Multifaceted implementation of stroke prevention guidelines in primary care: cluster-randomised evaluation of clinical and cost effectiveness Intensified secondary prevention intending a reduction of recurrent events in TIA and minor stroke patients (INSPiRE-TMS): a protocol for a randomised controlled trial Effectiveness of a postdischarge care management model for stroke and transient ischemic attack: a randomized trial. Secondary Prevention after Minor Stroke and TIA - Usual Care and Development of a Support Program Combining Multiple Approaches for the Secondary Prevention of Vascular Events After Stroke: A Quantitative Modeling Study In-Hospital Initiation of Secondary Stroke Prevention Therapies Yields High Rates of Adherence at Follow-up Controlled Education of patients after Stroke (CEOPS)- nurse-led multimodal and long-term interventional program involving a patient’s caregiver to optimize secondary prevention of stroke: study protocol for a randomized controlled trial Peer education for secondary stroke prevention in inner-city minorities: design and methods of the prevent recurrence of all inner-city strokes through education randomized controlled trial. Multifaceted Intervention Including Motivational Interviewing to Support Medication Adherence after Stroke/Transient Ischemic Attack: A Randomized Trial Cluster randomized controlled trial of TIA electronic decision support in primary care Tailored interventions to improve hypertension management after stroke or TIA--phase II (TIMS II). Cardiac rehabilitation adapted to transient ischaemic attack and stroke (CRAFTS): a randomised controlled trial The effect of a locally adapted, secondary stroke risk factor self-management program on medication adherence among veterans with stroke/TIA Stop Stroke: development of an innovative intervention to improve risk factor management after stroke. The NAILED stroke risk factor trial (Nurse based Age independent Intervention to Limit Evolution of Disease after stroke): study protocol for a randomized controlled trial Preventive effects of multiple domain interventions on lifestyle and risk factor changes in stroke survivors: Evidence from a two-year randomized trial Program of rehabilitative exercise and education to avert vascular events after non-disabling stroke or transient ischemic attack (PREVENT Trial): a multi-centred, randomised controlled trial
Objective : To evaluate clinical and cost effectiveness of implementing evidence -based guidelines for the prevention of stroke . Design : Cluster-r and omised trial Setting : Three primary care organisations in the North of Engl and covering a population of 400 000 . Participants : Seventy six primary care teams in four clusters : North , South & West , City I and City II . Intervention : Guidelines for the management of patients with atrial fibrillation and transient ischaemic attack ( TIA )  were developed and implemented using a multifaceted approach including evidence -based recommendations , audit and feedback , interactive educational sessions , patient prompts and outreach visits . Outcomes : Identification and appropriate treatment of patients with atrial fibrillation or TIA , and cost effectiveness . Results : Implementation led to 36 % increase ( 95 % CI 4 % to 78 % ) in diagnosis of atrial fibrillation , and improved treatment of TIA ( odds ratio of complying with guidelines 1.8 ; 95 % CI 1.1 to 2.8 ) . Combined analysis of atrial fibrillation and TIA estimates that compliance was significantly greater ( OR 1.46 95 % CI 1.10 to 1.94 ) in the condition for which practice s had received the implementation programme . The development and implementation of guidelines cost less than £ 1500 per practice . The estimated costs per quality -adjusted life year gained by patients with atrial fibrillation or TIA were both less than £ 2000 , very much less than the usual criterion for cost effectiveness . Conclusions : Implementation of evidence -based guidelines  improved the quality of primary care for atrial fibrillation and TIA . The intervention was feasible and very cost effective . Key components of the model include context ual analysis , strong professional support , clear recommendations based on robust evidence , simplicity of adoption , good communication and use of established networks and opinion leaders Background Patients with recent stroke or TIA are at high risk for new vascular events . Several evidence based strategies in secondary prevention of stroke are available but frequently underused . Support programs with multifactorial risk factor modifications after stroke or TIA have not been investigated in large-scale prospect i ve controlled trials so far . INSPiRE-TMS is a prospect i ve , multi-center , r and omized open intervention trial for intensified secondary prevention after minor stroke and TIA . Methods / design Patients with acute TIA or minor stroke admitted to the participating stroke centers are screened and recruited during in-hospital stay . Patients are r and omised in a 1:1 ratio to intervention ( support program ) and control ( usual care ) arms . Inclusion of 2.082 patients is planned . The support program includes cardiovascular risk factor measurement and feedback , monitoring of medication adherence , coaching in lifestyle modifications , and active involvement of relatives . St and ardized motivational interviewing is used to assess and enhance patients ’ motivation . Primary objective is a reduction of new major vascular events defined as nonfatal stroke and myocardial infa rct ion or vascular death . Recruitment time is planned for 3.5 years , follow up time is at least 2 years for every patient result ing in a total study time of 5 years ( first patient in to last patient out ) . Discussion Given the high risk for vascular re-events in acute stroke and the available effective strategies in secondary prevention , the INSPIRE-TMS support program has the potential to lead to a relevant reduction of recurrent events and a prolongation of the event-free survival time . The trial will provide the basis for the decision whether an intensified secondary prevention program after stroke should be implemented into regular care . A cost-effectiveness evaluation will be performed . Trial registration clinical trials.gov : BACKGROUND This r and omized controlled trial tested the effectiveness of comprehensive , interdisciplinary postdischarge care management in improving a profile of indicators of health recovery and secondary prevention ( profile of health and prevention ) in stroke and transient ischemic attack ( TIA ) patients . METHODS Ninety-six stroke/TIA patients were r and omized to usual care or intervention at discharge from our acute stroke unit . The intervention group received an in-home biopsychosocial assessment by an advanced practice nurse at 1 month . A care plan was developed by an interdisciplinary team and implemented in collaboration with the patient 's primary care physician . The profile of health and prevention , measured at 3 months , was comprised of 5 domains : ( 1 ) Neuromotor Function , ( 2 ) Severe Complications , ( 3 ) Quality of Life , ( 4 ) Management of Risk for common poststroke complications and recurrent stroke , and ( 5 ) Stroke Knowledge . A single global hypothesis test across multiple end points was used to compare the 2 groups . RESULTS The intervention significantly improved the profile of health and prevention ( P < .0001 ) . In addition , each domain showed a positive effect of the intervention . Effect sizes ( in st and ard deviation units ) of the intervention on domains were .1 for Neuromotor Function ( 90 % confidence interval [ CI ] = -.3 to .5 ) ; .4 for Severe Complications ( 90 % CI = .1 to .8 ) ; .5 for Quality of Life ( 90 % CI = .1 to .9 ) ; .6 for Management of Risk for common poststroke complications and recurrent stroke ( 90 % CI = .3 to 1 . ) ; and 1.0 for Stroke Knowledge ( 90 % CI = .6 to 1.4 ) . CONCLUSIONS This model of care management result ed in a significantly better profile of health and prevention for stroke/TIA patients 3 months postdischarge Background Effective methods of secondary prevention after stroke or TIA are available but adherence to recommended evidence -based treatments is often poor . The study aim ed to determine the quality of secondary prevention in usual care and to develop a stepwise modeled support program . Methods Two consecutive cohorts of patients with acute minor stroke or TIA undergoing usual outpatient care versus a secondary prevention program were compared . Risk factor control and medication adherence were assessed in 6-month follow-ups ( 6M-FU ) . Usual care consisted of detailed information concerning vascular risk factor targets given at discharge and regular outpatient care by primary care physicians . The stepwise modeled support program additionally employed up to four outpatient appointments . A combination of educational and behavioral strategies was employed . Results 168 patients in the observational cohort who stated their openness to participate in a prevention program ( mean age 64.7 y , admission blood pressure ( BP ) : 155/84 mmHg ) and 173 patients participating in the support program ( mean age 67.6 y , BP : 161/84 mmHg ) were assessed at 6 months . Proportions of patients with BP according to guidelines were 50 % in usual-care and 77 % in the support program ( p<0.01 ) . LDL<100 mg/dl was measured in 62 versus 71 % ( p = 0.12 ) . Proportions of patients who stopped smoking were 50 versus 79 % ( p<0.01 ) . 72 versus 89 % of patients with atrial fibrillation were on oral anticoagulation ( p = 0.09 ) . Conclusions Risk factor control remains unsatisfactory in usual care . Targets of secondary prevention were met more often within the supported cohort . Effects on (cerebro-)vascular recurrence rates are going to be assessed in a multicenter r and omized trial Background and Purpose — Numerous effective strategies for the secondary prevention of cardiovascular events in high-risk patients have now been established . We sought to calculate the cumulative benefit of combining multiple strategies for preventing recurrent events in patients with a history of ischemic stroke or transient ischemic attack . Methods — A comprehensive literature search was undertaken to identify meta-analyses of r and omized controlled trials reporting on the efficacy of secondary prevention strategies . The baseline incidence of vascular