A survey on adherence to secondary ischemic stroke prevention

Antithrombotics prescription and adherence among stroke survivors: A systematic review and meta-analysis

OBJECTIVES

We aimed to investigate the prescription of antithrombotic drugs (including anticoagulants and antiplatelets) and medication adherence after stroke.

METHODS

We performed a systematic literature search across MEDLINE and Embase, from January 1, 2015, to February 17, 2022, to identify studies reporting antithrombotic medications (anticoagulants and antiplatelets) post stroke. Two people independently identified reports to include, extracted data, and assessed the quality of included studies according to the Newcastle-Ottawa scale. Where possible, data were pooled using random-effects meta-analysis.

RESULTS

We included 453,625 stroke patients from 46 studies. The pooled proportion of prescribed antiplatelets and anticoagulants among patients with atrial fibrillation (AF) was 62% (95% CI: 57%-68%), and 68% (95% CI: 58%-79%), respectively. The pooled proportion of patients who were treated according to the recommendation of guidelines of antithrombotic medications from four studies was 67% (95% CI: 41%-93%). It was reported that 11% (95% CI: 2%-19%) of patients did not receive antithrombotic medications. Good adherence to antiplatelet, anticoagulant, and antithrombotic medications was 78% (95% CI: 67%-89%), 71% (95% CI: 57%-84%), and 73% (95% CI: 59%-86%), respectively.

CONCLUSION

In conclusion, we found that less than 70% of patients were prescribed and treated according to the recommended guidelines of antithrombotic medications, and good adherence to antithrombotic medications is only 73%. Prescription rate and good adherence to antithrombotic medications still need to be improved among stroke survivors.

Factors Influencing 1-Year Medication Adherence of Korean Ischemic Stroke Survivors

BACKGROUND

Medication adherence is important for secondary stroke prevention. However, suboptimal adherence to medication among patients after stroke or transient ischemic attack is reportedly 30.9%. We assessed medication adherence of Korean stroke survivors within 1 year of acute ischemic stroke and identified factors that influence adherence.

METHODS

We consecutively enrolled ischemic stroke survivors who visited the Department of Neurology of a university hospital from March 9 to June 15, 2016. Data were collected by face-to-face interviews using a structured questionnaire which assessed general characteristics, clinical characteristics, medication beliefs, social support, and depression. Medication adherence was measured using the 8-item Morisky Medication Adherence Scale. Multiple logistic regression was used to identify factors independently associated with medication adherence.

RESULTS

Of the total 250 participants, 183 (73%) were in the optimal adherence group. Age (p = 0.035), smoking (p = 0.020), number of prescribed medicines (p = 0.037), frequency of daily doses (p = 0.040), and beliefs about medication (p < 0.001) were associated with medication adherence. Optimal medication adherence was associated with being a non-smoker (OR, 3.19; 95% CI, 1.29-7.87; p = 0.012), more prescribed medicines (OR, 1.27; 95% CI, 1.05-1.54; p = 0.014), less frequency of daily doses (OR, 0.37; 95% CI, 0.18-0.79; p = 0.010), and stronger beliefs about medication (OR, 1.09; 95% CI, 1.03-1.15; p = 0.004).

CONCLUSION

To improve medication adherence of stroke survivors, post-stroke care should focus on bolstering patients' belief in the necessity of medication and encouraging lifestyle modifications, such as quitting smoking, as well as prescribing medicine with simple regimens.

