title: The ExStroke Pilot Trial: rationale, design, and baseline data of a randomized multicenter trial comparing physical training versus usual care after an ischemic stroke. 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abstract: INTRODUCTION A high level of physical activity is associated with a decreased risk of first stroke and physical activity modifies recognized stroke risk factors and is recommended for stroke survivors . Available research shows that stroke patients can increase their level of physical performance over a short period . When the intervention period is over , physical performance often declines towards baseline level . Currently , there is no evidence on the association between physical activity and the risk of recurrent stroke . The ExStroke Pilot Trial is a r and omized clinical trial with the aim of increasing stroke patients ' level of physical activity and secondarily to associate the level of physical activity to the risk of recurrent stroke , myocardial infa rct ion , and all-cause mortality in the two groups . We describe the rationale , design , and baseline data of the ExStroke Pilot Trial . METHODS Patients with ischemic stroke above 39 years were r and omized to intervention or control group . The intervention group will , over a 2-year period , receive information on and verbal instruction to exercise by a physiotherapist or a physician . The control group will receive the department 's usual care . Physical activity  is assessed in both groups seven times during follow-up using the  Physical Activity Scale for the Elderly ( PASE ) question naire , which quantifies the amount of physical activity done in the last seven days prior to interview . The PASE score constitutes the primary outcome measure . The secondary outcome is the time from r and omization to recurrent stroke , myocardial infa rct ion , or all-cause mortality . Further outcome measures include : time from r and omization to recurrent stroke , myocardial infa rct ion , and vascular death ; recurrent stroke ; modified Rankin Scale ; quality of life ; occurrence of falls and fractures . TRIAL STATUS From 9 centers in 4 countries , 314 patients were included and follow-up is ongoing . Mean age and st and ard deviation ( SD ) of the study participants was 68.4 ( 11.9 ) years and 56.4 % were male . Mean ( SD ) PASE score was 84.1 ( 55.9 ) and median ( interquartile range ) Sc and inavian Stroke Scale score was 54 ( 51 - 58 ) Background and Purpose — High rates of ischemic stroke and poor adherence to secondary prevention measures are observed in the Chinese population . Methods — We used a national , multicenter , cluster-r and omized controlled trial in which 47 hospitals were r and omized to either a  structured care program group ( n=23 ) or a usual care group ( n=24 ) . The structured care program consisted of a specialist-administered , guideline -recommended pharmaceutical treatment and a lifestyle modification algorithm associated with written and Internet-accessed educational material for patients for the secondary prevention of ischemic stroke . The primary efficacy outcome was the proportion of patients who adhered to the recommended measures at 12-month postdischarge . This trial is registered with Clinical Trial.gov ( NCT00664846 ) . Results — At 12 months , 1287 ( 72.1 % ) patients in the St and ard Medical Management in Secondary Prevention of Ischemic Stroke in China ( SMART ) group and 1430 ( 72 % ) patients in the usual care group had completed the 12-month follow-up ( P=0.342 ) . Compared with the usual care group , those in the SMART group showed higher adherence to statins ( 56 % versus 33 % ; P=0.006 ) but no difference in adherence to antiplatelet ( 81 % versus 75 % ; P=0.088 ) , antihypertensive ( 67 % versus 69 % ; P=0.661 ) , or diabetes mellitus drugs ( 73 % versus 67 % ; P=0.297 ) . No significant difference in the composite end point ( new-onset ischemic stroke , hemorrhagic stroke , acute coronary syndrome , and all-cause death ) was observed ( 3.56 % versus 3.59 % ; P=0.921 ) . Conclusions — The implementation of a program to improve adherence to secondary ischemic stroke prevention efforts in China is feasible , but these programs had only a limited impact on adherence and no impact on 1-year outcomes . Further development of a structured program to reduce vascular events after stroke is needed . Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00664846 Background Over 65 % of stroke survivors are either overweight or obese and have multiple cardiovascular risk factors . However , few studies have examined the effects of comprehensive lifestyle behavior interventions to promote weight loss and control cardiovascular risk factors in stroke survivors . Thus , the purpose of this study is to examine a novel behavior change approach - SystemCHANGE ™ - to promote weight loss and improve health and function in stroke survivors .  SystemCHANGE ™ focuses on re design ing the social environment to achieve a specific goal . Methods We will conduct a r and omized controlled pilot study to examine the efficacy , feasibility , and safety of the SystemCHANGE ™ weight management program in overweight and obese stroke survivors . The central hypothesis of the study is that the SystemCHANGE ™ intervention will help overweight and obese stroke survivors lose 5 % of their body weight , thereby improving health and function . Thirty-five stroke survivors will be r and omized into either the 6-month SystemCHANGE ™ intervention or a contact-control intervention . Outcome measures will be assessed at baseline and again at 3 and 6 months after the interventions . Body composition will be assessed using a Bod Pod . Patient-reported outcomes will be the Stroke Impact Scale and Reintegration to Normal Living Index . Objective outcomes will include the 6-Minute Walking Test and Rivermead Motor Assessment . Discussion This study will be the first r and omized controlled trial to evaluate the efficacy and safety of a weight management intervention in stroke survivors using the SystemCHANGE ™ approach . Furthermore , it will be the first empirically-examined comprehensive lifestyle intervention design ed to target physical activity , nutrition , and sleep to promote weight loss in stroke survivors . Trial registration Clinical Trials.gov Identifier : Objective : Despite evidence demonstrating that risk-factor management is effective in reducing recurrent cerebrovascular disease , there are very few structured care programmes for stroke survivors . The aim was to implement and evaluate an integrated care programme in stroke . Methods : 186 patients with stroke were r and omised to either the treatment ( integrated care ) or control ( usual care ) group and were followed up over 12 months . The Integrated Care for the Reduction of Secondary Stroke ( ICARUSS ) model of integrated care involved collaboration between a specialist stroke service , a hospital coordinator and a patient ’s general practitioner . The primary aim was to promote the management of vascular risk factors through ongoing patient contact and education . Results : In the 12 months poststroke , systolic blood pressure ( sBP ) decreased in the treatment group but increased in controls . The group difference was significant , and remained so when age , sex , disability and sBP at discharge were accounted for ( p = 0.04 ) . Treatment patients also exhibited better modification of body mass index ( p = 0.007 ) and number of walks taken ( p<0.001 ) than controls . Rankin scores indicated significantly reduced disability in treatment patients relative to controls in the year poststroke ( p = 0.003 ) . Conclusions : Through an integrated system of education , advice and support to both patient and GP , the ICARUSS model was effective in modifying a variety of vascular risk factors and therefore should decrease the likelihood or recurrent stroke or vascular event Background Case management has emerged as a promising alternative approach to supplement traditional one-on-one sessions between patients and doctors for improving the quality of care in chronic diseases such as coronary heart disease ( CHD ) . However , data are lacking in terms of its efficacy and cost-effectiveness when implemented in ethnic and low-income population s. Methods The Stanford and San Mateo Heart to Heart ( HTH ) project is a r and omized controlled clinical trial design ed to rigorously evaluate the efficacy and cost-effectiveness of a multi-risk cardiovascular case management program in low-income , primarily ethnic minority patients served by a local county health care system in California . R and omization occurred at the patient level . The primary outcome measure is the absolute CHD risk over 10 years . Secondary outcome measures include adherence to guidelines on CHD prevention practice . We documented the study design , methodology , and baseline sociodemographic , clinical and lifestyle characteristics of 419 participants . Results We achieved equal distributions of the sociodemographic , biophysical and lifestyle characteristics between the two r and omization groups . HTH participants had a mean age of 56 years , 63 % were Latinos/Hispanics , 65 % female , 61 % less educated , and 62 % were not employed . Twenty percent of participants reported having a prior  cardiovascular event . 10-year CHD risk averaged 18 % in men and 13 % in women despite a modest low-density lipoprotein cholesterol level and a high on-treatment percentage at baseline . Sixty-three percent of participants were diagnosed with diabetes and an additional 22 % had metabolic syndrome . In addition , many participants had depressed high-density lipoprotein ( HDL ) cholesterol levels and elevated values of total cholesterol-to-HDL ratio , triglycerides , triglyceride-to-HDL ratio , and blood pressure . Furthermore , nearly 70 % of participants were obese , 45 % had a family history of CHD or stroke , and 16 % were current smokers . Conclusion We have recruited an ethnically diverse , low-income cohort in which to implement a case management approach and test its efficacy and cost-effectiveness . HTH will advance the scientific underst and ing of better strategies for CHD prevention among these priority sub population s and aid in guiding future practice that will reduce health disparities Objective To investigate whether an internet based , nurse led vascular risk factor management programme promoting self management on top of usual care is more effective than usual care alone in reducing vascular risk factors in patients with clinical ly manifest vascular disease . Design Prospect i ve r and omised controlled trial . Setting Multicentre trial in secondary and tertiary healthcare setting . Participants 330 patients with a recent clinical manifestation of atherosclerosis in the coronary , cerebral , or peripheral arteries and with at least two treatable risk factors not at goal . Intervention Personalised website with an overview and actual status of patients ’ risk factors and mail communication via the website with a nurse practitioner for 12 months ; the intervention combined self management support , monitoring of disease control , and drug treatment . Main outcome measures The primary endpoint was the relative change in Framingham heart risk score after 1 year . Secondary endpoints were absolute changes in the levels of risk factors and the differences between groups in the change in proportion of patients reaching treatment goals for each risk factor . Results Participants ’ mean age was 59.9 ( SD 8.4 ) years , and most patients ( n=246 ; 75 % ) were male . After 1 year , the relative change in Framingham heart risk score of the intervention group compared with the usual care group was −14 % ( 95 % confidence interval −25 % to −2 % ) . At baseline , the Framingham heart risk score was higher in the intervention group than in the usual care group ( 16.1 ( SD 10.6 ) v 14.0 ( 10.5 ) ) , so the outcome was adjusted for the separate variables of the Framingham heart risk score and for the baseline Framingham heart risk score . This produced a relative change of −12 % ( −22 % to −3 % ) in Framingham heart risk score for the intervention group compared with the usual care group adjusted for the separate variables of the score and −8 % ( −18 % to 2 % ) adjusted for the baseline score . Of the individual risk factors , a difference between groups was observed in low density lipoprotein cholesterol ( −0.3 , −0.5 to −0.1 , mmol/L ) and smoking ( −7.7 % , −14.9 % to −0.4 % ) . Some other risk factors tended to improve ( body mass index , triglycerides , systolic blood pressure , renal function ) or tended to worsen ( glucose concentration , albuminuria ) . Conclusion An internet based , nurse led treatment programme on top of usual care for vascular risk factors had a small effect on lowering vascular risk and on lowering of some vascular risk factors in patients with vascular disease . Trial registration Clinical trials NCT00785031 Objectives To investigate if repeated verbal instructions about physical activity to patients with ischaemic stroke could increase long term physical activity . Design Multicentre , multinational , r and omised clinical trial with masked outcome assessment . Setting Stroke units in Denmark , China , Pol and , and Estonia . Participants 314 patients with ischaemic stroke aged ≥40 years who were able to walk—157 ( mean age 69.7 years ) r and omised to the intervention , 157 ( mean age 69.4 years ) in the control group . Interventions Patients r and omised to the intervention were instructed in a detailed training programme before discharge and at five follow-up visits during 24 months . Control patients had follow-up visits with the same frequency but without instructions in physical activity . Main outcome measures Physical activity assessed with the Physical Activity Scale for the Elderly ( PASE ) at each visit . Secondary outcomes were clinical events . Results The estimated mean PASE scores were 69.1 in the intervention group and 64.0 in the control group ( difference 5.0 ( 95 % confidence interval −5.8 to 15.9 ) , P=0.36 . The intervention had no significant effect on mortality , recurrent stroke , myocardial infa rct ion , or falls and fractures . Conclusion Repeated encouragement and verbal instruction in being physically active did not lead to a significant increase in physical activity measured by the PASE score . More intensive strategies seem to be needed to promote physical activity after ischaemic stroke . Trial registration Clinical Trials Background Self-monitoring of hypertension with self-titration of antihypertensives ( self-management ) results in lower systolic blood pressure for at least one year . However , few people in high risk groups have been evaluated to date and previous work suggests a smaller effect size in these groups . This trial therefore aims to assess the added value of self-management in high risk groups over and above usual care . Methods / Design The targets and self-management for the control of blood pressure in stroke and at risk groups ( TASMIN-SR ) trial will be a pragmatic primary care based , unblinded , r and omised controlled trial of self-management of blood pressure ( BP ) compared to usual care .  Eligible patients will have a history of stroke , coronary heart disease , diabetes or chronic kidney disease and will be recruited from primary care . Participants will be individually r and omised to either usual care or self-management . The primary outcome of the trial will be difference in office SBP between intervention and control groups at 12 months adjusted for baseline SBP and covariates . 540 patients will be sufficient to detect a difference in SBP between self-management and usual care of 5 mmHg with 90 % power . Secondary outcomes will include self-efficacy , lifestyle behaviours , health-related quality of life and adverse events . An economic analysis will consider both within trial costs and a model extrapolating the results thereafter . A qualitative analysis will gain insights into patients ’ views , experiences and decision making processes . Discussion The results of the trial will be directly applicable to primary care in the UK . If successful , self-management of blood pressure in people with stroke and other high risk conditions would be applicable to many hundreds of thous and s of individuals in the UK and beyond . Trial Registration IS RCT Background Enhanced secondary preventive follow-up after stroke or transient ischemic attack ( TIA ) is necessary for improved adherence to recommendations regarding blood pressure ( BP ) and low-density lipoprotein cholesterol ( LDL-C ) levels . We investigated whether nurse-led , telephone-based follow-up was more efficient than usual care at improving BP and LDL-C levels at 12 months after hospital discharge . Methods We r and omized 537 patients to either nurse-led , telephone-based follow-up ( intervention ) or usual care ( control ) .  