events was modeled from the Life Long After Cerebral Ischemia study . Strategies were combined on a multiplicative scale and cumulative risk reductions were computed over a 5-year interval . Results — The combination of 5 proven strategies applied to survivors of an initial stroke or transient ischemic attack — dietary modification , exercise , aspirin , a statin , and an antihypertensive agent — could result in a cumulative relative risk reduction of 80 % . Given a 5-year major cardiovascular event rate of 24 % , this translates to a number needed to treat of about 5 . Further gains would result from applying multimodality therapy over longer intervals and enriching the base strategy with dual antiplatelet therapy , high-dose statins , and more intensive blood pressure – lowering . Even more benefit would be present in high-risk subgroups with the addition , where appropriate , of carotid endarterectomy , moderate intensity oral anticoagulants , glycemic control , and smoking cessation . Conclusions — At least four-fifths of recurrent vascular events in patients with cerebrovascular disease might be prevented by application of a comprehensive , multifactorial approach Background and Purpose — The Stroke PROTECT ( Preventing Recurrence Of Thromboembolic Events through Coordinated Treatment ) program systematic ally implements , at the time of acute transient ischemic attack ( TIA ) or ischemic stroke admission , 8 medication/behavioral secondary prevention measures known to improve outcome in patients with cerebrovascular disease . The objective of this study was to determine if the high utilization rates previously demonstrated at hospital discharge were maintained at 90 days after discharge . Methods — Data were prospect ively collected on consecutively encountered ischemic stroke and TIA patients admitted to a university hospital stroke service beginning September 1 , 2002 .  PROTECT interventions were initiated before hospital discharge in all PROTECT – target ( underlying stroke mechanism large vessel atherosclerosis or small vessel disease ) and PROTECT – ACS ( At-risk for Coronary Sequelae ) patients . Adherence to program goals was assessed 3 months after discharge . Results — During the period from September 2002 to August 2003 , 144 individuals met criteria for PROTECT intervention . Of the 130 patients ( 90 % ) with available day 90 follow-up data , mean age was 72 ( range , 37 to 95 ) , and 63 % were male .  Adherence rates in patients without specific contraindications were 100 % for antithrombotics , 99 % for statins , 92 % for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers , and 80 % for thiazides . Awareness of the importance of calling 911 in response to stroke was 87 % . Adherence to diet and exercise guidelines were 78 % and 70 % , respectively . Of the 24 smokers , tobacco cessation was maintained in 20 ( 83 % ) . Conclusions — High rates of adherence to PROTECT therapies were maintained at 90 days after hospital discharge Background Setting up a follow-up secondary prevention program after stroke is difficult due to motor and cognitive impairment , but necessary to prevent recurrence and improve patients ’ quality of life . To involve a referent nurse and a caregiver from the patient ’s social circle in nurse-led multimodal and long-term management of risk factors after stroke could be an advantage due to their easier access to the patient and family . The aim of this study is to compare the benefit of optimized follow up by nursing personnel from the vascular neurology department including therapeutic follow up , and an interventional program directed to the patient and a caregiving member of their social circle , as compared with typical follow up in order to develop a specific follow-up program of secondary prevention of stroke . Methods / design The design is a r and omized , controlled , clinical trial conducted in the French Stroke Unit of the Strokavenir network . In total , 410 patients will be recruited and r and omized in optimized follow up or usual follow up for 2 years . In both group , patients will be seen by a neurologist at 6 , 12 and 24 months . The optimized follow up will include follow up by a nurse from the vascular neurology department , including therapeutic follow up , and a training program on secondary prevention directed to the patient and a caregiving member of their social circle . After discharge , a monthly telephone interview , in the first year and every 3 months in the second year , will be performed by the nurse . At 6 , 12 and 24 month , the nurse will give the patient and caregiver another training session . Usual follow up is only done by the patient ’s general practitioner , after classical information on secondary prevention of risk factors during hospitalization . The primary outcome measure is blood pressure measured after the first year of follow up . Blood pressure will be measured by nursing personnel who do not know the group into which the patient has been r and omized . Secondary endpoints are associated mortality , morbidity , recurrence , drug side-effects and medico-economic analysis . Discussion The result of this trial is expected to provide the benefit of a nurse-led