Adherence to Treatment in Stroke Patients

Background: Compliance with medication in patients who have suffered stroke is usually not-optimal. This study aims to measure the level of compliance with the treatment and to identify socio-demographic, clinical, and subjective factors related to the long-term compliance of stroke patients with their treatment. Methods: 140 patients (66.4% males) suffered an ischemic stroke at least six months old, participated in the survey. Compliance was measured using the Medication Adherence Report Scale and the quality of life by the Stroke Specific Quality of Life questionnaire. Furthermore, the Beliefs about Medicines Questionnaire and the Brief Illness Perception Questionnaire on perceptions about the disease were assessed. The doctor–patient relationship was assessed by the Common-Sense Model of Self-Regulation questionnaire and the family support was assessed by the FSS scale. Univariate and multivariate analysis was employed to identify the significant factors affecting compliance in these stroke patients. Results: In 68.6% of patients the compliance was classified as optimal, in 25.7% as partial and as poor in 5.7%; the last two categories were treated as sub-optimal compliance in multivariate analysis. The high compliance was related to patient’s mental state (OR:3.94 95% CI: 1.84–4.46), the perception medication necessity (OR:1.26 95% CI: 1.01–1.56), and the doctor–patient communication (OR:1.76 95% CI: 1.15–2.70). Men showed a lower compliance than women, as well as increased concerns about taking medication (OR: 0.83, 95% CI: 0.69–0.99). Paradoxically, the work /productivity related quality of life was inversely associated with compliance (OR (95% CI): 0.44 (0.23 to 0.82)). Conclusions: The perception of medication necessity and the doctor–patient communication are manageable factors associated with compliance in treating patients who have suffered stroke. In addition, rehabilitation and return to work programs should consider these factors when providing support to those persons.

Predictive factors of non-adherence to secondary preventative medication after stroke or transient ischaemic attack: A systematic review and meta-analyses

Purpose

Non-adherence to secondary preventative medications after stroke is relatively common and associated with poorer outcomes. Non-adherence can be due to a number of patient, disease, medication or institutional factors. The aim of this review was to identify factors associated with non-adherence after stroke.

Method

We performed a systematic review and meta-analysis of studies reporting factors associated with medication adherence after stroke. We searched MEDLINE, EMBASE, CINAHL, PsycINFO, CENTRAL and Web of Knowledge. We followed PRISMA guidance. We assessed risk of bias of included studies using a pre-specified tool based on Cochrane guidance and the Newcastle–Ottawa scales. Where data allowed, we evaluated summary prevalence of non-adherence and association of factors commonly reported with medication adherence in included studies using random-effects model meta-analysis.

Findings

From 12,237 titles, we included 29 studies in our review. These included 69,137 patients. The majority of included studies (27/29) were considered to be at high risk of bias mainly due to performance bias. Non-adherence rate to secondary preventative medication reported by included studies was 30.9% (95% CI 26.8%–35.3%). Although many factors were reported as related to adherence in individual studies, on meta-analysis, absent history of atrial fibrillation (OR 1.02, 95% CI 0.72–1.5), disability (OR 1.27, 95% CI 0.93–1.72), polypharmacy (OR 1.29, 95% CI 0.9–1.9) and age (OR 1.04, 95% CI 0.96–1.14) were not associated with adherence.

Discussion

This review identified many factors related to adherence to preventative medications after stroke of which many are modifiable. Commonly reported factors included concerns about treatment, lack of support with medication intake, polypharmacy, increased disability and having more severe stroke.

Conclusion

Understanding factors associated with medication taking could inform strategies to improve adherence. Further research should assess whether interventions to promote adherence also improve outcomes.

Whole-scale neurobehavioral assessments of photothrombotic ischemia in freely moving mice

BACKGROUND

Neurobehavioral assessments have been considered as an essential component of preclinical research in ischemic stroke. However, real-time neurobehavioral evaluation is seldom applied during ischemia induction as it is usually accompanied with anesthesia.

NEW METHOD

We induced photothrombosis in freely moving mice after one-week recovery from cannula implantation surgeries. After rose bengal (RB) injection (100 mg/kg, i.p.), photothrombosis was induced in freely moving mice by 473 nm laser irradiation through the cannulas implanted into unilateral primary motor cortex beforehand. Mice received nimodipine (15 mg/kg, i.p.), a widely used anti-ischemic agent, or vehicle before irradiation. Motor coordination and equilibrium were evaluated by rotarod and rung walk tests throughout the whole process of ischemia. Endurance capacity was assessed by treadmill at 1 day and 7 days after irradiation. Mice were decapitated at different time points post irradiation for TTC (2,3,5-triphenyltetrazolium chloride) staining.