BP and LDL-C measurements were performed at 1 month ( baseline ) and 12 months post-discharge . Intervention group patients who did not meet target values at baseline received additional follow-up , including titration of medication and lifestyle counselling , to reach treatment goals ( BP < 140/90 mmHg , LDL-C < 2.5 mmol/L ) . Results At 12 months , mean systolic BP , diastolic BP and LDL-C was 3.3 ( 95 % CI 0.3 to 6.3 ) mmHg , 2.3 mmHg ( 95 % CI 0.5 to 4.2 ) and 0.3 mmol/L ( 95 % CI 0.1 to 0.4 ) lower in the intervention group compared to controls . Among participants with values above the treatment goal at baseline , the difference in systolic BP and LDL-C was more pronounced ( 8.0 mmHg , 95 % CI 4.0 to 12.1 , and 0.6 mmol/L , 95 % CI 0.4 to 0.9 ) . A larger proportion of the intervention group reached the treatment goal for systolic BP ( 68.5 vs. 56.8 % , p = 0.008 ) and LDL-C ( 69.7 % vs. 50.4 % , p < 0.001 ) . Conclusions Nurse-led , telephone-based secondary preventive follow-up , including medication adjustment , was significantly more efficient than usual care at improving BP and LDL-C levels by 12 months post-discharge . Trial Registration IS RCT N Registry IS RCT Background Adherence to preventive medication is often poor , and current interventions have had limited success . Purpose This study was conducted to pilot a r and omised controlled trial aim ed at increasing adherence to preventive medication  in stroke survivors using a brief , personalised intervention . Methods Sixty-two stroke survivors were r and omly allocated to either a two-session intervention aim ed at increasing adherence via ( a ) introducing a plan linked to environmental cues ( implementation intentions ) to help establish a better medication-taking routine ( habit ) and ( b ) eliciting and modifying any mistaken patient beliefs regarding medication/stroke or a control group . Primary outcome was adherence to antihypertensive medication  measured objective ly over 3 months using an electronic pill bottle . Results Fifty-eight people used the pill bottle and were analysed as allocated ; 54 completed treatment . The intervention result ed in 10 % more doses taken on schedule ( intervention , 97 % ; control , 87 % ; 95 % CI for difference ( 0.2 , 16.2 ) ; p = 0.048 ) . Conclusions A simple , brief intervention increased medication adherence in stroke survivors , over and above any effect of increased patient contact or mere measurement . ( http://controlled-trials.com , number IS RCT N38274953 . Objective The purpose of this study is to identify factors which predict adherence in stroke survivors . Design This is a longitudinal study where 180 stroke survivors were assessed 1 year after their first ischaemic stroke . The relationship between adherence and illness and medication beliefs was tested at baseline ( time 1 ) and again 5–6 weeks later ( time 2).Main Outcome Measures The main outcome measures used in this study are Medication Adherence Report Scale and urinary salicylate levels . Results Four variables predicted time 1 poor adherence : ( 1 ) younger age , ( 2 ) increased specific concerns about medications , ( 3 ) reduced cognitive functioning and ( 4 ) low perceived benefit of medication . Three out of these four variables were again predictive of time 2 adherence and accounted for 24 % of the variance : ( 1 ) younger age , ( 2 ) increased specific concerns about medications and ( 3 ) low perceived benefit of medication . The urinary salicylate assay failed to differentiate between patients taking and not taking aspirin . Conclusion Interventions to improve adherence should target patients ’ beliefs about their medication The effectiveness of methods to prevent stroke recurrence and of education focusing on learners ' needs has not been fully explored . The aims of this study were to assess the effects of such interventions among stroke patients and their primary caregivers and to evaluate the feasibility of a web-based stroke education program . The participants were 36 patients with a clinical diagnosis of ischemic stroke within 12 months post-stroke and their primary caregivers . The participants were r and omly assigned to either an experimental or a control group . The primary measures included blood chemistry , self-reported health behaviors , sense of control , and health motivation for stroke patients , and caregiver mastery for caregivers . To test the feasibility of the intervention program , the rates of participation and occurrence of technical problems were calculated . The experimental group tended to improve significantly more than the control group in terms of exercise , diet , sense of control and health motivation for the stroke patients and in terms of caregiver mastery for the primary caregivers . The rate of participation in the web-based program was 63.1 % . This program , which focuses on recurrence prevention in stroke patients and caregivers , has the potential to improve health behaviors for stroke patients BACKGROUND The objective of this study was to examine the association of Joint National Committee ( JNC-V ) blood pressure and National Cholesterol Education Program ( NCEP ) cholesterol categories with coronary heart disease ( CHD ) risk , to incorporate them into coronary prediction algorithms , and to compare the discrimination properties of this approach with other noncategorical prediction functions . METHODS AND RESULTS This work was design ed as a prospect i ve , single-center study in the setting of a community-based cohort . The patients were 2489 men and 2856 women 30 to 74 years old at baseline with 12 years of follow-up . During the 12 years of follow-up , a total of 383 men and 227 women developed  CHD , which was significantly associated with categories of blood pressure , total cholesterol , LDL cholesterol , and HDL cholesterol ( all P<.001 ) . Sex-specific prediction equations were formulated to predict CHD risk according to age , diabetes , smoking , JNC-V blood pressure categories , and NCEP total cholesterol and LDL cholesterol categories . The accuracy of this categorical approach was found to be comparable to CHD prediction when the continuous variables themselves were used . After adjustment for other factors , approximately 28 % of CHD events in men and 29 % in women were attributable to blood pressure levels that exceeded high normal ( > or = 130/85 ) . The corresponding multivariable-adjusted attributable risk percent associated with elevated total cholesterol ( > or = 200 mg/dL ) was 27 % in men and 34 % in women . CONCLUSIONS Recommended guidelines of blood pressure , total cholesterol , and LDL cholesterol effectively predict CHD risk in a middle-aged white population sample . A simple coronary disease prediction algorithm was developed using categorical variables , which allows physicians to predict multivariate CHD risk in patients without overt CHD Background More than 60 % of new strokes each year are " mild " in severity and this proportion is expected to rise in the years to come . Within our current health care system those with " mild " stroke are typically discharged home within days , without further referral to health or rehabilitation services other than advice to see their family physician . Those with mild stroke often have limited access to support from health professionals with stroke-specific knowledge who would typically provide critical information on topics such as secondary stroke prevention , community reintegration , medication counselling and problem solving with regard to specific concerns that arise . Isolation and lack of knowledge may lead to a worsening of health problems including stroke recurrence and unnecessary and costly health care utilization . The purpose of this study is to assess the effectiveness , for individuals who experience a first " mild " stroke , of a sustainable , low cost , multimodal support intervention ( comprising information , education and telephone support ) - " WE CALL " compared to a passive intervention ( providing the name and phone number of a re source person available if they feel the need to ) - " YOU CALL " , on two primary outcomes : unplanned-use of health services for negative events and quality of life . Method / Design We will recruit 384 adults who meet inclusion criteria for a first mild stroke across six Canadian sites . Baseline measures will be taken within the first month after stroke onset . Participants will be stratified according to comorbidity level and r and omised to one of two groups : YOU CALL or WE CALL . Both interventions will be offered over a six months period . Primary outcomes include unplanned use of heath services for negative event ( frequency calendar ) and quality of life ( EQ-5D and Quality of Life Index ) . Secondary outcomes include participation level ( LIFE-H ) , depression ( Beck Depression Inventory II ) and use of health services for health promotion or prevention ( frequency calendar ) . Blind assessors will gather data at mid-intervention , end of intervention and one year follow up . Discussion If effective , this multimodal intervention could be delivered in both urban and rural environments . For example , existing infrastructure such as regional stroke centers and existing secondary stroke prevention clinics , make this intervention , if effective , deliverable and sustainable . Trial Registration IS RCT OBJECTIVE Given the large number of patients at high risk of vascular events , new strategies are needed to reduce vascular risk . We investigated whether self-efficacy promotion could change self-efficacy levels in patients with vascular diseases and whether baseline self-efficacy and changes in self-efficacy were related to changes in vascular risk factors . METHODS One hundred fifty-three recently referred patients with symptomatic vascular diseases ( cerebrovascular , abdominal , or peripheral arterial ) participated in a r and omized trial investigating the effect of nursing care , as compared with usual care , on vascular risk factors . Nursing care consisted of self-efficacy promotion and medical treatment of vascular risk factors .  Self-efficacy and vascular risk factors ( smoking , BMI , waist , blood pressure , lipid , and glucose levels ) were measured at baseline and after 1 year . RESULTS While total self-efficacy did not change over the 1-year intervention period in either treatment group , self-efficacy in choosing healthy food ( mean + 0.4+/-1.4 , p-value 0.01 ) and in doing extra exercise ( mean + 0.3+/-1.3 , p-value 0.03 ) increased in the intervention group . No relation was seen between baseline total self-efficacy or change in composite self-efficacy and change in vascular risk factors . CONCLUSION The nursing intervention did not influence total self-efficacy but did improve self-efficacy in choosing healthy food and doing extra exercise . Change in composite self-efficacy was not related to change in vascular risk factors in patients at high risk of developing ( new ) cardiovascular diseases . PRACTICE IMPLICATION S Influencing self-efficacy in choosing healthy food and doing extra exercise could be incorporated in vascular risk reduction programs in addition to medical treatment of vascular risk factors Abstract Background High blood pressure in patients with stroke increases the risk of recurrence but management in the community is often inadequate . Home blood pressure monitoring may increase patients ' involvement in their care , increase compliance , and reduce the need for patients to attend their General Practitioner if blood pressure is adequately controlled . However the value of home monitoring to improve blood pressure control is unclear . In particular its use has not been evaluated in stroke patients in whom neurological and cognitive ability may present unique challenges . Design Community based r and omised trial with follow up after 12 months . Participants : 360 patients admitted to three South London Stroke units with stroke or transient ischaemic attack within the past 9 months will be recruited from the wards or out patients and r and omly allocated into two groups . All patients will be visited by the specialist nurse at home at baseline when she will measure their blood pressure and administer a question naire . These procedures will be repeated at 12 months follow up by another research er blind as to whether the patient is in intervention or control group . Intervention : Intervention patients will be given a vali date d home blood pressure monitor and support from the specialist nurse . Control patients will continue with usual care ( blood pressure monitoring by their practice ) . Main outcome measures in both groups after 12 months : 1 . Change in systolic blood pressure.2 . Cost effectiveness : Incremental cost of the intervention to the National Health Service and incremental cost per quality adjusted life year gained . Trial registration Clinical Trials.gov registration Background and Purpose — Stroke prevention clinics ( SPCs ) are not usually involved with the active management of hypertension , hyperlipidemia , diabetes , and smoking . The effect of consultations generated at SPCs on the adequacy of the management of these risk factors for stroke has not been well described , and few studies have long-term follow-up . Methods — We performed a prospect i ve study of 119 consecutive patients referred to an SPC for secondary prevention .  One year after their baseline visit , patients were re-evaluated for the adequacy of the management of the above risk factors , and the proportion of improvement was assessed . Results — One-hundred twelve patients returned for their 1-year follow-up visit . Sixty-six were male , and the average age was 65 years . Hypertension was present in 83 patients , hyperlipidemia in 92 , diabetes in 26 , and smoking in 38 , and 80 had multiple risk factors . At baseline , 66 % of patients with hypertension , 17 % of patients with hyperlipidemia , and 23 % of diabetics had adequate management of their respective risk factors . During 1 year of follow-up , hypertension management improved 20 % ( P < 0.001 ) and lipid management improved 32 % ( P < 0.001 ) . There was no significant improvement in diabetes management or smoking cessation . Conclusions — Although our underst and ing of the benefit of addressing hypertension , hyperlipidemia , diabetes , and smoking for secondary prevention of stroke is evolving , we found marked room for improvement in the management of these four risk factors . SPCs may need to be more actively involved in the management of these modifiable risk factors , if we are to significantly impact the risk of recurrent stroke Objective Tailoring stroke information and providing reinforcement opportunities are two strategies proposed to enhance the effectiveness of education . This study aim ed to evaluate the effects of an education package which utilised both strategies on the knowledge , health and psychosocial outcomes of stroke patients and carers . Design Multisite , r and omised trial comparing usual care with an education and support package . Setting Two acute stroke units . Participants Patients and their carers ( N=138 ) were r and omised ( control n=67 , intervention n=71 ) of which data for 119 participants ( control n=59 , intervention n=60 ) were analysed . Intervention The package consisted of a computer-generated , tailored written information booklet and verbal reinforcement provided prior to , and for 3 months following , discharge . Outcome measures Outcome measures were administered prior to hospital discharge and at 3-month follow-up by blinded assessors . The primary outcome was stroke knowledge ( score range : 0–25 ) . Secondary outcomes were : self-efficacy ( 1–10 ) , anxiety and depression ( 0–21 ) , ratings of importance of information ( 1–10 ) , feelings of being informed ( 1–10 ) , satisfaction with information ( 1–10 ) , caregiver burden ( carers ) ( 0–13 ) and quality of life ( patients ) ( 1–5 ) . Results Intervention group participants reported better : self-efficacy for accessing stroke information ( adjusted mean difference ( MD ) of 1.0 , 95 % CI 0.3 to 1.7 , p=0.004 ) ; feeling informed ( MD 0.9 , 95 % CI 0.2 to 1.6 , p=0.008 ) ; and satisfaction with medical ( MD 2.0 , 95 % CI 1.1 to 2.8 , p<0.001 ) ; practical ( MD 1.1 , 95 % CI 0.3 to 1.9 , p=0.008 ) , services and benefits ( MD 0.9 , 95 % CI 0.1 to 1.8 , p=0.036 ) and secondary prevention information ( MD 1.7 , 95 % CI 0.9 to 2.5 , p<0.001 ) . There was no significant effect on other outcomes . Conclusions Intervention group participants had improved self-efficacy for accessing stroke information and satisfaction with information , but other outcomes were not significantly affected . Evaluation of a more intensive intervention in a trial with a larger sample size is required to establish the value of an educational intervention that uses tailoring and reinforcement strategies . Background Survivors of transient ischemic attack ( TIA ) or stroke are at high risk for recurrent vascular events and aggressive treatment of vascular risk factors can reduce this risk . However , vascular risk factors , especially hypertension and high cholesterol , are not managed optimally even in those patients seen in specialized clinics . This gap between the evidence for secondary prevention of stroke and the clinical reality leads to suboptimal patient outcomes . In this study , we will be testing a pharmacist case manager for delivery of stroke prevention services . We hypothesize this new structure will improve processes of care which in turn should lead to improved outcomes . Methods We will conduct a prospect i ve , r and omized , controlled open-label with blinded ascertainment of outcomes ( PROBE ) trial . Treatment allocation will be concealed from the study personnel , and all outcomes will be collected in an independent and blinded manner by observers who have not been involved in the patient 's clinical care or trial participation and who are masked to baseline measurements . Patients will be  r and omized to control or a pharmacist case manager treating vascular risk factors to guideline -recommended target levels . Eligible patients will include all adult patients seen at stroke prevention clinics in Edmonton , Alberta after an ischemic stroke or TIA who have uncontrolled hypertension ( defined as systolic blood pressure ( BP ) > 140 mm Hg ) or dyslipidemia ( fasting LDL-cholesterol > 2.00 mmol/L ) and who are not cognitively impaired or institutionalized . The primary outcome will be the proportion of subjects who attain ' optimal BP and lipid control'(defined as systolic BP < 140 mm Hg and fasting LDL cholesterol < 2.0 mmol/L ) at six months compared to baseline ; 12-month data will also be collected for analyses of sustainability of any effects . A variety of secondary outcomes related to vascular risk and health-related quality of life will also be collected . Conclusions Nearly one-quarter of those who survive a TIA or minor stroke suffer another vascular event within a year . If our intervention improves the provision of secondary prevention therapies in these patients , the clinical ( and financial ) implication s will be enormous Background There is growing interest in conducting clinical and cluster r and omized trials through