optimized multimodal and long-term interventional program for management of risk factors after stroke , personalizing the role of the nurse and including the patient ’s caregiver . Trial registration Clinical Trials.gov , NCT 02132364 . Registered on 7 May 2014 . EUDRACT , A 00473 - 40 BACKGROUND The highest risk for stroke is among survivors of strokes or transient ischemic attacks ( TIA ) . However , use of proven-effective cardiovascular medications to control stroke risk is suboptimal , particularly among the Black and Latino population s disproportionately impacted by stroke . METHODS A partnership of Harlem and Bronx community representatives , stroke survivors , research ers , clinicians , outreach workers and patient educators used community-based participatory research to conceive and develop the Prevent Recurrence of All Inner-city Strokes through Education ( PRAISE ) trial . Using data from focus groups with stroke survivors , they tailored a peer-led , community-based chronic disease self-management program to address stroke risk factors . PRAISE will test , in a r and omized controlled trial , whether this stroke education intervention improves blood pressure control and a composite outcome of blood pressure control , lipid control , and use of antithrombotic medications . RESULTS Of the 582 survivors of stroke and TIA enrolled thus far , 81 % are Black or Latino and 56 % have an annual income less than $ 15,000 . Many ( 33 % ) do not have blood pressures in the target range , and most ( 66 % ) do not have control of all three major stroke risk factors . CONCLUSIONS Rates of stroke recurrence risk factors remain suboptimal in the high risk , urban , predominantly minority communities studied . With a community-partnered approach , PRAISE has recruited a large number of stroke and TIA survivors to date , and may prove successful in engaging those at highest risk for stroke and reducing disparities in stroke outcomes in inner-city communities Background and Purpose : Adherence to medication is often suboptimal after stroke and transient ischemic attack ( TIA ) , which increases the risk of recurrent stroke and death . Complex interventions and motivational interviewing ( MI ) have been proven effective in other areas of medicine . The objective of this study was to investigate the effectiveness of a multifaceted intervention including MI in improving medication adherence for secondary stroke prevention . Methods : In this r and omized controlled trial , TIA and stroke patients receiving a pharmacist intervention in a hospital setting were compared with patients receiving usual care . The intervention consisted of a focused medication review , an MI-approached consultation and 3 follow-up telephone calls and lasted for 6 months . The primary outcome was a composite medication possession ratio ( MPR ) for antiplatelets , anticoagulants and statins in the year after hospitalization , assessed by analyzing pharmacy records and reported as both a continuous rate and a binary outcome . Secondary outcomes included composite MPRs at 3 , 6 and 9 months as well as adherence and persistence to specific thrombopreventive medications at 12 months . Clinical outcomes included a combined end point of cardiovascular death , stroke or acute myocardial infa rct ion . Patient satisfaction with the service was assessed for the intervention patients . Results : The analyses included 102 intervention patients and 101 controls . At 12 months , the median MPRs ( IQR ) were 0.95 ( 0.77 - 1 ) in the intervention group and 0.91 ( 0.83 - 0.99 ) in the control group , and 28 and 21 % of the patients , respectively , were nonadherent ( MPR < 0.80 ; risk difference : 7 % ; 95 % CI : -5 to 19 % ) . In both groups , the median MPR decreased over time . From 3 to 12 months , the MPR fell by 5 % ( p < 0.05 ) in the intervention group and by 9 % ( p < 0.05 ) in the control group , but between the groups , comparisons showed no statistically significant difference . No significant differences were found for adherence and persistence to specific thrombopreventive agents or for the clinical outcome . The intervention patients were satisfied with the service ; about half of them reported increased knowledge about medication , and one third reported increased confidence with medication use . Pharmacists identified drug-related problems in one third of the patients . Conclusions : A multifaceted pharmacist intervention including MI did not improve adherence or persistence to secondary stroke prevention therapy and had no impact on clinical outcomes . However , due to the high adherence rates , only little room for improvement existed . Future studies should focus on patients at high risk of nonadherence and include outcomes more sensitive to the impact of behavioral interventions Objective : To test if  TIA/stroke electronic decision support in primary care improves management . Methods : Multicenter , single-blind , parallel-group , cluster r and omized , controlled trial comparing TIA/stroke electronic decision support guided management with usual care . Main outcomes were guideline adherence and 90-day stroke risk . Secondary outcomes were cerebrovascular/vascular/death/adverse