RESULTS

Consistent with the results of TTC staining, motor deficits firstly occurred at 15-min post irradiation and aggravated 1-day later, while the capacity improved 3-days later and partially recovered 7-days post irradiation. And, the recovery process was accelerated by nimodipine application.

COMPARISON WITH EXISTING METHODS

This method established a precise linkage between focal brain ischemia development and neurobehavioral deficits throughout a full scale of photothrombosis, which avoided the confounding factors of anesthetics and surgeries on neurobehavioral assessments, as infarct was induced in freely moving mice.

CONCLUSIONS

This method with high temporal and spatial resolution will be an optimal model for neurobehavioral evaluation in preclinical anti-ischemic drug screening.

Cost-effectiveness of clopidogrel-aspirin versus aspirin alone for acute transient ischemic attack and minor stroke

Background

Treatment with the combination of clopidogrel and aspirin taken soon after a transient ischemic attack (TIA) or minor stroke was shown to reduce the 90‐day risk of stroke in a large trial in China, but the cost‐effectiveness is unknown. This study sought to estimate the cost‐effectiveness of the clopidogrel‐aspirin regimen for acute TIA or minor stroke.

Methods and Results

A Markov model was created to determine the cost‐effectiveness of treatment of acute TIA or minor stroke patients with clopidogrel‐aspirin compared with aspirin alone. Inputs for the model were obtained from clinical trial data, claims databases, and the published literature. The main outcome measure was cost per quality‐adjusted life‐years (QALYs) gained. One‐way and multivariable probabilistic sensitivity analyses were performed to test the robustness of the findings. Compared with aspirin alone, clopidogrel‐aspirin resulted in a lifetime gain of 0.037 QALYs at an additional cost of CNY 1250 (US$ 192), yielding an incremental cost‐effectiveness ratio of CNY 33 800 (US$ 5200) per QALY gained. Probabilistic sensitivity analysis showed that clopidogrel‐aspirin therapy was more cost‐effective in 95.7% of the simulations at a willingness‐to‐pay threshold recommended by the World Health Organization of CNY 105 000 (US$ 16 200) per QALY.

Conclusions

Early 90‐day clopidogrel‐aspirin regimen for acute TIA or minor stroke is highly cost‐effective in China. Although clopidogrel is generic, Plavix is brand in China. If Plavix were generic, treatment with clopidogrel‐aspirin would have been cost saving.

Aspirin for cardioprotection and strategies to improve patient adherence

Cardiovascular disease (CVD) is the leading cause of morbidity and mortality in North America. Aspirin therapy has proven clinical effectiveness in the prevention and treatment of CVD and is one of the most widely used drugs nationwide. However, despite the medication's popularity and utility, adherence to a proper aspirin regimen is suboptimal, resulting in adverse health outcomes and increased health care costs. Our review outlines current knowledge on aspirin therapy adherence, causes of nonadherence, and strategies available to increase adherence to aspirin and medications in general. We demonstrate that, indeed, aspirin adherence rates are suboptimal, ranging from 72% to 92%, and that a combination of patient- and medication-related factors contribute to nonadherence. A multidimensional approach involving patient education and medication innovations to reduce aspirin side effects is imperative to improving rates of aspirin therapy adherence.

Risk awareness in secondary stroke prevention: a review of the literature

Despite improvements in the diagnosis and treatment of cardiovascular disease through medical advances, it remains the largest single cause of disability and the second leading cause of death on a global scale. Despite this, patient awareness of cardiovascular risk is low and adherence to secondary prevention measures is inadequate. This combined with an ageing population could have serious consequences for both personal and health care costs. Risk management has been used to design strategies to prevent both primary and secondary stroke. These strategies have largely relied upon health professionals providing information, support and monitoring of patients conditions and control of individual risk factors. However, these strategies have not always been successful in the long-term management and prevention of secondary cardiovascular disease. This review explores the literature surrounding risk awareness as a tool to improve patient adherence to medications and lifestyle behaviours to reduce risk of secondary stroke.