electronic health records . This paper reports on the method ological issues identified during the implementation of two cluster r and omized trials using the electronic health records of the Clinical Practice Research Data link ( CPRD ) . Methods Two trials were completed in primary care : one aim ed to reduce inappropriate antibiotic prescribing for acute respiratory infection ; the other aim ed to increase physician adherence with secondary prevention interventions after first stroke . The paper draws on documentary records and trial data sets to report on the method ological experience with respect to research ethics and research governance approval , general practice recruitment and allocation , sample size calculation and power , intervention implementation , and trial analysis . Results We obtained research governance approvals from more than 150 primary care organizations in Engl and , Wales , and Scotl and . There were 104 CPRD general practice s recruited to the antibiotic trial and 106 to the stroke trial , with the target number of practice s being recruited within six months . Interventions were installed into practice information systems remotely over the internet . The mean number of participants per practice was 5,588 in the antibiotic trial and 110 in the stroke trial , with the coefficient of variation of practice sizes being 0.53 and 0.56 respectively . Outcome measures showed substantial correlations between the 12 months before , and after intervention , with coefficients ranging from 0.42 for diastolic blood pressure to 0.91 for proportion of consultations with antibiotics prescribed , defining practice and participant eligibility for analysis requires careful consideration . Conclusions Cluster r and omized trials may be performed efficiently in large sample s from UK general practice s using the electronic health records of a primary care data base . The geographical dispersal of trial sites presents a difficulty for research governance approval and intervention implementation . Pretrial data analyses should inform trial design and analysis plans . Trial registration Current Controlled Trials IS RCT N47558792 and IS RCT N35701810 ( both registered on 17 March 2010 ) Background Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites . This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these population s. Home blood pressure telemonitoring ( HBPTM ) and nurse case management ( NCM ) have proven efficacy in addressing the multilevel barriers to blood pressure ( BP ) control and reducing BP . However , the effectiveness of these interventions has not been evaluated in stroke patients . This study is design ed to evaluate the comparative effectiveness , cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension . Methods / Design A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are r and omly assigned to one of two 12-month interventions : 1 ) HBPTM with wireless feedback to primary care providers or 2 ) HBPTM plus individualized , culturally-tailored , telephone-based NCM .  Patients are recruited from stroke centers and primary care practice s within the Health and Hospital Corporations ( HHC ) Network in New York City . Study visits occur at baseline , 6 , 12 and 24 months . The primary outcomes are within-patient change in systolic BP at 12 months , and the rate of stroke recurrence at 24 months . The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months ; and exploratory outcomes include changes in stroke risk factors , health behaviors and treatment intensification . Recruitment for the stroke telemonitoring hypertension trial is currently ongoing . Discussion The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation . Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension . If effective among Black and Hispanic stroke survivors , these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence . Trial registration Clinical Trials.gov NCT02011685 . Registered 10 December 2013 Background This study aim ed to inform the design of a pragmatic trial of stroke prevention in primary care by evaluating data recorded in electronic patient records ( EPRs ) as potential outcome measures . The study also evaluated achievement of recommended st and ards of care ; variation between family practice s ; and changes in risk factor values from before to after stroke . Methods Data from the UK General Practice Research Data base ( GPRD ) were analysed for 22,730 participants with an index first stroke between 2003 and 2006 from 414 family practice s. For each subject , the EPR was evaluated for the 12 months before and after stroke . Measures relevant to stroke secondary prevention were analysed including blood pressure ( BP ) , cholesterol , smoking , alcohol use , body mass index ( BMI ) , atrial fibrillation , utilisation of antihypertensive , antiplatelet and cholesterol lowering drugs . Intraclass correlation coefficients ( ICC ) were estimated by family practice . R and om effects models were fitted to evaluate changes in risk factor values over time . Results In the 12 months following stroke , BP was recorded for 90 % , cholesterol for 70 % and body mass index ( BMI ) for 47 % . ICCs by family practice ranged from 0.02 for BP and BMI to 0.05 for LDL and HDL cholesterol . For subjects with records available both before and after stroke , the mean reductions from before to after stroke were : mean systolic BP , 6.02 mm Hg ; diastolic BP , 2.78 mm Hg ; total cholesterol , 0.60 mmol/l ; BMI , 0.34 Kg/m2 . There was an absolute reduction in smokers of 5 % and heavy drinkers of 4 % . The proportion of stroke patients within the recommended guidelines varied from less than a third ( 29 % ) for systolic BP , just over half for BMI ( 54 % ) , and over 90 % ( 92 % ) on alcohol consumption . Conclusions Electronic patient records have potential for evaluation of outcomes in pragmatic trials of stroke secondary prevention . Stroke prevention interventions in primary care remain suboptimal but important reductions in vascular risk factor values were observed following stroke . Better recording of lifestyle factors in the GPRD has the potential to exp and the scope of the GPRD for health care research and practice Rationale Recurrent stroke is prevalent in both developed and developing countries , contributing significantly to disability and death . Recurrent stroke rates can be reduced by adequate risk factor management . However , adherence to prescribed medications and lifestyle changes recommended by physicians at discharge after stroke is poor , leading to a large number of preventable recurrent strokes . Using behavior change methods such as Motivational Interviewing early after stroke occurrence has the potential to prevent recurrent stroke . Aims and /or hypothesis The overall aim of the study is to determine the effectiveness of motivational interviewing in improving adherence to medication and lifestyle changes recommended by treating physicians at and after hospital discharge in stroke patients 12 months poststroke to reduce risk factors for recurrent stroke . Design Recruitment of 430 first-ever stroke participants will occur in the Auckl and and Waikato regions . R and omization will be to intervention or usual care groups . Participants r and omized to intervention will receive four motivational interviews and five follow-up assessment s over 12 months . Nonintervention participants will be assessed at the same time points . Study outcomes Primary outcome measures are changes in systolic blood pressure and low-density lipoprotein levels 12 months poststroke . Secondary outcomes include self-reported adherence and barriers to prescribed medications , new cardiovascular events ( including stroke ) , changes in quality of life , and mood . Discussion The results of the motivational interviewing in stroke trial will add to our underst and ing of whether motivational interviewing may be potentially beneficial in the management of stroke and other diseases where similar lifestyle factors or medication adherence are relevant 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 CONTEXT Level of acuity and number of referrals for home health care have been escalating exponentially . As referrals continue to increase , health care organizations are encouraged to find more effective methods for providing high- quality patient care with cost savings . OBJECTIVE To evaluate the use of remote video technology in the home health care setting as well as the quality , use , patient satisfaction , and cost savings from this technology . DESIGN Quasi-experimental study conducted from May 1996 to October 1997 . SETTING Home health department in the Sacramento , Calif , facility of a large health maintenance organization . PARTICIPANTS Newly referred patients diagnosed as having congestive heart failure , chronic obstructive pulmonary disease , cerebral vascular accident , cancer , diabetes , anxiety , or need for wound care were eligible for r and om assignment to intervention ( n = 102 ) or control ( n = 110 ) groups . INTERVENTION The control and intervention groups received routine home health care ( home visits and telephone contact ) . The intervention group also had access to a remote video system that allowed nurses and patients to interact in real time . The video system included peripheral equipment for assessing cardiopulmonary status . MAIN OUTCOME MEASURES Three quality indicators ( medication compliance , knowledge of disease , and ability for self-care ) ; extent of use of services ; degree of patient satisfaction as reported on a 3-part scale ; and direct and indirect costs of using the remote video technology .  RESULTS No differences in the quality indicators , patient satisfaction , or use were seen . Although the average direct cost for home health services was $ 1830 in the intervention group and $ 1167 in the control group , the total mean costs of care , excluding home health care costs , were $ 1948 in the intervention group and $ 2674 in the control group . CONCLUSIONS Remote video technology in the home health care setting was shown to be effective , well received by patients , capable of maintaining quality of care , and to have the potential for cost savings . Patients seemed pleased with the equipment and the ability to access a home health care provider 24 hours a day . Remote technology has the potential to effect cost savings when used to substitute some in-person visits and can also improve access to home health care staff for patients and caregivers . This technology can thus be an asset for patients and providers BACKGROUND Comprehensive and long-term patient education programs design ed to improve self-management can help patients better manage their medical condition . Using disease management programs ( DMPs ) that were created for each of the risk factor according to clinical practice guidelines , we evaluate their influence on the prevention of stroke recurrence . METHODS This is a r and omized study conducted with ischemic stroke patients within 1 year from their onset . Subjects in the intervention group received a 6-month DMPs that included self-management education provided by a nurse along with support in collaboration with the primary care physician . Those in the usual care group received ordinary outpatient care . The primary end point is a difference of the Framingham risk score-general cardiovascular disease 10-year risk [ corrected ] . Patients were enrolled for 2 years with plans for a 2-year follow-up after the 6-month education period ( total of 30 months ) . RESULTS A total of 321 eligible subjects ( average age , 67.3 years ; females , 96 [ 29.9 % ] ) , including 21 subjects ( 6.5 % ) with transient ischemic attack , were enrolled in this study . Regarding risk factors for stroke , 260 subjects ( 81.0 % ) had hypertension , 249 subjects ( 77.6 % ) had dyslipidemia , 102 subjects ( 31.8 % ) had diabetes mellitus , 47 subjects ( 14.6 % ) had atrial fibrillation , and 98 subjects ( 30.5 % ) had chronic kidney disease .  There were no significant differences between the 2 groups with respect to subject characteristics . CONCLUSIONS This article describes the rationale , design , and baseline features of a r and omized controlled trial that aim ed to assess the effects of DMPs for the secondary prevention of stroke . Subject follow-up is in progress and will end in 2015 Background The purpose of this research is to develop and evaluate methods for conducting pragmatic cluster r and omized trials in a primary care electronic data base . The proposal describes one application , in a less frequent chronic condition of public health importance , secondary prevention of stroke . A related protocol in antibiotic prescribing was reported previously . Methods / Design The study aims to implement a  cluster r and omized trial ( CRT )  using the electronic patient records of the General Practice Research Data base ( GPRD ) as a sampling frame and data source . The specific objective of the trial is to evaluate the effectiveness of a computer-delivered intervention at enhancing the delivery of stroke secondary prevention in primary care . GPRD family practice s will be allocated to the intervention or usual care . The intervention promotes the use of electronic prompts to support adherence with the recommendations of the UK Intercollegiate Stroke Working Party and NICE guidelines for the secondary prevention of stroke in primary care . Primary outcome measure will be the difference in systolic blood pressure between intervention and control trial arms at 12-month follow-up . Secondary outcomes will be differences in serum cholesterol , prescribing of antihypertensive drugs , statins , and antiplatelet therapy . The intervention will continue for 12 months . Information on the utilization of the decision-support tools will also be analyzed . Discussion The CRT will investigate the effectiveness of using a computer-delivered intervention to reduce the risk of stroke recurrence following a first stroke event . The study will provide method ological guidance on the implementation of CRTs in electronic data bases in primary care . Trial registration Current Controlled Trials IS RCT Background There is a need to find innovative approaches for translating best practice s for chronic disease care into daily primary care practice routines . Primary care plays a crucial role in the prevention and management of cardiovascular disease . There is , however , a substantive care gap , and many challenges exist in implementing evidence -based care . The Improved Delivery of Cardiovascular Care ( IDOCC ) project is a pragmatic trial design ed to improve the delivery of evidence -based care for the prevention and management of cardiovascular disease in primary care practice s using practice outreach facilitation . Methods The IDOCC project is a stepped-wedge cluster r and omized control trial in which Practice Outreach Facilitators work with primary care practice s to improve cardiovascular disease prevention and management for patients at highest risk . Primary care practice s in a large health region in Eastern Ontario , Canada , were eligible to participate . The intervention consists of regular monthly meetings with the Practice Outreach Facilitator over a one- to two-year period . Starting with audit and feedback , consensus building , and goal setting , the practice s are supported in changing practice behavior by incorporating chronic care model elements . These elements include ( a ) evidence -based decision support for providers , ( b ) delivery system re design for practice s , ( c ) enhanced self-management support tools provided to practice s to help them engage patients , and ( d ) increased community re source linkages for practice s to enhance referral of patients . The primary outcome is a composite score measured at the level of the patient to represent each practice 's adherence to evidence -based guidelines for cardiovascular care . Qualitative analysis of the Practice Outreach Facilitators ' written narratives of their ongoing practice interactions will be done . These textual analyses will add further insight into underst and ing critical factors impacting project implementation . Discussion This pragmatic , stepped-wedge r and omized controlled trial with both quantitative and process evaluations demonstrates innovative methods of implementing large-scale quality improvement and evidence -based approaches to care delivery . This is the first Canadian study to examine the impact of a large-scale multifaceted cardiovascular quality -improvement program in primary care . It is anticipated that through the evaluation of IDOCC , we will demonstrate an effective , practical , and sustainable means of improving the cardiovascular health of patients across Canada . Trial Registration Clinical Trials.gov : Background and Purpose — Efforts to reduce disparities in recurrent stroke among Black and Latino stroke survivors have met with limited success . We aim ed to determine the effect of peer education on secondary stroke prevention among predominantly minority stroke survivors . Methods — Between 2009 and 2012 , we enrolled 600 stroke or transient ischemic attack survivors from diverse , low-income communities in New York City into a 2-arm r and omized clinical trial that compared a 6 week ( 1 session/week ) , peer-led , community-based , stroke prevention self-management group workshop ( N=301 ) to a wait-list control group ( N=299 ) . The primary outcome was the proportion with a composite of controlled blood pressure ( < 140/90 mm Hg ) , low-density lipoprotein cholesterol < 100 mg/dL , and use of antithrombotic medications at 6 months . Secondary outcomes included control of the individual stroke risk factors . All analyses were by intent-to-treat . Results — There was no difference in the proportion of intervention and control group participants achieving the composite outcome ( 34 % versus 34 % ; P=0.98 ) . The proportion with controlled blood pressure at 6 months was greater in the intervention group than in the control group ( 76 % versus 67 % ; P=0.02 ) . This