events , cost , and user feedback . Main analysis was logistic regression with a normal r and om effect for clusters using a generalized linear mixed model . Results : Twenty-nine clinics were r and omized to intervention , 27 to control , recruiting 172 and 119 eligible patients . More intervention patients received guideline -adherent care ( 131/172 ; 76.2 % ) than control patients ( 49/119 ; 41.2 % ) ( adjusted odds ratio [ OR ] 4.57 ; 95 % confidence interval [ CI ] 2.39–8.71 ; p < 0.001 ) . Ninety-day stroke occurred in 2/172 ( 1.2 % ) intervention and 5/119 ( 4.2 % ) control patients ( OR 0.27 ; 95 % CI 0.05–1.41 ; p = 0.098 ) . Ninety-day TIA or stroke occurrence was lower in the intervention group , 4/172 ( 2.3 % ) compared to 10/119 ( 8.5 % ) control ( adjusted OR 0.26 ; 95 % CI 0.70–0.97 ; p = 0.045 ) . Fewer vascular events/deaths occurred in intervention , 6/172 ( 3.5 % ) , than in control patients , 14/119 ( 11.9 % ) ( adjusted OR 0.27 ; 95 % CI 0.09–0.78 ; p = 0.016 ) . Treatment cost ratio of 0.65 ( 95 % CI 0.47–0.91 ; p = 0.013 ) favored the intervention without increased adverse events . Clinician feedback was positive . Conclusion : Primary care use of the TIA/stroke electronic decision support tool  improves guideline adherence , safely reduces treatment cost , achieves positive user feedback , and may reduce cerebrovascular and vascular event risk following TIA/stroke . Classification of evidence : This study provides Class II evidence that a primary care electronic decision support tool improves guideline adherence and might reduce 90-day stroke risk BACKGROUND Reduction of blood pressure ( BP )  after stroke or TIA decreases stroke recurrence and is a major goal of secondary Stroke Prevention Clinics ( SPCs ) . Health care providers need effective screening processes to identify those clients at highest risk of not achieving BP targets and those clients at highest risk ofnon-adherence to medication . METHODS This multicentred , r and omized controlled study used a screening process to identify SPC patients with psychosocial/cognitive deficits ( e.g. , lack of confidence in the utility of medications , poor memory , mild cognitive impairment ) who were experiencing difficulty managing their BP to target values and evaluated whether a model of nurse-led case management program ( monthly telephone calls , motivational interviewingfor lifestyle change , plus home BP monitoring and use ofdosettes for medication administration ) would improve BP measures and adherence to medications . RESULTS Both  intervention ( n=29 ) and usual care  groups ( n=27 ) showed a trend-for'reduced BP at six months ( Median ql-q3 , Systolic BR p=0.46 ; Diastolic BR p=0.37 ) . Diabetic patients , irrespective of the group to which they were r and omized , were less likely to meet Best Practice Guideline targets than those without diabetes ( Chi Square test , p=0.0001 ) . CONCLUSION Stroke and TIA patients with diabetes may require additional re sources and support in order to reach BP target values Background Coronary Heart Disease and Cerebrovascular Disease share many predisposing , modifiable risk factors ( hypertension , abnormal blood lipids and lipoproteins , cigarette smoking , physical inactivity , obesity and diabetes mellitus ) . Lifestyle interventions and pharmacological therapy are recognised as the cornerstones of secondary prevention . Cochrane review has proven the benefits of programmes incorporating exercise and lifestyle counselling in the cardiac disease population . A Cochrane review highlighted as priority , the need to establish feasibility and efficacy of exercise based interventions for Cerebrovascular Disease . Methods A single blind r and omised controlled trial is proposed to examine a primary care cardiac rehabilitation programme for adults post transient ischemic attack ( TIA ) and stroke in effecting a positive change in the primary outcome measures of cardiac risk scores derived from Blood Pressure , lipid profile , smoking and diabetic status and lifestyle factors of habitual smoking , exercise and healthy eating participation . Secondary outcomes of interest include health related quality of life as measured by the Hospital Anxiety and Depression Scale , the Stroke Specific Quality of Life scale and WONCA COOP Functional Health Status charts and cardiovascular fitness as measured by a sub-maximal fitness test .  A total of 144 patients , over 18 years of age with confirmed diagnosis of ischaemic stroke or TIA , will be recruited from Dublin community stroke services and two tertiary T.I.A clinics . Exclusion criteria will include oxygen dependence , unstable cardiac conditions , uncontrolled diabetes , major medical conditions , claudication , febrile illness , pregnancy or cognitive impairment . Participants will be block-statified , r and omly allocated to one of two groups using a pre-prepared computer generated r and omisation schedule . Both groups will receive a two hour education class on  risk reduction  post stroke  .  