External Validation of the ASTRAL Score to Predict 3- and 12-Month Functional Outcome in the China National Stroke Registry

Background and Purpose—

The ASTRAL score was recently introduced as a prognostic tool for acute ischemic stroke. It predicts 3-month outcome reliably in both the derivation and the validation European cohorts. We aimed to validate the ASTRAL score in a Chinese stroke population and moreover to explore its prognostic value to predict 12-month outcome.

Methods—

We applied the ASTRAL score to acute ischemic stroke patients admitted to 132 study sites of the China National Stroke Registry. Unfavorable outcome was assessed as a modified Rankin Scale score >2 at 3 and 12 months. Areas under the curve were calculated to quantify the prognostic value. Calibration was assessed by comparing predicted and observed probability of unfavorable outcome using Pearson correlation coefficient.

Results—

Among 3755 patients, 1473 (39.7%) had 3-month unfavorable outcome. Areas under the curve for 3 and 12 months were 0.82 and 0.81, respectively. There was high correlation between observed and expected probability of unfavorable 3- and 12-month outcome (Pearson correlation coefficient: 0.964 and 0.963, respectively).

Conclusions—

ASTRAL score is a reliable tool to predict unfavorable outcome at 3 and 12 months after acute ischemic stroke in the Chinese population. It is a useful tool that can be readily applied in clinical practice to risk-stratify acute stroke patients.

What are the patient-held illness beliefs after a transient ischaemic attack, and do they determine secondary prevention activities: an exploratory study in a North London General Practice

BACKGROUND

A transient ischaemic attack (TIA) is a strong predictor of future stroke. Stroke is the most common cause of mortality in the United Kingdom. Management of risk factors can reduce the possibility of future strokes; however, these are often difficult to achieve optimally. Current evidence suggests that beliefs about causal attributions, severity and perceived risk of stroke may influence uptake of secondary prevention activities amongst this patient group.

AIM

To explore the illness beliefs of patients about TIAs and future risk of stroke, and to determine whether these beliefs determine secondary stroke prevention activities.

METHOD

A qualitative study comprising face-to-face, semi-structured interviews conducted in the homes of participants. Sampling was purposive and drawn from a single North London General Practice. A thematic framework analysis method was followed.

FINDINGS

Eleven participants took part in the study (aged 46-86 years, three female participants and eight male participants). Time since diagnosis ranged from 2 to 25 years. There was a commonly held belief that TIAs are 'short-lived events' associated with full recovery, whereas strokes always lead to permanent 'disability'. Only those who believed their TIAs to be 'serious' undertook activities to prevent further recurrence. Concordance with medication was the most popular prevention activity.

CONCLUSION

The traditional medical definition of TIA and stroke do not reflect the views of patients who have had TIAs. One's perception of the severity of the initial TIA event and the risk of future stroke episodes may influence the uptake of secondary stroke prevention activities. Post TIA stroke prevention interventions should include tailored discussions focussing on the importance of the acute event and its implications for long-term health and future stroke risk.

Predicting Compliance With Treatment Following Stroke: A New Model of Adherence Following Rehabilitation

Background and purpose: Adherence to medication is fundamental to optimal health recovery yet compliance to medication rates are lower than 50% in most studies. This study aimed to investigate the correlates of adherence in stroke patients. Method: Twenty-six stroke patients and 29 amputee patients who had completed a rehabilitation program at Melbourne Rehabilitation Centre were investigated. Medical adherence was determined from computed adherence metrics based on pill counts and subjective reports of patient knowledge of medication use. Model components that were believed to contribute to poor adherence, included emotional and cognitive dysfunction, beliefs about medication, and social support. These factors were assessed by patient and partner self-rating questionnaires. Results: Stroke patients showed a lower level of adherence compared to amputee patients. Cognitive and emotional dysfunction, beliefs about medication, and the level of care were significantly associated with low adherence to medicine regimes in stroke patients. Level of cognitive impairment and emotional impairment were significantly associated with low adherence to medicines in amputee patients. Emotional dysfunction was the best predictor of poor adherence in both patient groups. Conclusion: The findings are in keeping with past adherence studies with other patient groups and support the position that emotional, cognitive, and social factors are important factors in adherence. The specific nonadherence profile for this brain-damaged group is modeled and the application for outpatients following rehabilitation is discussed.