corresponded to a greater change in systolic blood pressure in the intervention versus control group ( −3.63 SD , 19.81 mm Hg versus + 0.34 SD , 23.76 mm Hg ; P=0.04 ) . There were no group differences in the control of cholesterol or use of antithrombotics . Conclusions — A low-cost peer education self-management workshop modestly improved blood pressure , but not low-density lipoprotein cholesterol or antithrombotic use , among stroke and transient ischemic attack survivors from vulnerable , predominantly minority urban communities . Clinical Trial Registration — URL : http://www . clinical trials.gov/show/NCT0102727 . Unique identifier : NCT01027273 Background Patients with manifest vascular disease are at high risk of a new vascular event or death . Modification of classical risk factors is often not successful . We determined whether the extra care of a nurse practitioner could be beneficial to the cardiovascular risk profile of high-risk patients . Design We conducted a r and omized , controlled trial based on the Zelen design . Methods Two hundred and thirty-six patients with manifestations of a vascular disease and who had two or more modifiable vascular risk factors were pre-r and omized to receive treatment by a nurse practitioner plus usual care or usual care alone . After 1 year , risk factors were remeasured . The primary endpoint was achievement of treatment goals for blood pressure , lipid , glucose and homocysteine levels , body mass index , and smoking . Results Of the pre-r and omized patients , 95 of 119 ( 80 % ) in the intervention group and 80 of 117 ( 68 % ) in the control group participated in the study . After a mean follow-up of 14 months , the patients in the intervention group achieved significantly more treatment goals than did the patients in the control group ( systolic blood pressure 63 versus 37 % , total cholesterol 79 versus 61 % , low density lipoprotein-cholesterol 88 versus 67 % , and body mass index 38 versus 24 % ) . Medication use was increased in both groups and no differences were found in patients ' quality of life ( SF-36 ) at follow-up . Conclusion Treatment delivered by nurse practitioners , in addition to a vascular risk factor screening and prevention program , result ed in a better management of vascular risk factors than usual care alone in vascular patients after 1-year follow-up Background — Stroke is the leading cause of adult disability . Inpatient programs optimize secondary stroke prevention care at the time of hospital discharge , but such care may not be continued after hospital discharge . Methods — To improve the delivery of secondary stroke preventive services after hospital discharge , we have design ed a chronic care model – based program called SUSTAIN ( Systemic Use of STroke Averting INterventions ) . This care intervention includes group clinics , self-management support , report cards , decision support through care guides and protocol s , and coordination of ongoing care . The first specific aim is to test , in a r and omized , controlled trial , whether SUSTAIN improves blood pressure control among an analytic sample of 268 patients with a recent stroke or transient ischemic attack discharged from 4 Los Angeles County public hospitals . Secondary outcomes consist of control of other stroke risk factors , lifestyle habits , medication adherence , patient perceptions of care quality , functional status , and quality of life . A second specific aim is to conduct a cost analysis of SUSTAIN from the perspective of the Los Angeles County Department of Health Services by using direct costs of the intervention , cost equivalents of associated utilization of county system re sources , and cost equivalents of the observed and predicted averted vascular events . Conclusions — If SUSTAIN is effective , we will have the expertise and findings to advocate for its continued support at Los Angeles County hospitals and to disseminate the SUSTAIN program to other setting s serving indigent , minority population s. Clinical Trial Registration — URL : http://www . clinical trials.gov . Unique identifier : NCT00861081 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 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 Current guidelines recommend global risk assessment to guide vascular risk factor management ; however , most provider-patient communication focuses on individual risk factors in isolation . We sought to evaluate the impact of personalized coronary heart disease and stroke risk communication on patients ' knowledge , beliefs , and health behavior . METHODS We conducted a r and omized controlled trial testing personalized risk communication based on Framingham stroke and coronary heart disease risk scores compared with a st and ard risk factor education . A total of 89 patients were recruited from primary care clinics and followed up for 3 months . Outcomes included the following : risk perception and worry , risk factor knowledge , risk reduction preferences and decision conflict , medication adherence , health behaviors , and blood pressure . RESULTS Participants had a very low underst and ing of numeric information , high perceived risk for stroke or myocardial infa rct ion , and high proportion of medication nonadherence . Patients ' ability to identify vascular risk factors increased with personalized risk communication ( mean 1.8 additional risk factors , 95 % CI 1.3 - 2.2 ) and st and ard risk factor education ( mean 1.6 additional risk factors , 95 % CI 1.1 - 2.1 ) immediately after the intervention but was not sustained at 3 months . Patients in the personalized group had less decision conflict than the st and ard risk factor education group over intended risk reduction strategies ( 5.9 vs 10.1 , P = .003 ) . There was no appreciable impact of either communication strategy on medication adherence , exercise , smoking cessation , or blood pressure . CONCLUSIONS Personalized risk communication was preferred by patients and had a small impact on risk reduction preferences and decision conflict but had no impact on patient beliefs or behavior compared with st and ard risk factor education AIMS The effectiveness of multifactorial cardiovascular disease prevention in patients aged 75 years or older is uncertain , because these patients have often been excluded from trials . The aim of this pre-planned , first-year analysis of the Drugs and Evidence -Based Medicine in the Elderly ( DEBATE ) Study was to determine the feasibility of prevention efforts in elderly cardiovascular patients . METHODS AND RESULTS For DEBATE , home-dwelling individuals aged 75 years and over with cardiovascular diseases ( n=400 , mean age 80 years , 65 % women ) were recruited from the community . These high-risk participants were r and omly assigned to the intervention group  ( n=199 ) where both lifestyle modification and pharmacological cardiovascular treatments are individualized by a geriatrician according to current European guidelines . The control group ( n=201 ) receives the usual care . Interim analysis of the study groups at one year shows that intervention has succeeded in increasing the use of statins , aspirin , beta-blockers , and ACE inhibitors  , and decreasing serum cholesterol ( p<0.0001 ) , LDL-cholesterol ( p<0.0001 ) , and hsCRP ( p=0.04 ) . Body mass index , blood pressure , and blood glucose were similar at one year in both groups . No safety problems or adverse effects on health-related quality of life were observed and compliance was good . CONCLUSIONS It is possible and safe to institute evidence -based cardiovascular treatments in the 75 + cardiovascular patients in a real life setting , but only serum cholesterol and hsCRP are significantly decreased Background Strokes are a common cause of adult disability and mortality worldwide . Transient ischaemic attacks ( TIA ) are associated with a high risk of subsequent stroke , and rapid intervention has the potential to reduce stroke burden . This study will assess a novel electronic decision support ( EDS ) tool to allow general practitioners ( GPs ) to implement evidence -based care rapidly without full reliance on specialists . Methods / design This is a cluster r and omized controlled trial comparing  TIA/stroke management of GPs with access to the EDS tool versus usual care .  The intervention period is 12 months with a 3-month follow-up period for individual patients . Primary outcomes consist of stroke within 90 days of presenting event and adherence to the New Zeal and national TIA guideline . Discussion A positive study will provide strong evidence for widespread implementation of this tool in practice and has the potential to improve key outcomes for patients and reduce the burden of stroke . Trial registration Australia New Zeal and Clinical Trials Registry Abstract Background The effectiveness of medication is influenced by treatment adherence . After TIA or minor disabling stroke patients usually are advised to take antithrombotic medication .  Stroke patients are an interesting group of patients with respect to adherence , since cardiovascular risk factors and stroke may ( indirectly ) negatively influence brain function , which can affect adherence . We investigated determinants of non – adherence in patients who used aspirin or oral anticoagulation after cerebral ischaemia of arterial origin . Methods Data of patients prospect ively followed in two clinical trials ( the Dutch TIA Trial and the Stroke Prevention In Reversible Ischaemia Trial ) were analysed with Cox proportional hazards modelling . Results In the two trials 3796 patients were treated with aspirin .  During a mean follow – up of 2.1 years , 689 patients ( 18 % ) prematurely stopped treatment , 305 ( 8 % ) did so without a clear medical reason ( non – adherence ) . Age ≥ 65 years and the use of 300 instead of 30 mg of aspirin were independently associated with non – adherence . Diastolic blood pressure of ≥ 90 mmHg and dizziness were associated with better adherence . Of 651 patients on oral anticoagulation  , 143 patients ( 22 % ) stopped after a mean follow – up of 1.0 year , 66 ( 10 % ) did so because of nonadherence . No statistically significant determinants for non – adherence were identified . Conclusion As found in the literature on nonadherence in general , age of ≥ 65 years and a higher dose of aspirin ( 300 mg versus 30 mg ) were independently associated with non – adherence with aspirin treatment that was prescribed for secondary prevention after cerebral ischaemia of arterial origin . Older patients may require extra encouragement to continue antithrombotic treatment . Lower doses of aspirin may improve treatment adherence 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 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 — The aim of this study was to evaluate whether the remote introduction of electronic decision support tools into family practice s improves risk factor control after first stroke . This study also aim ed to develop methods to implement cluster r and omized trials in stroke using electronic health records . Methods — Family practice s were recruited from the UK Clinical Practice Research Data link and allocated to intervention and control trial arms by minimization .  Remotely installed , electronic decision support tools promoted intensified secondary prevention for 12 months with last measure of systolic blood pressure as the primary outcome . Outcome data from electronic health records were analyzed using marginal models . Results — There were 106 Clinical Practice Research Data link family practice s allocated ( intervention , 53 ; control , 53 ) , with 11 391 ( control , 5516 ; intervention , 5875 ) participants with acute stroke ever diagnosed . Participants at trial practice s had similar characteristics as 47 887 patients with stroke at nontrial practice s. During the intervention period , blood pressure values were recorded in the electronic health records for 90 % and cholesterol values for 84 % of participants . After intervention , the latest mean systolic blood pressure was 131.7 ( SD , 16.8 ) mm Hg in the control trial arm and 131.4 ( 16.7 ) mm Hg in the intervention trial arm , and adjusted mean difference was −0.56 mm Hg ( 95 % confidence interval , −1.38 to 0.26 ; P=0.183 ) . The financial cost of the trial was approximately US $ 22 per participant , or US $ 2400 per family practice allocated . Conclusions — Large pragmatic intervention studies may be implemented at low cost by using electronic health records . The intervention used in this trial was not found to be effective , and further research is needed to develop more effective intervention strategies . Clinical Trial Registration — URL : http://www.controlled-trials.com . Current Controlled Trials identifier : IS RCT N35701810 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 Background and Purpose — Many stroke patients and informal carers experience a decreased quality of life after discharge home and are dissatisfied with the care received . We assessed the effectiveness of an outreach nursing care program . Methods — In a multicenter trial , 536 stroke patients were r and omized at discharge to st and ard care ( n=273 ) or st and ard care plus outreach care ( n=263 ) . The outreach care consisted of 3 telephone calls and 1 home visit within 5 months after discharge by 1 of 13 stroke nurses . Patients were masked for the trial objectives . Six months after discharge , they assessed the 2 primary outcomes : quality of life ( Short Form 36 [ SF-36 ] ) and dissatisfaction with care . Secondary measures of outcome were disability , h and icap , depression , anxiety , and use of health care services and secondary prevention drugs . Informal carers assessed strain , and social support . Analysis was by intention to treat . Results — Twelve patients died  before follow-up , 38 declined outcome assessment , and 486 completed the primary outcome assessment s. Outreach care patients had better scores on the SF-36 domain “ Role Emotional ” than controls ( mean difference 7.9 [ 95 % confidence limit , 0.1 to 15.7 ] ) . No statistically significant differences were found on the other primary outcome measures . For secondary outcomes , no statistically significant differences were found , except that intervention patients used fewer rehabilitation services ( relative risk , 0.66 [ 0.44 to 1.00 ] ) and had lower anxiety scores ( median difference 1 [ 0.19 to 2.79 ] ) . Conclusions — This outreach nursing stroke care was not effective in improving quality of life and dissatisfaction with care of recently discharged patients Background Racial and ethnic disparities persist in stroke occurrence , recurrence , morbidity and mortality . Uncontrolled hypertension ( HTN ) is the most important modifiable risk factor for stroke risk . Home health care organizations care for many patients with uncontrolled HTN and history of stroke ; however , recurrent stroke prevention has not been a home care priority . We are conducting a r and omized controlled trial ( RCT ) to compare the effectiveness , relative to usual home care ( UHC ) , of two Community Transitions Interventions ( CTIs ) . The CTIs aim to reduce recurrent stroke risk among post-stroke patients via home-based transitional care focused on better HTN management . Methods / Design This 3-arm trial will r and omly assign 495 black and Hispanic post-stroke home care patients with uncontrolled systolic blood pressure ( SBP ) to one of three arms : UHC , UHC complemented by nurse practitioner-delivered transitional care ( UHC + NP ) or UHC complemented by an NP plus health coach ( UHC + NP + HC ) . Both intervention arms emphasize : 1 ) linking patients to continuous , responsive preventive and primary care , 2 ) increasing patients ’ /caregivers ’ ability to manage a culturally and individually tailored BP reduction plan , and 3 ) facilitating the patient ’s reintegration into the community after home health care discharge . The primary hypothesis is that both NP-only and NP + HC transitional care will be more effective than UHC alone in achieving a SBP reduction . The primary outcome is change in SPB at 3 and 12 months . The study also will examine cost-effectiveness , quality of life and moderators ( for example , race/ethnicity ) and mediators ( for example , changes in health behaviors ) that may affect treatment outcomes . All outcome data are collected by staff blinded to group assignment . Discussion This study targets care gaps affecting a particularly vulnerable black/Hispanic population characterized by persistent stroke disparities . It focuses on care transitions , a juncture when patients are particularly susceptible to adverse events . The CTI is innovative in adapting for stroke patients an established transitional care model shown to be effective for HF patients , pairing the professional NP with a HC , implementing a culturally tailored intervention , and placing primary emphasis on longer-term risk factor reduction and community reintegration rather than shorter-term transitional care outcomes .Trial registration Clinical Trials.gov NCT01918891 ; Registered 5 August 2013 Background Blood pressure ( BP ) lowering in people who have had a stroke or transient ischaemic attack ( TIA ) leads to reduced risk of further stroke . However , it is not clear what the target BP should be , since intensification of therapy may lead to additional adverse effects . PAST BP will determine whether more intensive BP targets can be achieved in a primary care setting , and whether more intensive therapy is associated with adverse effects on quality of life . Methods / Design This is a r and omised controlled trial ( RCT ) in patients with a past history of stroke or TIA . Patients will be r and omised to two groups and will either have their blood pressure ( BP ) lowered intensively to a target of 130 mmHg systolic , ( or by 10 mmHg if the baseline systolic pressure is between 125 and 140 mmHg ) compared to a st and ard group where the BP will be reduced to a target of 140 mmHg systolic . Patients will be managed by their practice at 1 - 3 month intervals depending on level of BP and followed-up