The intervention group will receive a 10 week programme of supervised aerobic exercises ( twice weekly ) and individually tailored brief intervention lifestyle counselling . Both groups will be tested on week one and week ten of the programme . Follow-up at 1 year will assess longer term benefits . Analysis will test for significant changes in the key variables indicated . Discussion Application of the Cardiac Rehabilitation paradigm to patients with ischaemic stroke or TIA has not been explored despite the obvious overlap in aetiology . It is hoped the anticipated improvement in vascular risk factors and fitness result ing from such a programme will enhance health and social gain in this population .Trial Registration Current Controlled Trials ISCTRN90272638 We targeted stroke/transient ischemic attack ( TIA ) survivors to engage in self-management practice s to manage secondary stroke risk factors . We conducted a r and omized , regional pilot trial of a locally adapted , secondary stroke prevention program . We implemented the program at two Veterans Administration Medical Centers . Program sessions targeted stroke risk factor self-management . Specifically , we evaluated the effect of the program on the reach , implementation , and effectiveness on patient self-efficacy ; stroke-specific , health-related quality of life ; and medication adherence for the prevalent stroke risk factors : ( 1 ) diabetes , ( 2 ) hypertension , and ( 3 ) hyperlipidemia . Medication possession ratios were calculated to evaluate medication adherence using VA pharmacy benefits data pre ( 6 months prior ) and post ( 6 months after ) the stroke/TIA event . Based upon the literature st and ard of 80 % compliance rate , we dichotomized compliance and modeled the data using logistical regression . Final sample included 174 veterans with an acute stroke or TIA who were r and omized to receive either the intervention ( n = 87 ) or attention control program ( n = 87 ) .  Patient self-efficacy and stroke-specific , health-related quality of life at 6 months did not significantly differ between groups . We found improvements in medication adherence within the intervention group . In the intervention group , the odds of compliance with diabetes medications post-stroke were significantly larger than the odds of compliance prior to the stroke ( odds ratio = 3.45 ( 95 % CI = 1.08–10.96 ) . For compliance to hypertension medications , the intervention group showed significantly greater odds of compliance post intervention than pre intervention ( odds ratio = 3 . 68 ( 95 % CI = 1.81–7.48 ) . The control group showed no difference in compliance rates from baseline to follow-up . For adherence to hypercholesterolemia medications , both the intervention ( odds ratio = 5.98 ( 95 % CI = 2.81–12.76 ) and control groups ( odds ratio = 3.83 ( 95 % CI = 1.83–8.01 ) , had significant increases in the odds of compliance to statin medications ; however , the comparison of changes in log odds of compliance between these two groups showed that the increases were not significantly different . We observed within group improvements in medication adherence among those receiving a post-stroke risk factor self-management program suggesting that a self-management format may be feasible to enable adherence to prescribed medications to reduce secondary stroke risk after stroke in concordance with guideline care . Additional research is needed to enhance intervention components to improve effectiveness outcomes 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 review ing the literature and undertaking quantitative and qualitative studies to identify current practice s 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 r and omised controlled trial . Further research is needed to test generalisability to other aspects of stroke management and for other chronic diseases . PRACTICE IMPLICATION S The MRC Framework for complex interventions provides a structured approach to guide the development of novel interventions in public health . Implication s for practice in stroke secondary prevention will emerge when the results of our r and omised controlled trial are published Background Secondary prevention after stroke and transient ischemic attack ( TIA ) is essential in order to reduce morbidity and mortality . Secondary stroke prevention studies have , however , been fairly small , or performed as clinical trials with non-representative patient selection . Long-term follow-up data is also limited . A nurse-led follow-up for risk factor improvement may be effective but the evidence is limited . The aims of this study are to perform an adequately sized , nurse-led , long-term secondary preventive follow-up with a population -based inclusion of stroke and TIA patients . The focus will be on blood pressure and lipid control as well as tobacco use and physical activity . Methods A r and omized , controlled , long-term , population -based trial with two parallel groups . The patients will be included during the initial hospital stay . Important outcome variables are sitting systolic and diastolic blood pressure , LDL cholesterol and total cholesterol . Outcomes will be measured after 12 , 24 and 36 months of follow-up . Trained nurses will manage the intervention group with a focus on reaching set treatment goals as soon as possible . The control group will receive usual care .  