Adherence with levodopa/carbidopa/entacapone versus levodopa/carbidopa and entacapone as separate tablets in patients with Parkinson's disease

BACKGROUND

Observational studies suggest that single-tablet formulations are associated with improved adherence versus the same components taken as separate tablets. The objective of this study was to compare adherence in patients with Parkinson's disease (PD) receiving levodopa therapy as levodopa/carbidopa/entacapone tablets (LCE) versus levodopa/carbidopa (LC) tablets and entacapone (E) as separate tablets (LC and E).

METHODS

This was a retrospective, observational cohort study using a large health insurance claims database. Subjects included persons with a PD diagnosis who were receiving LC without E and then received either an add-on therapy with E as a separate tablet (LC and E) or LCE as one tablet (LCE). The primary study outcome was treatment adherence, estimated from pharmacy refills based on the 'percent of days covered' (PDC) with LCE or LC and E during follow-up and compared for patients receiving LCE and LC and E using multivariate regression analyses.

RESULTS

In multivariate analyses controlling for differences between groups in baseline characteristics, including pre-index dosage of and adherence with LC, receipt of LCE (n = 388) was associated with 79% lower mean non-adherence during follow-up (95% CI: 73-83%; p < 0.001) versus LC and E (n = 823), 86% lower odds of unsatisfactory adherence (95% CI: 80-91%; p < 0.001), and a 26% lower risk of discontinuation (95% CI: 6-42%; p < 0.013).

LIMITATIONS

This was an observational study with the inherent potential for selection bias. Pharmacy claims may not provide an accurate estimate of adherence. Requiring subjects to have a certain number of prescriptions before and after the index date may yield a sample that is not representative of all patients initiating levodopa therapy in typical clinical practice.

CONCLUSIONS

Better adherence with LCE may have important implications for maintaining function in patients receiving chronic oral levodopa therapy. Further research is needed to confirm these results and examine the association between improved adherence and clinical and economic outcomes.

Aspirin resistance and compliance with therapy

INTRODUCTION

Aspirin resistance is associated with increased cardiovascular risk in aspirin-treated patients. Poor compliance may explain many cases of "resistance," yet few clinical studies have used objective measurement of therapy compliance. We did so in a case-controlled study.

METHODS

We enrolled patients within 24 h of ischemic stroke and a group of controls taking aspirin who had never suffered a vascular event on therapy. All claimed to be compliant. We assessed platelet function using platelet function analyser (PFA)-100 and rapid platelet function analyser (RPFA) devices, applying standard definitions of resistance. We used high-performance liquid chromatography for levels of aspirin metabolites in the urine to confirm compliance with therapy. We compared rates of resistance in stroke patients and controls, and performed subgroup analysis restricted to patients with objective confirmation of recent aspirin ingestion.

RESULTS

We recruited 90 cases and 90 controls. Complete platelet function tests were available in 177. Resistance rates seen in cases and controls, respectively, were: resistance on one or more test, 30 (34%) versus 21 (25%), P= 0.19; on PFA-100 testing only, 28 (32%) versus 15 (18%), P= 0.031; on RPFA testing only, 16 (18%) versus 12 (14%), P= 0.54; resistance on both tests, 12 (14%) versus 5 (6%), P= 0.037. When only patients with objective evidence of recent aspirin ingestion were considered (n = 71), rates were similar regardless of definition of resistance used.

CONCLUSION

Aspirin resistance is common but poor compliance accounted for nearly half of cases of apparent aspirin "failure." Objective measures to assess compliance are essential in studies of aspirin resistance.

Impact of persistence with antiplatelet therapy on recurrent ischemic stroke and predictors of nonpersistence among ischemic stroke survivors

OBJECTIVE

Medication adherence is an important component of effective secondary stroke prevention. The objectives of this study were to examine the impact of persistence with two prescription antiplatelet therapies on the outcome of recurrent hospitalized stroke, and to identify the predictors of nonpersistence with these antiplatelet therapies.