by the research team at six monthly intervals for 12 months.610 patients will be recruited from approximately 50 general practice s. The following exclusion criteria will be applied : systolic BP < 125 mmHg at baseline , 3 or more anti-hypertensive agents , orthostatic hypotension , diabetes mellitus with microalbuminuria or other condition requiring a lower treatment target or terminal illness . The primary outcome will be change in systolic BP over twelve months . Secondary outcomes include quality of life , adverse events and cardiovascular events . In-depth interviews with 30 patients and 20 health care practitioners will be undertaken to investigate patient and healthcare professionals underst and ing and views of BP management . Discussion The results of this trial will inform whether intensive blood pressure targets can be achieved in people who have had a stroke or TIA in primary care , and help determine whether or not further research is required before recommending such targets for this population .Trial Registration IS RCT BACKGROUND hypertension is a common risk factor for stroke/transient ischaemic attack ( TIA ) and there is good evidence that blood pressure ( BP ) control prevents recurrent stroke . We investigated whether telephone follow-up ( TFU ) improved risk factor management in hypertensive patients after stroke/TIA . METHODS we conducted a r and omised controlled trial and assigned hypertensive patients within 1 month of stroke or TIA to receive usual care ( n = 27 ) or usual care plus regular TFU ( n = 29 ) . Primary outcome was the difference in 12 h ambulatory systolic BP change from baseline to 6 months ( DeltaSBP ) in both groups . TFU at 7 days , 1 , 2 and 4 months included patient-focussed education and goal setting . RESULTS mean baseline BP was 145/83 mm Hg ( st and ard deviation ( SD ) 21/14 ) . There was no significant difference in DeltaSBP over 6 months with TFU . Median DeltaSBP was 0 mm Hg ( interquartile range 19.5 ) in the TFU group and 3.0 mm Hg ( 20 ) fall in the usual care group ( P = 0.29 ) . Post hoc analysis showed that statin use increased from baseline to 6 months ( P = 0.02 ) and cholesterol was significantly lower at 6 months in all patients ( mean reduction 0.95 mmol/l ; P < 0.001 ) . CONCLUSION our study found TFU that promoted patient-led management of risk factors did not improve BP control over 6-month follow-up in primary care after stroke/TIA Background : Optimization of systolic blood pressure and lipid levels are essential for secondary prevention after ischemic stroke , but there are substantial gaps in care , which could be addressed by nurse- or pharmacist-led care . We compared 2 types of case management ( active prescribing by pharmacists or nurse-led screening and feedback to primary care physicians ) in addition to usual care . Methods : We performed a prospect i ve r and omized controlled trial involving adults with recent minor ischemic stroke or transient ischemic attack whose systolic blood pressure or lipid levels were above guideline targets . Participants in both groups had a monthly visit for 6 months with either a nurse or pharmacist . Nurses measured cardiovascular risk factors , counselled patients and faxed results to primary care physicians ( active control ) . Pharmacists did all of the above as well as prescribed according to treatment algorithms ( intervention ) . Results : Most of the 279 study participants ( mean age 67.6 yr , mean systolic blood pressure 134 mm Hg , mean low-density lipoprotein [ LDL ] cholesterol 3.23 mmol/L ) were already receiving treatment at baseline ( antihypertensives : 78.1 % ; statins : 84.6 % ) , but none met guideline targets ( systolic blood pressure ≤ 140 mm Hg , fasting LDL cholesterol ≤ 2.0 mmol/L ) . Substantial improvements were observed in both groups after 6 months : 43.4 % of participants in the pharmacist case manager group met both systolic blood pressure and LDL guideline targets compared with 30.9 % in the nurse-led group ( 12.5 % absolute difference ; number needed to treat = 8 , p = 0.03 ) . Interpretation : Compared with nurse-led case management ( risk factor evaluation , counselling and feedback to primary care providers ) , active case management by pharmacists substantially improved risk factor control at 6 months among patients who had experienced a stroke . Trial registration : Clinical Trials.gov , no. Background Good blood pressure ( BP ) control reduces the risk of recurrence of stroke/transient ischaemic attack ( TIA ) . Although there is strong evidence that BP telemonitoring helps achieve good control , none of the major trials have considered the effectiveness in stroke/TIA survivors . We therefore conducted a feasibility study for a trial of BP telemonitoring for stroke/TIA survivors with uncontrolled BP in primary care . Method Phase 1 was a pilot trial involving 55 patients stratified by stroke/TIA r and omised 3:1 to BP telemonitoring for 6 months or usual care . Phase 2 was a qualitative evaluation and comprised semi-structured interviews with 16 trial participants who received telemonitoring and 3 focus groups with 23 members of stroke support groups and 7 carers . Results Overall , 125 patients ( 60 stroke patients , 65 TIA patients ) were approached and 55 ( 44 % ) patients were r and omised including 27 stroke patients and 28 TIA patients . Fifty-two participants ( 95 % ) attended the 6-month follow-up appointment , but one declined the second daytime ambulatory blood pressure monitoring ( ABPM ) measurement result ing in a 93 % completion rate for ABPM − the proposed primary outcome measure for a full trial . Adherence to  telemonitoring  was good ; of the 40 participants who were  telemonitoring  , 38 continued to provide readings throughout the 6 months . There was a mean reduction of 10.1 mmHg in systolic ABPM in the telemonitoring group compared with 3.8 mmHg in the control group , which suggested the potential for a substantial effect from telemonitoring . Our qualitative analysis found that many stroke patients were concerned about their BP and telemonitoring increased their engagement , was easy , convenient and reassuring . Conclusions A full-scale trial is feasible , likely to recruit well and have good rates of compliance and follow-up . Trial Registration IS RCT N61528726 15/12/2011 This study examined the baseline characteristics , racial/ethnic differences , and geographic differences among participants in the Secondary Prevention of Small Subcortical Strokes ( SPS3 ) study . The SPS3 trial enrolled patients who experienced a symptomatic small subcortical stroke ( lacunar stroke ) within the previous 6 months and an eligible lesion on detected on magnetic resonance imaging . The patients were r and omized , in a factorial design , to antiplatelet therapy ( aspirin 325 mg daily plus clopidogrel 75 mg daily vs aspirin 325 mg daily plus placebo ) and to one of two levels of systolic blood pressure targets ( " intensive " [ < 130 mmHg ] or " usual " [ 130 - 149 mmHg ] ) . A total of 3020 participants were recruited from 81 clinical sites in 8 countries . In this cohort , the mean age was 63 years , 63 % were men , 75 % had a history of hypertension , and 37 % had diabetes . The racial distribution was 51 % white , 30 % Hispanic , and 16 % black . Compared with white subjects , black subjects were younger ( mean age , 58 years vs 64 years ; P < .001 ) and had a higher prevalence of hypertension ( 87 % vs 70 % ; P < .001 ) . The prevalence of diabetes was higher in the Hispanic and black subjects compared with the white subjects ( 42 % and 40 % vs 32 % ; both P < .001 ) . Tobacco smoking at the time of qualifying stroke was much more frequent in the Spanish participants than in subjects from North America and from Latin America ( 32 % , 22 % , and 9 % , respectively ; P < .001 ) . Mean systolic blood pressure at study entry was 4 mmHg lower in the Spanish subjects compared with the North American subjects ( P < .01 ) . The SPS3 cohort is the largest magnetic resonance imaging-defined series of patients with S3 . Among the racially/ethnically diverse SPS3 participants , important differences in patient features and vascular risk factors could influence prognosis for recurrent stroke and response to interventions 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 AND OBJECTIVE In spite of publication of many guidelines , management of patients on secondary prevention of cardiovascular disease is still not appropriated . We design a r and omized trial , in usual clinical practice conditions , to compare the results in cardiovascular morbimortality of intensive and integral management of cardiovascular risk factors ( CVRF ) management versus conventional care . PATIENTS AND METHOD We selected patients discharged between October 2002 and January 2004 who suffered an acute coronary syndrome with or without ST-segment elevation or a stroke , 247 patients that met inclusion s criteria were r and omized to intensive care of CVRF  in a specific Internal Medicine outpatient clinic ( n = 121 ) or usual care according to National Health Service recommendations ( n = 126 ) . A year after r and omization , the percentage of patients who met CVRF control , treatment received and the number of cardiovascular events ( cardiovascular death , acute coronary syndrome with or without ST-segment elevation , stroke , transient ischemic attack , revascularization , lower limb amputation , heart failure admission and sudden death ) were revised . RESULTS CVRF control was greater in patients assigned to intensive care . 74.1 % of hypertensive patients assigned to this treatment were controlled vs 41.7 % in the usual care group ( relative risk [ RR ] = 1.78 ; 95 % confidence interval [ CI ] , 1.27 - 2 - 49 ) ; 70.2 % of patients had low-densi-tiy lipoprotein cholesterol lower than 100 mg/dl vs 55.8 % ( RR = 1.26 ; 95 % CI , 1.00 - 1.58 ) of patients in usual care group ; 93.1 % of diabetic patients had glycosylated haemoglobin lower than 7 % vs. 57.1 % ( RR = 1.63 ; 95 % CI , 1.11 - 2.39 ) in the usual care group . There were 12 cardiovascular events in the intensive care group vs 35 in the usual care group . CONCLUSIONS Intensive management of CVRF leads to a better control of them and a reduction of the morbimortality one year after an acute cardiovascular event IMPORTANCE Self-monitoring of blood pressure with self-titration of antihypertensives ( self-management ) results in lower blood pressure in patients with hypertension , but there are no data about patients in high-risk groups . OBJECTIVE To determine the effect of self-monitoring with self-titration of antihypertensive medication compared with usual care on systolic blood pressure among patients with cardiovascular disease , diabetes , or chronic kidney disease . DESIGN , SETTING , AND PATIENTS A primary care , unblinded , r and omized clinical trial involving 552 patients who were aged at least 35 years with a history of stroke , coronary heart disease , diabetes , or chronic kidney disease and with baseline blood pressure of at least 130/80 mm Hg being treated at 59 UK primary care practice s was conducted between March 2011 and January 2013 . INTERVENTIONS Self-monitoring of blood pressure combined with an individualized self-titration algorithm . During the study period , the office visit blood pressure measurement target was 130/80 mm Hg and the home measurement target was 120/75 mm Hg . Control patients received usual care consisting of seeing their health care clinician for routine blood pressure measurement and adjustment of medication if necessary . MAIN OUTCOMES AND MEASURES The primary outcome was the difference in systolic blood pressure between intervention and control groups at the 12-month office visit . RESULTS Primary outcome data were available from 450 patients ( 81 % ) . The mean baseline blood pressure was 143.1/80.5 mm Hg in the intervention group and 143.6/79.5 mm Hg in the control group . After 12 months , the mean blood pressure had decreased to 128.2/73.8 mm Hg in the intervention group and to 137.8/76.3 mm Hg in the control group , a difference of 9.2 mm Hg ( 95 % CI , 5.7 - 12.7 ) in systolic and 3.4 mm Hg ( 95 % CI , 1.8 - 5.0 ) in diastolic blood pressure following correction for baseline blood pressure . Multiple imputation for missing values gave similar results : the mean baseline was 143.5/80.2 mm Hg in the intervention group vs 144.2/79.9 mm Hg in the control group , and at 12 months , the mean was 128.6/73.6 mm Hg in the intervention group vs 138.2/76.4 mm Hg in the control group , with a difference of 8.8 mm Hg ( 95 % CI , 4.9 - 12.7 ) for systolic and 3.1 mm Hg ( 95 % CI , 0.7 - 5.5 ) for diastolic blood pressure between groups . These results were comparable in all subgroups , without excessive adverse events . CONCLUSIONS AND RELEVANCE Among patients with hypertension at high risk of cardiovascular disease , self-monitoring with self-titration of antihypertensive medication compared with usual care result ed in lower systolic blood pressure at 12 months . TRIAL REGISTRATION is rct n.org Identifier : IS RCT N87171227 BACKGROUND Developing countries are experiencing increasing levels of cardiovascular disease ( CVD ) . Although there is a good underst and ing of how to deliver CVD prevention programs in developed countries , there are few data regarding strategies for CVD prevention in re source -poor setting s. This study aim ed to implement and evaluate a CVD prevention program in a rural area of India . METHODS The 2 strategies of CVD prevention to be investigated are an algorithm-based care approach and a health-promotion campaign . A factorial , cluster-r and omized trial design will be used to evaluate these , in which villages will be exposed to one , both , or neither of the interventions for a period of about 12 months . Surveys of households in every village will be used to assess outcomes in all high-risk individuals and a sample of the general adult population . RESULTS The primary outcome of the algorithm-based component of this study will be the percentage of high-risk individuals that have been " identified"-defined as having received a cardiovascular-risk assessment in the last 12 months . The primary outcome for the health-promotion component will be the percentage of the adult population with correct knowledge about the effects of 6 behavioral determinants of cardiovascular risk ( green-leafy vegetables , fruits , oily foods , salt , smoking , physical activity ) . Secondary outcomes include a range of measures defining uptake of different preventive strategies . CONCLUSIONS This study will provide evidence about the effectiveness of a simple practical mechanism of CVD preventive care specifically design ed for delivery in a re source -poor area in India BACKGROUND The study examined the effects of a 12-week health promotion intervention for a predominantly urban African-American population of stroke survivors . DESIGN A pre-test/post-test lag control group design was employed . PARTICIPANTS / SETTING Participants were 35 stroke survivors ( 9 male , 26 female ) recruited from local area hospitals and clinics . MAIN OUTCOME MEASURES Biomedical , fitness , nutritional , and psychosocial measures were employed to assess program outcomes . RESULTS Treatment group made significant gains over lag controls in the following areas : ( 1 ) reduced total cholesterol , ( 2 ) reduced weight , ( 3 ) increased cardiovascular fitness , ( 4 ) increased strength , ( 5 ) increased flexibility , ( 6 ) increased life satisfaction and ability to manage self-care needs , and ( 7 ) decreased social isolation . CONCLUSION A short-term health promotion intervention for predominantly African-American stroke survivors was effective in improving several physiological and psychological health outcomes The aim was to study if health outcome and secondary prevention were satisfactory 1 year after stroke and if nurse-led interventions 3 months after stroke could have impact . Design was a r and omized controlled open trial in a 1-year population . Primary outcome was health status 1 year after stroke . One month after stroke , survivors were r and omized into  intervention group ( IG ) with follow-up by a specialist nurse ( SN ) after 3 months ( n = 232 ) , and control group ( CG ) with st and ard care ( n = 227 ) , all to be followed up 1 year after stroke . At the first follow-up , patients grade d their health , replied to the EuroQol-5 Dimensions ( EQ-5D ) health outcome questions , health problems were assessed , and supportive counseling was provided in the IG . Health problems requiring medical interventions were primarily referred to a general practitioner ( GP ) . One year after stroke , 391 survivors were followed up . Systolic blood pressure ( BP ) had decreased in IG ( n = 194 ) from median 140 to 135 ( P = .05 ) , but about half were above the limit 139 in both groups . A larger proportion ( 22 % ) had systolic BP > 155 in the CG ( n = 197 ) than in the IG ( 14 % ; P = .05 ) . In the IG , 62 % needed referrals compared with the 75 % in the CG ( P = .009 ) . Forty percent in the IG and 52.5 % in the CG ( P = .04 ) reported anxiety/depression . In the IG , 75 % and 67 % in the CG rated their general health as fairly good or very good ( P = .05 ) . Although nurse-led interventions could have some effect , the results were not optimal . A more powerful strategy could be closer collaboration between the SN and a stroke clinician , before referring to primary care BACKGROUND Lowering blood pressure ( BP ) after stroke remains a challenge , even in the context of clinical trials . The Secondary Prevention of Small Subcortical Strokes ( SPS3 ) BP protocol , BP management during the study , and achieved BPs are described here . METHODS Patients with recent symptomatic lacunar stroke were r and omized to 1 of 2 levels of systolic BP ( SBP ) targets : lower : < 130 mm Hg , or higher : 130 - 149 mm Hg . SBP management over the course of the trial was examined by race/ethnicity and other baseline conditions . RESULTS Mean SBP decreased for both groups from baseline to the last follow-up , from 142.4 to 126.7 mm Hg for the lower SBP target group and from 143.6 to 137.4 mm Hg for the higher SBP target group . At baseline , participants in both groups used an average of 1.7±1.2 antihypertensive medications , which increased to a mean of 2.4±1.4 ( lower group ) and 1.8±1.4 ( higher group ) by the end- study visit . It took an average of 6 months for patients to reach their SBP target , sustained to the last follow-up . Black participants had the highest proportion of SBP ≥150 mm Hg at both study entry ( 40 % ) and end- study visit ( 17 % ) , as compared with whites ( 9 % ) and Hispanics ( 11 % ) . CONCLUSIONS These results show that it is possible to safely lower BP even to a SBP goal < 130 mm Hg in a variety of patients and setting s , including private and academic centers in multiple countries . This provides further support for protocol -driven care in lowering BP and consequently reducing the burden of stroke BACKGROUND AND PURPOSE There have been few community-based studies of long-term prognosis after acute stroke . This study aims to provide precise estimates of the absolute and relative risks of stroke recurrence in an unselected cohort of patients with a first-ever stroke . METHODS Six hundred seventy-five patients were registered in a community-based stroke register ( the Oxfordshire Community Stroke Project ) and prospect ively followed for up to 6.5 years .  