Abstract
Background
People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Evidence-based strategies for secondary stroke prevention have been established. However, the implementation of prevention strategies could be improved.
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 2013), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2013), CENTRAL (The Cochrane Library 2013, issue 3), MEDLINE (1950 to April 2013), EMBASE (1981 to April 2013) and 10 additional databases. 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
Two review authors selected studies for inclusion and independently extracted data. One review author assessed the risk of bias for the included studies. We sought missing data from trialists.
Main results
This review included 26 studies involving 8021 participants. Overall the studies were of reasonable quality, but one study was considered at high risk of bias. Fifteen studies evaluated predominantly organisational interventions and 11 studies evaluated educational and behavioural interventions for patients. Results were pooled where appropriate, although some clinical and methodological heterogeneity was present. The estimated effects of organisational interventions were compatible with improvements and no differences in the modifiable risk factors mean systolic blood pressure (mean difference (MD) -2.57 mmHg; 95% confidence interval (CI) -5.46 to 0.31), mean diastolic blood pressure (MD -0.90 mmHg; 95% CI -2.49 to 0.68), blood pressure target achievement (OR 1.24; 95% CI 0.94 to 1.64) and mean body mass index (MD -0.68 kg/m2; 95% CI -1.46 to 0.11). There were no significant effects of organisational interventions on lipid profile, HbA1c, medication adherence or recurrent cardiovascular events. Educational and behavioural interventions were not generally associated with clear differences in any of the review outcomes, with only two exceptions.
Authors’ conclusions
Pooled results indicated that educational interventions were not associated with clear differences in any of the review outcomes. The estimated effects of organisational interventions were compatible with improvements and no differences in several modifiable risk factors. We identified a large number of ongoing studies, suggesting that research in this area is increasing. The use of standardised outcome measures would facilitate the synthesis of future research findings.
Plain language summary
Healthcare interventions for reducing the risk of future stroke in people with previous stroke or transient ischaemic attack (TIA)
Question
We wanted to assess the effects of interventions for implementing secondary stroke prevention strategies to reduce the risk of further stroke or other cardiovascular events in people who have already had a stroke or transient ischaemic attack (TIA).
Background
Stroke and TIA are diseases that are caused by interruptions in the blood supply to the brain. People who experience a stroke or TIA are at risk of future stroke and other cardiovascular events. Several medications and lifestyle changes can be used to lower stroke risk by improving the control of modifiable risk factors. In this review, modifiable risk factors for stroke included systolic and diastolic blood pressure, blood lipids, atrial fibrillation, diabetes management, body mass index (BMI) and the use of preventive medications as prescribed. Research evidence suggests that modifiable risk factors are often not managed effectively following a stroke or TIA. Therefore, it is important to identify healthcare interventions that can facilitate stroke prevention by improving modifiable risk factor control and patient adherence to prescribed medications. The categories of interventions considered in this systematic review were educational and behavioural interventions for patients; educational and behavioural interventions for stroke service providers; organisational interventions.
Study characteristics
We identified 26 studies, up to April 2013, for inclusion in the review. These studies included a total of 8021 participants with cerebrovascular disease and were undertaken in the USA, Canada, Europe, Asia and Australia. The mean or median age of participants ranged from 60 to 73 years. Six studies included participants with a diagnosis of ischaemic stroke, whereas three studies included participants with either ischaemic or haemorrhagic stroke, or did not specify stroke subtype. The majority of studies were set in primary care or community settings. Eleven studies involved educational or behavioural interventions for participants and 15 studies involved predominantly organisational interventions. The majority of interventions had a duration of between three and 12 months.
Key results
Analysis of the effects of changes to the organisation of healthcare services was compatible with meaningful improvements in systolic blood pressure, diastolic blood pressure, blood pressure target achievement and BMI; although the imprecision of these estimates meant that absence of improvements could not be ruled out. The effects of these interventions on changes in blood lipids, diabetes management, use of preventive medications as prescribed, or the occurrence of stroke and other cardiovascular events were imprecise and consistent with benefit and harm. Changes to healthcare services that addressed only patient education or behaviour, without any changes to the organisation of patient care, were generally not associated with clear evidence of changes in modifiable risk factors for stroke. We identified a large number of ongoing studies, suggesting that research in this area is increasing.
Quality of the evidence
We judged all but one of the included studies to be of reasonable quality.