RESEARCH DESIGN AND METHODS

Administrative claims from a large, geographically diverse US health plan were used to evaluate acetylsalicylic acid / extended-release dipyridamole (ASA/ERDP) treated and clopidogrel treated patients from November 1, 2002 - December 31, 2005 who had an ischemic stroke requiring hospitalization. Nonpersistence was defined as failure to refill index medication within 30 days from the run-out date of the prior prescription. A Cox proportional hazards model was used to identify key factors associated with time to nonpersistence.

MAIN OUTCOME MEASURES

Patient demographic variables, clinical characteristics, comorbidities hypothesized to affect the risk of current stroke, stroke outcomes, treatment patterns, and compliance were assessed.

RESULTS

A total of 1413 patients hospitalized for ischemic stroke were identified. Mean age was 63.4 years and 44.2% were female. The proportion of patients persistent per person-year was 45.1%. Persistence with medication was significantly associated with a longer time to recurrent hospitalized stroke (HR 0.275; 95% CI 0.134-0.564; p < 0.0004). A medication copayment of >$40 (relative to a copayment of < or =$20) was the only significant factor predicting time to nonpersistence (HR 1.320; 95% CI 1.091-1.596; p < 0.0042).

CONCLUSIONS

Persistence with antiplatelet medication within a cohort of hospitalized ischemic stroke patients was associated with a 72.5% lower likelihood of recurrent hospitalized stroke. Higher medication copayment was found to negatively impact patient persistence with antiplatelet therapy. The findings of this study must be considered within the limitations of database analysis, as claims data are collected for the purpose of payment and not research.

Medication compliance in ischaemic stroke patients

AIM

This study aimed to assess the degree of patient compliance with medications prescribed at hospital discharge following ischaemic stroke, and concordance between self-reported medication use and general practitioner (GP) records.

METHODS

The Auckland City Hospital Stroke database was used to identify consecutive patients with ischaemic stroke over a three-month period. Participants were contacted and invited to participate in a telephone questionnaire that asked about current medications. GPs were also asked to list the medications their patients were taking.

RESULTS

Fifty-one patients were approached to participate of whom 48 consented to be interviewed at 6 weeks and 47 at 6 months. At 6 weeks, 36 of 38 (95%) were compliant with aspirin, 12 of 13 (92%) dipyridamole, 8 of 9 (88%) warfarin, 36 of 41 (88%) statins, 33 of 38 (87%) antihypertensive medications, and 7 of 7 (100%) diabetes medications. At 6 months, 97% were compliant with aspirin, 100% dipyridamole, 100% warfarin, 94% statins, 91% antihypertensive medications, and 100% diabetes medications. Natural or herbal remedy use was reported by 10 of 48 (21%) at 6 weeks and 11 of 47 (23%) at 6 months. Blister packs were used by 8 of 48 (17%) at 6 weeks and 5 of 47 (11%) at 6 months.

CONCLUSION

Adherence to secondary stroke prevention medication was between 87% and 100% at 6 weeks with similar findings at 6 months after discharge. We speculate that these high compliance rates may be due to one-on-one stroke nurse counselling and the use of stroke information packs, which include information about the importance of adherence to secondary prevention medication.

Persistent Use of Secondary Preventive Drugs Declines Rapidly During the First 2 Years After Stroke

Background and Purpose— To prevent new cardiovascular events after stroke, prescribed preventive drugs should be used continuously. This study measures persistent use of preventive drugs after stroke and identifies factors associated with persistence.

Methods— A 1-year cohort (21 077 survivors) from Riks-Stroke, the Swedish Stroke Register, was linked to the Swedish Prescribed Drug Register.

Results— The proportion of patients who were persistent users of drugs prescribed at discharge from hospital declined progressively over the first 2 years to reach 74.2% for antihypertensive drugs, 56.1% for statins, 63.7% for antiplatelet drugs, and 45.0% for warfarin. For most drugs, advanced age, comorbidity, good self-perceived health, absence of low mood, acute treatment in a stroke unit, and institutional living at follow-up were independently associated with persistent medication use.