Their relative risk of recurrent stroke was calculated using age- and sex-specific incidence rates for first stroke in Oxfordshire . RESULTS One hundred eighty recurrent episodes of stroke were identified , of which 135 were first recurrences . Given survival , the actuarial risk of suffering a recurrence was 30 % ( 95 % confidence interval , 20 % to 39 % ) by 5 years , about nine times the risk of stroke in the general population . The risk was highest early after the first stroke : 13 % ( 95 % confidence interval , 10 % to 16 % ) by 1 year , 15 times the risk in the general population . After the first year the average annual risk was about 4 % . The risk of stroke recurrence did not appear to be related to age or pathological type of stroke . CONCLUSIONS The absolute and relative risks of recurrent stroke are highest early after the first stroke but remain elevated for several years thereafter . Efforts at secondary prevention should be initiated as soon as possible and continued for several years to gain greatest benefit Objective : To describe the number and types of problems mentioned by successfully contacted home-dwelling stroke patients and their carers , and nursing interventions applied . Design : In this multicentre quantitative study in the Netherl and s , stroke patients and carers received outreach nurse support consisting of three telephone contacts and one home visit within six months after discharge . St and ardized checklists describing a wide range of potential problems were used to record problems and interventions . Subjects : A sample of 173 patients admitted for a stroke and discharged home , and 148 carers . Results : Of 173 patients , 166 ( 96 % ) were contacted and 162 mentioned in total 1419 problems . Physical problems were mentioned most frequently ( 92 % ; 153/166 ) , followed by emotional problems ( 60 % ; 99/166 ) . The proportion of patients with problems decreased from 94 % ( 142/151 ) at the first contact to 74 % ( 108/145 ) at the last contact . Of 148 carers , 118 ( 80 % ) were contacted and 84 mentioned 266 problems . ‘ Psychosocial burden ’ was mentioned most frequently ( 45 % ; 53/118 ) . Proportions of carers with problems were 56 % ( 54/96 ) at the first contact and 37 % ( 26/70 ) at the last contact . Of 864 interventions to patients , stroke nurses most frequently applied ‘ supportive listening ’ ( 55 % ; 471/864 ) and ‘ reassuring or encouraging ’ ( 12 % ; 107/864 ) , and of 258 interventions to carers 45 % ( 115/258 ) were ‘ supportive listening ’ and 17 % ( 43/258 ) ‘ informing ’ . Conclusions : Almost all patients and most carers were contacted . Though the number of needs decreased during the consecutive contacts , many patients and carers still raised problems during the last contact . Nurses most frequently applied the intervention ‘ supportive listening ’ OBJECTIVE To compare a specialized interprofessional team approach to community-based stroke rehabilitation with usual home care for stroke survivors using home care services . METHODS R and omized controlled trial of 101 community-living stroke survivors ( < 18 months post-stroke ) using home care services . Subjects were r and omized to intervention ( n=52 ) or control ( n=49 ) groups . The intervention was a 12-month specialized , evidence -based rehabilitation strategy involving an interprofessional team . The primary outcome was change in health-related quality of life and functioning ( SF-36 ) from baseline to 12 months . Secondary outcomes were number of strokes during the 12-month follow-up , and changes in community reintegration ( RNLI ) , perceived social support ( PRQ85-Part 2 ) , anxiety and depressive symptoms ( Kessler-10 ) , cognitive function ( SPMSQ ) , and costs of use of health services from baseline to 12 months . RESULTS A total of 82 subjects completed the 12-month follow-up . Compared with the usual care group , stroke survivors in the intervention group showed clinical ly important ( although not statistically significant ) greater improvements from baseline in mean SF-36 physical functioning score ( 5.87 , 95 % CI -3.98 to 15.7 ; p=0.24 ) and social functioning score ( 9.03 , CI-7.50 to 25.6 ; p=0.28 ) . The groups did not differ for any of the secondary effectiveness outcomes . There was a higher total per-person costs of use of health services in the intervention group compared to usual home care although the difference was not statistically significant ( p=0.76 ) . CONCLUSIONS A 12-month specialized , interprofessional team is a feasible and acceptable approach to community-based stroke rehabilitation that produced greater improvements in quality of life compared to usual home care . Clinical trials.gov identifier : NCT00463229 Nir Z , Weisel-Eichler A : Improving knowledge and skills for use of medication by patients after stroke : Evaluation of a nursing intervention . Am J Phys Med Rehabil 2006;85:582–592 . Objective : The objective of this study was to determine if a tailored nursing intervention , as opposed to usual rehabilitation care , can improve knowledge and behavioral skills for correct use of medication use in aged stroke patients . Design : Stratified r and om sampling created two homogenous groups : 73 intervention patients , who were provided with the nursing intervention program along with usual rehabilitation care , and 82 controls , who underwent usual rehabilitation care alone .  Participants were assessed within the first week of admission to the rehabilitation ward , 3 mos after stroke ( at the end of the intervention ) , and 6 mos after stroke . An assessment instrument measuring correct knowledge and skills concerning medications was used . Results : After 3 and 6 mos , intervention subjects were significantly better than controls in knowledge of shape and dosage of their medications , in knowledge of side effects and correct response to side effects , and in adherence to their dietary regimen . However , for knowledge of color and daily schedule of medications , there were differences at 3 mos , but differences were diminished after 6 mos . Conclusions : This nursing intervention , tailored to the specific needs of the aged stroke patient , increased the patients ’ knowledge and skills concerning medication therapy , but to a limited extent and for a limited time Objective : Little is known about the long-term effectiveness after stroke of interventions for behaviour modification and ensuring concordance with therapies . We describe a follow-up study of a previous r and omized controlled trial of a brief period of behaviour modification . The aim of this study was to determine outcomes three years after the initial intervention . Design : Survivors of the original cohort were contacted and asked to attend for follow-up interview , within a geriatric day hospital . This study was carried out in the Geriatric Day Hospital at Stobhill Hospital , Balornock Road , Glasgow . Interventions : Details of risk factor control , including blood pressure , cholesterol levels and diabetic control , were assessed . Question naires used in the initial study were repeated including the Geriatric Depression Scale score , Euroqol Perceived Health Status and Stroke Services Satisfaction Question naire . Main measures : Primary outcome was collective risk factor control . Clinical outcomes including recurrent cerebrovascular events , medication persistence and perceived health status were also recorded . Results : Mean length of follow-up was 3.6 years ( SD 0.43 ) . Of the 205 patients enrolled in the initial study , 102 patients attended for repeat interview ( 49 intervention/53 control ) . There were no significant differences in the percentage of controlled risk factors between groups ( intervention 51.7 % versus control 55.9 % , P = 0.53 ) . Similarities were observed in the number of recurrent clinical events and medication persistence between groups . No overall difference was observed in perceived health status , satisfaction with care or depression scores . Conclusions : Brief intervention with respect to behaviour modification and risk factor control does not appear to have any long-term benefit . These results must be cautiously interpreted in light of the small study number and further research is required Rationale Stroke and vascular risk factors disproportionately affect minority population s , with Blacks and Hispanics experiencing a 2.5- and 2.0-fold greater risk compared with whites , respectively . Patients with transient ischemic attacks and mild , nondisabling strokes tend to have short hospital stays , rapid discharges , and inaccurate perceptions of vascular risk . Aim The primary aim of the Discharge Educational Strategies for Reduction of Vascular Events ( DESERVE ) trial is to evaluate the efficacy of a novel community health worker-based multilevel discharge intervention vs. st and ard discharge care on vascular risk reduction among racially/ethnically diverse transient ischemic attack/mild stroke patients at one-year postdischarge . We hypothesize that those r and omized to the discharge intervention will have reduced modifiable vascular risk factors as determined by systolic blood pressure compared with those receiving usual care . Sample size estimates Given 300 subjects per group and alpha of 0.05 , the power to detect a 6 mmHg reduction in systolic blood pressure is 89 % . Design DESERVE trial is a prospect i ve , r and omized , multicenter clinical trial of a novel discharge behavioral intervention .  Patients with transient ischemic attack/mild stroke are r and omized during hospitalization or emergency room visit to intervention or usual care . Intervention begins prior to discharge and continues postdischarge . Study outcomes The primary outcome is difference in systolic blood pressure reduction between groups at 12 months . Secondary outcomes include between-group differences in change in glycated hemoglobin , smoking rates , medication adherence , and recurrent stroke/transient ischemic attack at 12 months . Discussion DESERVE will evaluate whether a novel discharge education strategy leads to improved risk factor control in a racially diverse population Rationale PROTECT DC examines whether stroke navigators can improve cardiovascular risk factors in urban underserved individuals newly hospitalized for stroke or ischemic attack . Within one-year of hospital discharge , up to one-third of patients no longer adhere to secondary prevention behaviors . Adherence rates are lower in minority-underserved groups , contributing to health disparities . In-hospital programs increase use of stroke prevention therapies but may not be as successful in underserved individuals . In these groups , low literacy , limited healthcare access , and sparse community re sources may reduce adherence . Lay community health workers ( navigators ) improve adherence in other illnesses through education and assisting in overcoming barriers to achieving desired health behaviors and obtaining needed healthcare services . Aims and design PROTECT DC is a Phase II , single-blind , r and omized , controlled trial comparing in-hospital education plus stroke navigators to usual care .  Atherogenic ischemic stroke and transient ischemic attack survivors are recruited from Washington , DC hospitals .  Navigators meet with participants during the index hospitalization , perform home visits , and meet by phone . They focus on stroke education , medication compliance , and overcoming practical barriers to adherence . The interventions are driven by the theories of reasoned action and planned behavior . Study outcomes The primary dependent measure is a summary score of four objective measures of stroke risk factor control : systolic blood pressure , low-density lipoprotein , hemoglobin Hb A1C , and antiplatelet agent pill counts . Secondary outcomes include stroke knowledge , exercise , dietary modification , and smoking cessation . Conclusion PROTECT DC will determine whether a Phase III trial of stroke navigation for urban underserved individuals to improve adherence to secondary stroke prevention behaviors is warranted 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 Although guidelines for secondary ischemic stroke have been developed , there is a gap between guidelines and clinic practice . Aims This study will investigate the current status of secondary ischemic stroke prevention in China , and implement a st and ard medical program in ischemic stroke and /or transient ischemic attack patients , and to examine the feasibility and efficacy of the program . Design This is a multicentre , parallel , r and omized , open label , controlled trial to evaluate the feasibility and efficacy of a recommended guideline based program ( SMART ) in secondary stroke prevention .  Forty-eight sites across Mainl and China will participate in the trial . The number of enrolled patients in the study will be 4074 . Primary outcome includes the proportion of patients adherent to eligible measures recommend by the SMART program  , which is derived from current prevention guidelines for ischemic stroke , and the proportion of the patients achieving the treatment target . Secondary outcomes include new onset ischemic stroke , hemorrhagic stroke , acute coronary syndrome and all causes of death . The study has been registered on Clinical trials.gov ( NCT00664846 ) ; to date , 3380 patients have been enrolled Objective : To evaluate whether enhanced secondary prevention more significantly influences readiness to change health behaviour after minor stroke/transient ischaemic attack , compared with conventional stroke secondary prevention . Design : Single-blind r and omized control trial . Setting : Rural district general hospital outpatient clinic . Subjects : Fifteen women and 37 men with a mean age of 68.3 years with first minor stroke or transient ischaemic attack . Interventions : The intervention group received ‘ enhanced secondary prevention ’ ( additional advice , motivational interviewing and telephone support ) to change health behaviour . Both groups received ‘ conventional care ’ which included advice given during routine care . Main measures : The primary outcome was ‘ readiness to change behaviour ’ measured using a vali date d stroke specific score based on the transtheoretical model . Secondary outcomes were the Hospital Anxiety and Depression Scale , and self-reported alcohol consumption , smoking behaviour , exercise frequency , and fruit and vegetable consumption . Results : Analysis of the data for the 52 participants showed no statistical difference in the groups for the primary outcome of readiness to change behaviour . Statistically significant improvements for change in self-reported exercise were demonstrated ( P = 0.007 ) ; to 2—3 times per week in the intervention group compared to 0—1 times per week in the control group , and in fruit and vegetable consumption ( P = 0.033 ) ; to 10 portions of fruit and vegetables consumed per week in the intervention group compared to 1 or 2 portions a week for the control group . No evidence of a difference between groups was seen for alcohol consumption or Hospital Anxiety and Depression Scale . Conclusions : While no difference was demonstrated between the groups for readiness to change behaviour , a clinical ly significant effect in reported exercise behaviour and diet were demonstrated in the intervention group . This interesting finding indicates a dissonance between the behaviour scale and actual behaviour change , potentially indicating a lack of sensitivity of the scale to detect a change in this patient group Lowering blood pressure ( BP ) in stroke survivors reduces the risk of recurrent stroke . We tested the hypothesis that a nurse-led nonpharmacologic intervention would lower the BP of participants in an intervention group compared with a control group . A total of 349 patients who had sustained acute stroke or transient ischemic attack were r and omly assigned to either usual care or to 4 home visits by a nurse . During the visits , the nurse measured and recorded BP and provided individually tailored counseling on a healthy lifestyle . A total of 303 patients completed the 1-year follow up . No change in systolic BP was noted in either the intervention group or the control group . Because of an increase in diastolic BP in the control group ( P = .03 ) , a difference in mean diastolic BP between the 2 groups was found at follow-up ( P = .007 ) . Mean BP at follow-up was 139/82 mm Hg in the intervention group and 142/86 mm Hg in the control group . Linear regression analysis demonstrated that BP at the point of discharge was the strongest predictor of BP 1 year later ( P < .0001 ) . The proportion of patients on antihypertensive medication increased in the intervention group ( P = .002 ) . Patients were compliant with antihypertensive therapy , and 92 % of the hypertensive patients in the intervention group followed the advice to see a general practitioner ( GP ) for BP checkups . At follow-up , 187 patients ( 62 % ) were hypertensive , with no difference in the rate of hypertension seen between the groups . Our data indicate that home visits by nurses did not result in a lowering of BP . Patients complied with antihypertensive therapy and GP visits in the case of hypertension . Nonetheless , the majority of patients were hypertensive at the 1-year follow up Background : Lifestyle modification is associated with a substantially decreased risk of cardiovascular events . However , the role of lifestyle intervention for secondary prevention in patients with noncardioembolic ischemic stroke is inadequately defined . We assessed the hypothesis that lifestyle intervention can reduce the onset of new vascular events in patients with noncardioembolic mild ischemic stroke . Methods : We conducted an observer-blind r and omized controlled trial that enrolled 70 patients ( 48 men , mean age 63.5 years ) with acute noncardioembolic mild ischemic stroke . The patients were allocated in equal numbers to a lifestyle intervention group or a control group . We performed lifestyle interventions , which comprised exercise training , salt restriction and nutrition advice for 24 weeks . Then all patients were prospect ively followed up for occurrence of the primary endpoints , including hospitalization due to stroke recurrence and the onset of other vascular events . We also evaluated systolic blood pressure ( SBP ) at the clinic and at home , low-density lipoprotein cholesterol ( LDL-C ) , high-density lipoprotein cholesterol ( HDL-C ) , hemoglobin A1c ( HbA1c ) and high-sensitivity C-reactive protein ( hs-CRP ) to compare the efficacy of the lifestyle interventions . Results : This trial was terminated earlier than expected because of the prespecified early stopping rule for efficacy . After the 24-week intervention period , the intervention group showed a significant increase in daily physical activity and a significant decrease in salt intake ( physical activity , p = 0.012 ; salt intake , p < 0.001 ) , with a significant difference between the r and omized groups ( physical activity , p < 0.001 ; salt intake , p = 0.018 ) . Similarly , blood pressure was decreased and the HDL-C levels were increased in the intervention group ( SBP , p < 0.001 ; HDL-C , p = 0.018 ) , with significant differences between the r and omized groups ( SBP , p < 0.001 ; HDL-C , p = 0.022 ) . In contrast , LDL-C , HbA1c and hs-CRP tended to decrease in the intervention group , but this decrease did not achieve significance . After a median follow-up period of 2.9 years , 12 patients allocated to the control group and 1 patient in the lifestyle intervention group experienced at least 1 vascular event . A sequential plans analysis indicated the superiority of the lifestyle intervention in interim analysis . Kaplan-Meier survival curves after the log-rank test showed a significant prognostic difference between the r and omized groups ( p = 0.005 ) . Conclusions : Lifestyle intervention with appropriate medication is beneficial for reducing the incidence of new vascular events and improving vascular risk factors in patients with noncardioembolic mild ischemic stroke Background Comprehensive community care has the potential to improve risk factor management of patients with stroke or transient ischaemic attack . Aim The primary aim is to determine the effectiveness of an individualized management program on risk factor management for patients discharged from hospital after stroke . Design Multicentre , cluster-r and omized , controlled trial , with clusters by general practice . Participants are r and omized to receive intervention or control after a baseline assessment undertaken after discharge from hospital . The general practice they attend is marked as an intervention or control accordingly . All subsequent participants attending those practice s are automatically assigned as intervention or control . Baseline and all outcome assessment s , including an analysis of risk factors , are undertaken by assessors blinded to patient r and omization . Intervention Details Based on the results of blinded assessment s , the individualized management program group will receive targeted advice on how to manage their risk factors using a st and ardized , evidence -based template to communicate ‘ ideal ’ management with their general practitioner . In addition , patients r and omized to the individualized management program group will receive counselling and education about stroke risk factor management by an intervention study nurse . Individualized management programs will be review ed at three-months , six-months , 12 months , and 18 months after stroke , at which times they will be modified if appropriate . Stroke risk management will be evaluated using changes in the Framingham cardiovascular risk score . Analysis will be on an intention-to-treat basis using analysis of covariance or generalized linear model to adjust for baseline risk score and other relevant confounding factors 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 AND PURPOSE Shared care initiatives , albeit commonly utilised in managing other chronic conditions have not been implemented in the area of stroke in Australia . The aims of this project were to adopt a shared care approach for stroke survivors comparing an experimental " shared-care " group with a " treatment-as-usual " control group in reference to the normalization or reversal of vascular risk factors and the detection and management of post-stroke depression . METHODS A r and omised controlled experimental research design was implemented with participants r and omized to an intervention or control group and followed over a 12-month period . The treatment group consisted of a r and omly selected group of patients  , discharged from an acute stroke unit and transferred into the shared care model . Risk factors for stroke and depression were compared between the two groups . RESULTS Of 97 patients originally included in the study , 17 dropped out . At 12 months , 80 patients remained for analysis ( 35 in the intervention group and 45 in the control group ) . The findings demonstrated positive trends for patients within the intervention group that were not found within the control group . The percentage of intervention patients reaching target systolic blood pressure ( sBP ) of 140 mmHg after 12 months tended to be greater than in the control group ( p=0.11 , NS ) . In the intervention group , at 12 months , the total cholesterol greater than 5.18 mmol/L was 12.5 % compared to 58.8 % at discharge . In contrast this trend was not so distinct in the control group ( 57.7 % to 42.9 % ) . The percentage of patients reaching target ( recommended ) total cholesterol of 5.18 mmol/L was significantly greater in the shared care patients intervention group relative to the control group ( p=0.02 ) . The average number of walks per week was also significantly greater in intervention group compared to the control group ( p=0.048 ) . Moreover , 45 % of the control group screened as depressed compared with 20 % of the intervention group at 12 months ( p=0.06 ) . CONCLUSIONS This study demonstrates that major risk factors for recurrent stroke and vascular disease in general are better managed with the shared care model than with usual post-discharge care . The significantly reduced depression as found on the screening PHQ9 at 12 months indicated that the intervention was beneficial not only in the detection of depression but also treatment ABSTRACT Secondary stroke prevention is championed as guideline care ; yet there are no systematic programs offered . We developed a stroke self-management program to address this gap and pilot test the program . We conducted a r and omized controlled trial at two Veterans Administration ( VA ) hospital sites where we recruited patients with an acute stroke to receive either the stroke program or an attention-control protocol over a 12-week period following hospital discharge . The stroke program included six sessions that facilitated stroke self management focusing on increasing self-efficacy to recover from stroke and engage in secondary stroke risk factor management . We surveyed outcomes at baseline , 3 and 6 months . We conducted an intention to treat analysis comparing the intervention to the control group on changes of outcomes between baseline and follow-up modeled by a linear model with fixed effects for treatment , visit , and the treatment by visit interaction adjusting for baseline . We recruited 63 participants ( 33 control and 30 intervention ) who were hospitalized with a primary diagnosis of ischemic stroke . We found trends in differences between groups on self-efficacy to communicate with physicians , weekly minutes spent in aerobic exercise , and on dimensions of stroke-specific quality of life . This pilot study demonstrated the feasibility of delivering a  stroke self-management program to recent stroke survivors in a healthcare organization . The program also demonstrated improvements in patient self-efficacy , self-management behaviors , specific dimensions of stroke-specific quality of life compared to a group that received an attention placebo program INTRODUCTION patients have reported a lack of knowledge and underst and ing of stroke and its risk factors . Uncertainty remains about the most appropriate and effective method of educating patients after stroke . OBJECTIVE to assess the impact of the CareFile , an individualized information booklet , on patients ' knowledge and satisfaction level after stroke . DESIGN r and omised pilot study for a controlled trial . SETTING a large teaching hospital in Liverpool , UK . METHODS consecutive stroke patients admitted over a 9-month period , who met the inclusion criteria and consented to participate , were r and omised into this study . All patients received the usual stroke information leaflets provided by the stroke unit . In addition , the intervention group received the ; CareFile ' , a booklet containing general information and patient-specific information on stroke . Patients in both groups completed a stroke knowledge question naire at baseline , and at three and six months post-stroke . RESULTS of the 259 admissions , 100 were eligible to participate , and 50 were r and omised to each group . There was no significant difference in patient knowledge between the groups at baseline ( P>0.05 ) . However , at three ( P<0.05 ) and six ( P<0.005 ) months post-stroke , the intervention group had significantly better knowledge of stroke . There were no differences between the groups regarding satisfaction with the information received . CONCLUSIONS a simple education package , in the form of an individualized information booklet , result ed in a significant improvement in knowledge and recognition of risk factors for stroke . The CareFile should make a valuable contribution in meeting the requirements of the National Sentinel Audit and National Service Framework regarding provision of information to patients after stroke OBJECTIVE We sought to evaluate whether comprehensive postdischarge care management for stroke survivors is superior to organized acute stroke department care with enhanced discharge planning in improving a profile of health and well-being . METHODS This was a r and omized trial of a comprehensive postdischarge care management intervention for patients with ischemic stroke and National Institutes of Health Stroke Scale scores greater than or equal to 1 discharged from an acute stroke department . An advanced practice nurse performed an in-home assessment for the intervention group from which an interdisciplinary team developed patient-specific care plans . The advanced practice nurse worked with the primary care physician and patient to implement the plan during the next 6 months . The intervention and usual care groups were compared using a global and closed hypothesis testing strategy . Outcomes fell into 5 domains : ( 1 ) neuromotor function , ( 2 ) institution time or death , ( 3 ) quality of life , ( 4 ) management of risk , and ( 5 ) stroke knowledge and lifestyle . RESULTS Treatment effect was near 0 SD for all except the stroke knowledge and lifestyle domain , which showed a significant effect of the intervention ( P = .0003 ) . CONCLUSIONS Postdischarge care management was not more effective than organized stroke department care with enhanced discharge planning in most domains in this population . The intervention did , however , fill a postdischarge knowledge gap 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 Rationale Stroke is the second-leading cause of death in low- and middle-income countries , but use of evidence -based therapies for stroke prevention in such countries , especially those in Africa , is extremely poor . This study is design ed to enhance the implementation and sustainability of secondary stroke-preventive services following hospital discharge . Aim /Hypothesis The primary study aim is to test whether a Chronic Care Model-based initiative entitled the Tailored Hospital-based Risk reduction to Impede Vascular Events after Stroke ( THRIVES ) significantly improves blood pressure control after stroke . Design This prospect i ve triple-blind r and omized controlled trial will include a cohort of 400 patients with a recent stroke discharged from four medical care facilities in Nigeria . The culturally sensitive , system-appropriate intervention comprises patient report cards , phone text messaging , an educational video , and coordination of posthospitalization care . Study Outcomes The primary outcome is improvement of blood pressure control . Secondary endpoints include control of other stroke risk factors , medication adherence , functional status , and quality of life . We will also perform a cost analysis of THRIVES from the viewpoint of government policy-makers . Discussion We anticipate that a successful intervention will serve as a scalable model of effective postdischarge chronic blood pressure management for stroke in sub-Saharan Africa and possibly for other symptomatic cardiovascular disease entities in the region BACKGROUND Statins reduce the risk of vascular events , however statin prescribing is often sub optimal and better evidence is needed to inform quality improvements . The Statin Outreach Support ( SOS ) trial was design ed to test the efficacy of pharmacist led educational outreach directed at General Practice s , aim ing to improve statin prescribing for community dwelling patients with vascular disease . This paper describes the study rationale , design , methods and baseline characteristics of participants . DESIGN The SOS trial was design ed to investigate whether practice s receiving SOS improve their statin prescribing and patients achieve reduced cholesterol levels . It was a prospect i ve , single blind , cluster r and omised controlled trial with a follow-up period of 5months minimum post SOS intervention delivery . RESULTS Thirty one practice s were recruited from the UK 's largest Health Board area . At r and omisation , 16 practice s were allocated to SOS and 15 to usual care with 4040 patients included at baseline . Participating practice s showed few differences compared with non-participating practice s ; practice s and patients r and omised to each arm of the study had similar distributions with respect to age , complications , cholesterol levels and statin prescribing . Baseline data compared favourably with l and mark , placebo-controlled statin trials . CONCLUSIONS Compared with existing implementation research , SOS trial has more participants , a detailed description of baseline characteristics and over 90 % power ( at 5 % significance ) to detect a difference of 12 % in the proportion of patients with controlled cholesterol after SOS Context Interventions to promote guideline -recommended care have met with limited success . Quality improvement experts believe that multicomponent interventions are more effective than simpler strategies , but this belief rests on limited evidence . Contribution In this r and omized trial of 20 primary care practice s , intervention practice s received quarterly site visits and 2 network meetings about quality improvement in addition to copies of practice guidelines and quarterly performance reports . Intervention practice s had greater improvement in providing guideline -recommended care for cardiovascular disease prevention and treatment than practice s that received only the guidelines and performance reports . Caution s The study involved a small number of practice s. The Editors Widespread evidence reveals inadequate implementation of evidence -based clinical practice guidelines for prevention and management of cardiovascular disease and stroke in primary care setting s ( 1 - 3 ) . Primary prevention deficiencies exist in the screening and management of dyslipidemia ( 4 ) and hypertension ( 5 ) . Secondary prevention deficiencies include inadequate treatment of dyslipidemia in patients with coronary heart disease ( CHD ) ( 6 ) and inadequate use of antiplatelet therapy in patients with CHD or cerebrovascular disease ( 7 ) , inadequate use of -blockers after myocardial infa rct ion ( 8) , inadequate use of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers in patients with heart failure ( 9 ) , and inadequate use of oral anticoagulant therapy in patients with atrial fibrillation ( 10 ) . Finally , patients with diabetes mellitus who are at high risk for cardiovascular disease as well as microvascular disease infrequently receive recommended screening and adequate treatment for elevated glycosylated hemoglobin levels , hypertension , and dyslipidemia ( 11 ) . Published systematic review s point to the importance of multifaceted interventions in increasing adherence to practice guidelines and improving disease control ( 12 , 13 ) . Little is known , however , about the relative effectiveness of different