there was a significant reduction in waist circumference (−6.69 cm, −11.44 to −1.93, P = 0.006, I² = 0%, 96 participants). There was no significant difference in smoking continuance, or improved fruit and vegetable consumption. There was a significant difference in compliance with antithrombotic medication (OR 1.45, 1.21 to 1.75, P<0.0001, I² = 0%, 2,792 participants) and with statins (OR 2.53, 2.15 to 2.97, P< 0.00001, I² = 0%, 2,636 participants); however, there was no significant difference in compliance with antihypertensives. There was a significant reduction in anxiety (−1.20, −1.77 to −0.63, P<0.0001, I² = 85%, 143 participants). Although there was no significant difference in odds of death or recurrent TIA/stroke, there was a significant reduction in the odds of cardiac events (OR 0.38, 0.16 to 0.88, P = 0.02, I² = 0%, 4,053 participants).

Conclusions

There are benefits to be derived from multimodal secondary prevention interventions. However, the findings are complex and should be interpreted with caution. Further, high quality trials providing comprehensive detail of interventions and outcomes, are required.

Review Registration

PROSPERO CRD42012002538.

A Systematic Review of School-Based Alcohol and other Drug Prevention Programs

BACKGROUND

Alcohol use in adolescents constitutes a major public health concern. Europe is the heaviest drinking region of the world. Several school-based alcohol prevention programs have been developed but it is not clear whether they are really effective. The present study was aimed at identifying the typology with the best evidence of effectiveness in European studies.

METHODS

A systematic search of meta-analyses and/or randomized controlled trials (RCTs) on interventions school-based prevention programs aimed at preventing alcohol consumption or changing the attitudes to consume alcohol.

RESULTS

A meta-analysis published in 2011 and 12 RCTs more recently published were identified. The meta-analysis evaluated 53 RCTs but only 11.3% of them were conducted in Europe. Globally, 23 RCTs (43.4%) showed some evidence of effectiveness, and 30 RCTs (56.6%) did not find significant difference between the groups. According to the conclusions of the meta-analysis, the Unplugged program should be considered as a practice option in Europe. Among the other 12 RCTs, 42% were conducted in Europe. Globally, 7 studies (58.3%) achieved positive results, and 5 studies (41.7%) did not find significant differences or produced a mixed pattern of results. Three of the 5 European trials (60%) used the Unplugged program with positive results.

CONCLUSION

Even if further studies should be conducted to confirm these results, Unplugged appears to be the prevention project with the best evidence of effectiveness in European studies.