Conclusion— Persistent secondary prevention treatment declines rapidly during the first 2 years after stroke, particularly for statins and warfarin. Effective interventions to improve persistent secondary prevention after stroke need to be developed.

Stroke in China

1. Following rapid economic development in China, the epidemiological characteristics, management and prevention strategies for stroke are changing. In the present article, we review recent epidemiological data, as well as studies into the management and prevention of stroke in China. 2. The main findings of the studies reviewed suggest that stroke mortality in China has been reduced significantly. The percentage of haemorrhagic strokes in China is significantly higher than that reported in Western countries. The incidence and subtype of stroke varied widely in different regions in China. Some of the modifiable risk factors for stroke are on the increase in China, including hypertension. 3. Management of stroke is slowly being developed and standardized, as evidenced by the establishment of stroke units and improvements in emergency care. Studies on primary and secondary stroke prevention remain insufficient. Well-designed epidemiological surveys and clinical trials for stroke prevention and management are urgently needed in China.

Appropriate secondary prevention of acute atherothrombotic events and strategies to improve guideline adherence

The use of guideline-recommended secondary prevention measures is essential for reducing the risk of subsequent events and mortality in patients who have survived an acute atherothrombotic event or have peripheral arterial disease. Although initial hospitalization provides an ideal environment to initiate such therapies, implementation of effective longterm prevention strategies is hindered by the absence of a systematic approach. In general, evidence-based clinical practice guidelines recommend antiplatelet therapy as a cornerstone of post-discharge secondary prevention, in addition to preventive measures targeting risk factors such as hypertension, dyslipidemia, cigarette smoking, and physical inactivity. Observational data indicate that, although there has been improvement over time, current utilization of guideline-recommended post-discharge treatment remains suboptimal. Recognizing the importance of a systematic approach to discharge planning, numerous hospital-based initiatives have been established. In conjunction with effective lines of communication between hospital and primary care teams, initiation of the most effective secondary prevention strategy at the time of hospital discharge will help to ensure optimal long-term management of patients after an atherothrombotic event.

Stroke care development in Mainland China: past, present and future

Stroke care in China was less developed than in western countries but great headway has been made in recent years through unremitting efforts by a group of local neurologists working in this field.

Stop Stroke: development of an innovative intervention to improve risk factor management after stroke

OBJECTIVE

Stroke survivors are at high risk of stroke recurrence yet current strategies to reduce recurrence risk are sub-optimal. The UK Medical Research Council (MRC) have proposed a framework for developing and evaluating complex interventions, such as community management of stroke secondary prevention. The Framework outlines a five-phased approach from theory through to implementation of effective interventions. This paper reports Phases I-III of the development of a novel intervention to improve risk factor management after stroke.

METHODS

The pre-clinical/theoretical phase entailed reviewing the literature and undertaking quantitative and qualitative studies to identify current practices and barriers to secondary prevention. In Phase I (modelling), findings were used to design an intervention with the potential to overcome barriers to effective stroke secondary prevention management. The feasibility of delivering the intervention and its acceptability were tested in the Phase II exploratory trial involving 25 stroke survivors and their general practitioners.

RESULTS

This led to the development of the definitive risk factor management intervention. This comprises multiple components and involves using an on-going population stroke register to target patients, carers and health care professionals with tailored secondary prevention advice. Clinical, socio-demographic and service use data collected by the stroke register are transformed to provide an individualised secondary prevention package for patients, carers and health care professionals at three time points: within 10 weeks, 3 and 6 months post-stroke.

CONCLUSION

The intervention is currently being evaluated in a randomised controlled trial. Further research is needed to test generalisability to other aspects of stroke management and for other chronic diseases.

PRACTICE IMPLICATIONS

The MRC Framework for complex interventions provides a structured approach to guide the development of novel interventions in public health. Implications for practice in stroke secondary prevention will emerge when the results of our randomised controlled trial are published.