In-hospital Initiation of Secondary Prevention Is Associated With Improved Vascular Outcomes at 3 Months
ABSTRACT Although various in-hospital stroke quality improvement programs have been associated with high treatment rates at hospital discharge, there are few data on the impact of these programs on clinical outcomes. We evaluated the impact of the PROTECT (Preventing Recurrence Of Thromboembolic Events through Coordinated Treatment) program on short-term vascular risk.
Prospective data collected after discharge for ischemic stroke or transient ischemic attack caused by presumed atherosclerotic mechanism from a PROTECT intervention hospital and a comparison community hospital, which used conventional care, were compared. The 3-month follow-up clinical outcome data were then evaluated and differences in outcome frequency data between the two hospital groups were analyzed using Fisher's exact test. Covariate adjusted comparisons of percent with a vascular event was computed via logistic regression methods.
A total of 224 patients met study criteria: 126 patients at a PROTECT hospital and 98 patients at a comparator hospital. The 3-month postdischarge data were available for 78 patients at PROTECT hospital versus 65 control patients. Patients at a PROTECT hospital were more likely to be younger, be current smokers, and not have a history of atrial fibrillation. At 3 months, there was a covariate-adjusted difference in the intervention-hospital group versus the control-hospital group with regard to the incidence of a vascular event (transient ischemic attack, stroke, or myocardial infarction), 8.4% versus 22% (P = .036).
Compared with conventional care, PROTECT was associated with better 3-month vascular outcomes after stroke hospitalization. Further study is needed to confirm the potential favorable impact of stroke quality improvement programs on clinical outcomes.
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ABSTRACT: A large proportion of ischemic stroke and transient ischemic attack patients do not receive prompt and appropriate treatment with evidence-based, guideline-recommended, vascular risk reduction therapies when exposed to traditional care. Consequently, implementing effective strategies that can bolster the use of proven preventive therapies among persons with established cerebrovascular disease remains an important goal. The Stroke PROTECT (Preventing Recurrence Of Thromboembolic Events through Coordinated Treatment) program, which systematically implements 8 medication and behavioral secondary prevention measures, was significantly associated with increased treatment utilization at hospital discharge, as well as greater adherence, target biomarker control, and better clinical outcomes in the post-discharge setting. This award lecture paper presents the background, rationale, results, limitations and future directions of the original PROTECT program, depicts the progress and preliminary data from ongoing national and international PROTECT-based programs, and suggests potential next steps in the development and implementation of more empirically derived models geared at bridging the stroke prevention knowledge-evidence-practice chasm.Journal of the Neurological Sciences 09/2008; 275(1-2):1-6. DOI:10.1016/j.jns.2008.07.014 · 2.26 Impact Factor
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ABSTRACT: Approximately one third of the 780,000 people in the United States who have a stroke each year have recurrent events. Although efficacious secondary prevention measures are available, levels of adherence to these strategies in patients who have had stroke are largely unknown. Understanding medication-taking behavior in this population is an important step to optimizing the appropriate use of proven secondary preventive therapies and reducing the risk of recurrent stroke. The Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) registry is a prospective study of adherence to stroke prevention medications from hospital discharge to 1 year in patients admitted with stroke or transient ischemic attack. The primary outcomes are medication usage as determined by patient interviews after 3 and 12 months. Potential patient-, provider-, and system-level barriers to persistence of medication use are also collected. Secondary outcomes include the rates of recurrent stroke or transient ischemic attack, vascular events, and rehospitalization and functional status as measured by the modified Rankin score. The AVAIL enrolled about 2,900 subjects from 106 hospitals from July 2006 through July 2008. The 12-month follow-up will be completed in August 2009. The AVAIL registry will document the current state of adherence and persistence to stroke prevention medications among a nationwide sample of patients. These data will be used to design interventions to improve the quality of care post acute hospitalization and reduce the risks of future stroke and cardiovascular events.American heart journal 04/2009; 157(3):428-435.e2. DOI:10.1016/j.ahj.2008.11.002 · 4.56 Impact Factor
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ABSTRACT: Patients hospitalized with recent symptomatic cerebral ischemia are at high early risk for subsequent cerebrovascular events. This notwithstanding, an unacceptably high proportion of these patients do not receive prompt and appropriate treatment with evidence-based, guideline-recommended, vascular risk-reduction therapies when exposed to conventional care. Studies of ischemic stroke and transient ischemic attack patients reveal that treatment guidelines are often not followed or variably applied, thereby impeding improvements in care quality and clinical outcomes. A likely contributor to this evidence-practice chasm has been the unavailability to care providers of user-friendly, broadly applicable tools/algorithms that could facilitate ready and uniform implementation of proven therapies.The Stroke PROTECT (Preventing Recurrence Of Thromboembolic Events through Coordinated Treatment) program, was designed for inpatient, outpatient, and transitional care settings, and systematically implements evidence-based medication and behavioral secondary prevention measures following the occurrence of an ischemic stroke or transient ischemic attack. PROTECT program pathways and tools incorporate early recognition and prompt initiation of evidence-based, guideline-recommended care in eligible patients without contraindications. The program has been associated with significant increases in discharge treatment utilization, as well as better therapy adherence, target biomarker control and enhanced clinical outcomes in the postdischarge setting. By utilizing best-care practices, PROTECT aims to help practitioners caring for patients with established cerebrovascular disease, to improve the quality of in-hospital and postdischarge stroke care.Critical pathways in cardiology 12/2009; 8(4):151-5. DOI:10.1097/HPC.0b013e3181bce3eb