At least 200 patients will be included in each group , in order to reliably detect a difference in mean systolic blood pressure of 5 mmHg . This sample size is also adequate for detection of clinical ly meaningful group differences in the other outcomes . Discussion This study will test the hypothesis that a nurse-led , long-term follow-up after stroke with a focus on reaching set treatment goals as soon as possible , is an effective secondary preventive method . If proven effective , this method could be implemented in general practice at a low cost . Trial registration Current Controlled Trials IS RCT Background and aim Behavioral and lifestyle interventions in stroke patients need to be intense enough to result in sustainable treatment differences among groups of a r and omized trial . Therefore , we report the effects of multidomain interventions on lifestyle and laboratory parameters after 12 and 24 months from a trial that examined whether intensive risk factor management can prevent cognitive decline in ischemic stroke patients . Methods This prospect i ve r and omized , open-label , blinded endpoint trial recruited patients within three months after acute stroke in five Austrian neurological clinics during June 2010 and November 2012 . One hundred and one patients were r and omized into multidomain intervention and 101 into st and ard care . Lifestyle interventions were individualized to match predefined targets of regular physical activity , healthy diet , and adequate physiological risk factor control . Results A total of 167 participants ( 80 intervention , 87 control ) completed the 12-month visit and 155 ( 76 intervention , 79 control ) the 24-month visit . During the first 12 months , adherence to healthy lifestyle and adequately controlled physiological parameters ( measured by summary scores ) improved significantly in the intervention group compared to controls ( p < 0.01 ) . The consumption of reduced-fat milk ( p = 0.031 ) , reduced-fat spreads ( p = 0.007 ) , and fish ( p = 0.021 ) increased in the intervention group from baseline to 12 months but not in controls . After 24 months , the group difference was significant for the lifestyle summary score but no longer for the combined laboratory lifestyle score . Conclusions These results demonstrate that intensified individualized multidomain lifestyle interventions in stroke patients are effective in promoting healthy lifestyle in stroke care Background Despite lack of outward signs , most individuals after non-disabling stroke ( NDS ) and transient ischemic attack ( TIA ) have significant cardiovascular and cerebrovascular disease and are at high risk of a major stroke , hospitalization for other vascular events , or death . Most have multiple modifiable risk factors ( e.g. , hypertension , physical inactivity , hyperlipidaemia , diabetes , tobacco consumption , psychological stress ) . In addition , accelerated rates of depression , cognitive decline , and poor quality of sleep have been reported following TIA , which correlate with poor functional outcomes and reduced quality of life . Thus , NSD and TIA are important warning signs that should not be overlooked . The challenge is not unlike that facing other ' silent ' conditions - to identify a model of care that is effective in changing people 's current behaviors in order to avert further morbidity . Methods / Design A single blind , r and omized controlled trial will be conducted at two sites to compare the effectiveness of a program of rehabilitative exercise and education versus usual care in modifying vascular risk factors in adults after NDS/TIA . 250 adults within 90 days of being diagnosed with NDS/TIA will be r and omly allocated to a 12-week program of exercise and education ( PREVENT ) or to an outpatient clinic assessment and discussion of secondary prevention recommendations with return clinic visits as indicated ( USUAL CARE ) . Primary outcome measures will include blood pressure , waist circumference , 12-hour fasting lipid profile , and 12-hour fasting glucose/hemoglobin A1c . Secondary measures will include exercise capacity , walking endurance , physical activity , cognitive function , depression , goal attainment and health-related quality of life . Outcome assessment will be conducted at baseline , post-intervention , and 6- and 12-month follow-ups . Direct health care costs incurred over one year by PREVENT versus USUAL CARE participants will also be compared . Ethical approval for the trial has been obtained from the relevant Human Research Ethics Boards . Discussion Whether timely delivery of an adapted cardiac rehabilitation model is effective in attaining and maintaining vascular risk reduction targets in adults after NDS/TIA is not yet known . We anticipate that the findings of this trial will make a meaningful contribution to the knowledge base regarding secondary stroke prevention . Trial registration This trial is registered with the Clinical Trials.gov Registry ( NCT00885456 )
There was no significant difference in smoking continuance , or improved fruit and vegetable consumption .
CONCLUSIONS There are benefits to be derived from multimodal secondary prevention interventions .
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 .