implementation strategies . More research is needed to develop and vali date effective , theoretically sound , and practical strategies for improving the provision of evidence -based medicine in primary care . Particularly important are studies that address multiple common , chronic conditions , which together reflect a large proportion of the work of primary care providers ( 14 ) . This study was design ed as a pragmatic clinical trial ( 15 ) , intended to assess whether a  multi method quality improvement intervention  was more effective than a less intensive intervention  for improving adherence to 21 quality indicators relevant to the primary and secondary prevention of cardiovascular disease and stroke . The multi method quality improvement intervention added practice site visits ( for academic detailing and quality improvement facilitation ) and network meetings ( for sharing best practice s ) to the approach of guideline dissemination and audit and feedback used in the less intensive intervention . The study was conducted in a practice -based research network ( PPRNet ) among users of a common electronic medical record ( Practice Partner Patient Records , Seattle , Washington ) , which historically provided audit and feedback to its practice members . Audit and feedback have already been shown to improve the practice of health care professionals , particularly in prescribing and test ordering ( 16 ) . Additional research is needed to assess the effect of audit and feedback in combination with other interventions . Methods Design The design was a cluster r and omized , controlled clinical trial , with the practice as the unit of r and omization . Twenty-three office-based primary care practice s in 15 states agreed to participate . The institutional review board at the Medical University of South Carolina approved the study . Study Indicators We derived the study indicators ( Table 1 ) from published sources ( 17 - 22 ) . Fourteen were process measures , which reflected whether recommended tests were done , appropriate diagnoses made , or appropriate medication prescribed . Seven were outcome measures , which reflected whether patients achieved recommended treatment goals . Some of the measures represented primary prevention , for example , screening for hypertension or dyslipidemia . Others represented secondary prevention , for example , reaching treatment goals for glycosylated hemoglobin levels , low-density lipoprotein ( LDL ) cholesterol levels , and blood pressure in patients with diabetes . An additional indicator , hormone replacement therapy for postmenopausal women , was included at the beginning of the study but was withdrawn in July 2002 when the results from the Women 's Health Initiative trial were published ( 23 ) . Table 1 . Study Indicators We determined practice performance for each study indicator at baseline and quarterly throughout the study . To determine performance , participating practice s ran a computer program to extract patient activity during the previous quarter from their electronic medical record . To protect patient confidentiality , the extract program assigned a unique , anonymous numerical identifier to each patient . The extract program obtained demographic information , such as age , race , and sex ; diagnoses ; medications ; laboratory data ; and vital signs . Text of progress notes , consultation reports , and discharge summaries were not extracted . The data were copied to a diskette and mailed to PPRNet or sent electronically via a secure server . In the PPRNet offices , the data were bridged to st and ard data dictionaries and converted to SAS data sets ( SAS Institute , Inc. , Cary , North Carolina ) on st and ard microcomputers for analyses . Interventions The intervention began on 1 January 2001 and was completed on 1 January 2003 . During the first quarter of 2001 , the medical director of each practice was sent printed copies of each practice guideline referenced in the study . Beginning in the first quarter of 2001 , the medical director was sent quarterly performance reports documenting the practice 's adherence to each of the 21 study indicators . Each report contained the practice 's current performance , calculated as the percentage of eligible patients who had received the recommended service , the number of patients who were receiving the recommended medication , or the number of patients who had achieved the treatment goal . The report also presented data on the practice s ' previous performance since the beginning of the study and the performance target , calculated as the 90th percentile at baseline among all practice s. In practice s with more than 1 clinician , individual provider data were not given because the study emphasized improvement at the practice level . The medical director was encouraged to share the reports with others in the practice in order to stimulate motivation for improvement . The 90th percentile was selected as the performance target because it reflected a bold but achievable goal ( at least 2 practice s were at this level of performance at baseline ) . Practice s in the control group received no other interventions during the study . An example of 1 page of a practice report is available in the Appendix Figure . Appendix Figure . Sample practice report for blood pressure in coronary heart disease .  Practice s in the intervention group also participated in practice site visits and network meetings . Six or seven 1- or 2-day site visits were held at each practice approximately every 3 months during 2001 and 2002 . The practice site visit was led by 1 of the physician co authors , assisted during the first few visits in 2001 by a clinical pharmacist with expertise in academic detailing ( 24 ) , and at later visits by other co authors with expertise in quality improvement . Initial site visits focused on engaging clinicians and staff members in the project , through a formal presentation by the site visitors and group discussion with all members of the practice team , including providers , nurses , medical assistants , and reception and administrative personnel . Because of vacation or hospital coverage responsibilities , 1 or 2 providers were occasionally absent in the multiprovider practice s , and 1 practice involved only a few members of their staff . We placed detailed attention on the scientific justification for the chosen study indicators and on published frameworks for clinician behavior change ( 25 , 26 ) . Baseline practice performance on each study indicator was discussed , and previous evidence of the ability of PPRNet practice s to improve care was presented ( 27 ) . Practice s were encouraged to increase the use of quality improvement tools available in the electronic medical record , such as note templates with embedded practice guidelines , query functions , prompts , reminders , and messaging . At each visit , a participatory planning session was held in which practice members identified specific clinical indicators they wished to work on and improvement activities to conduct before the next site visit . Lessons from complexity theory were used in this exercisethe influence of each practice member on the system , the importance of replicating successful approaches and focusing on motivators for patients and staff , and the notion that simple changes are easiest to adopt and can have profound effects . In subsequent site visits , we focused on discussing the practice 's success in adopting its planned improvement activities , presenting up date d performance data , and planning additional practice -level interventions . The site visitors presented results from recently published studies relevant to the study indicators . Successful and unsuccessful approaches to improvement by other intervention sites were also presented . Two-day network meetings were held in Charleston , South Carolina , in May 2001 and May 2002 . The lead clinician from each intervention practice and the research team attended the first meeting . At this Fundamental bias can be introduced in r and omised trials if patients can not be masked for the allocated strategy and assess subjective outcomes . In such a trial , on the effectiveness of outreach stroke care in addition to st and ard care , we masked patients by modifying the informed consent procedure . Before discharge home we informed patients that we were study ing their needs six months after discharge ; we could not inform about an additional research question because that would affect the results ; this question entailed no risk and would be clarified after follow up ; and the ethics committee approved this study .1 After we got consent we r and omised patients . We informed patients in the intervention group about the outreach care programme and asked them to participate , but we kept them ignorant that we were study ing the programme for effectiveness . Controls received no further information . After follow up , we sent all participants a Background – Transient ischemic attack ( TIA ) and stroke patients often show a striking lack of knowledge about their disease . We developed a computer program that provided health education fitting the educational level , risk profile and symptoms of patients and evaluated it in a r and omized controlled trial 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 OBJECTIVES To assess the efficacy of a comprehensive secondary prevention programme to reduce morbidity and mortality in patients who have suffered a cardiovascular ( CV ) event ; to control CV risk factors and prophylactic treatment in order to prevent recurrence ; and to improve the quality of life of patients with cardiovascular disease . DESIGN R and omised , pragmatic , open clinical trial in primary care . SETTING A total of 42 primary care centres of 8 different areas in Spain . PARTICIPANTS Men and women below 86 years old , diagnosed with coronary disease and /or stroke and /or peripheral vascular disease in the preceding year , and who have no serious or terminal disease . INTERVENTION Primary care centres will be r and omised to following usual care ( control group ) , or to following a comprehensive programme of secondary prevention ( intervention group ) . MAIN MEASUREMENTS Cardiovascular fatal events , cardiovascular non-fatal events , total mortality and health-related quality of life ( SF-36 ) AIM This paper reports a study evaluating the short-term impact of nursing-led , co-ordinated care after discharge  following carotid endarterectomy . BACKGROUND Patient education about stroke risk factors , combined systematic ally with carotid endarterectomy , holds unrealized potential to improve patient outcomes . Nurses are well-placed in the healthcare system to co-ordinate this type of education . METHODS A r and omized controlled trial was conducted between October 2001 and October 2002 . Patients having carotid endarterectomy ( n = 133 ) were r and omized to either the intervention ( n = 66 ) or control group ( n = 67 ) . The intervention consisted of telephone liaison with the patient by a Registered Nurse at 2 , 6 and 12 weeks following carotid endarterectomy , combined with education about stroke risk factor management and structured liaison with the patient 's surgeon and referring general practitioner . While patients allocated to the control group did not receive any postoperative telephone contact directly from the Registered Nurse during the study , their general practitioners received structured postoperative liaison . RESULTS The co-ordinated care postdischarge intervention had a statistically significant positive effect on patient knowledge of stroke warning signs ( P = 0.002 ) , patient self-reported changes to improve lifestyle ( P = 0.006 ) and diet modification ( P < 0.001 ) . Statistically significant improvements from baseline to follow-up were detected in both groups for other outcomes . CONCLUSIONS While nursing-led , co-ordinated care after discharge achieves important improvements for short-term outcomes , carotid endarterectomy itself may have been a catalyst for improved patient outcomes . Further research of nursing-led co-ordinated care initiatives for vascular surgery patients is needed BACKGROUND Determinants of survival and of risk of vascular events after transient ischaemic attack ( TIA ) or minor ischaemic stroke are not well defined in the long term . We aim ed to re study these risks in a prospect i ve cohort of patients after TIA or minor ischaemic stroke ( Rankin grade < or = 3 ) , after 10 years or more . METHODS We assessed the survival status and occurrence of vascular events in 2473 participants of the Dutch TIA Trial ( recruitment in 1986 - 89 ; arterial cause of cerebral ischaemia ) . We included 24 hospitals in the Netherl and s that recruited at least 50 patients . Primary outcomes were all-cause mortality and the composite event of death from all vascular causes , non-fatal stroke , and non-fatal myocardial infa rct ion . We assessed cumulative risks by Kaplan-Meier analysis and prognostic factors with Cox univariate and multivariate analysis . FINDINGS Follow-up was complete in 2447 ( 99 % ) patients . After a mean follow-up of 10.1 years , 1489 ( 60 % ) patients had died and 1336 ( 54 % ) had had at least one vascular event . 10-year risk of death was 42.7 % ( 95 % CI 40.8 - 44.7 ) . Age and sex-adjusted hazard ratios were 3.33 ( 2.97 - 3.73 ) for age over 65 years , 2.10 ( 1.79 - 2.48 ) for diabetes , 1.77 ( 1.45 - 2.15 ) for claudication , 1.94 ( 1.42 - 2.65 ) for previous peripheral vascular surgery , and 1.50 ( 1.31 - 1.71 ) for pathological Q waves on baseline electrocardiogram . 10-year risk of a vascular event was 44.1 % ( 42.0 - 46.1 ) . After falling in the first 3 years , yearly risk of a vascular event increased over time . Predictive factors for risk of vascular events were similar to those for risk of death . INTERPRETATION Long-term secondary prevention in patients with cerebral ischaemia still has room for further improvement BACKGROUND The number of patients aged 75 + years with cardiovascular diseases ( CVD ) is increasing , but few studies of secondary prevention in this age group exist . The aim of the Drug and Evidence Based Medicine in the Elderly ( DEBATE ) study is to test the applicability and effectiveness of established CVD treatments in elderly patients . METHODS From 1998 to 2000 , population -based postal surveys were performed in Helsinki , Finl and , including the age groups 75 , 80 , 85 , 90 , and 95 years ( n = 4821 ) . Of the 812 individuals reporting any atherosclerotic disease , 400 patients ( 66 % of those eligible ) were included in a r and omized trial . In the intervention group , CVD treatments will be individualized according to current guidelines . A control group will receive the usual care . The trial period will last 2 years with a 3-year extension . The primary end point will be a composite of major CVD . In addition , a number of secondary end points will be recorded , including permanent institutionalization , decline in cognitive and physical function , and quality of life . RESULTS During 2000 , 400 home-dwelling patients were r and omized to the intervention ( n = 199 ) and control ( n = 201 ) groups . The mean age is 80.2 years and 65.3 % are women . Of the participants , 82 % have coronary heart disease ( 41 % with history of myocardial infa rct ion ) , 37 % history of stroke , 19 % non-insulin-dependent diabetes mellitus , and 45 % hypertension , and 6 % are current smokers . Before r and omization , 67 % used aspirin , 40 % b-blockers , 14 % angiotensin-converting enzyme inhibitors , 36 % nitrates , and 20 % lipid-lowering drugs . The groups were well balanced at baseline . CONCLUSION We have successfully r and omized elderly patients with a high degree of comorbidity into a multifactorial CVD prevention trial This paper describes the background and methods of an Agency for Healthcare Research and Quality -funded study design ed to evaluate the impact of a  quality improvement model  using academic detailing and electronic medical records ( EMRs ) on adherence with 22 clinical practice guidelines for prevention of cardiovascular disease and stroke . The study is being conducted in 23 primary care practice s in 14 states that use a common EMR and pool data for research . Control practice s receive copies of the clinical practice guidelines and quarterly up date s of their adherence with them . Intervention practice s receive similar information and participate in regular site visits and investigator meetings design ed to catalyze their quality improvement efforts . The intervention began January 1 , 2001 and will be completed on June 30 , 2003 Abstract Goal : Evidence -based guidelines exist for the prevention and treatment of patients with cerebral ischemia . Despite these guidelines , there are gaps in clinical practice . Our study aim ed to determine if a physician-directed , nurse-case-management program could reduce individual patient vascular risk factors . Methods : Patients hospitalized with atherosclerotic cerebral ischemia with ≥ 1 major uncontrolled risk factor for stroke ( hypertension , tobacco use , dyslipidemia , diabetes ) were eligible to enroll in our study . Patients were r and omized to management by the nurse-prevention program or usual care .  Patients in the usual-care group received their initial risk-factor assessment and a scheduled follow-up at 1 year . Patients in the usual-care group underwent further follow-up by primary care and /or neurology as recommended during their hospitalization or outpatient visit . Patients assigned to the prevention group received individualized education , motivational interviewing , and were aided in setting up their risk-factor modification goal plan . Additional education was tailored to each patient based on individualized risk factors . Prevention-group patients also underwent consultation with a registered dietitian and an exercise physiologist . The primary endpoint of the study was improvement of ≥ 1 major patient risk factor for occurrence of stroke to goal at 1 year . Results : At 1-year post-hospitalization , patients in the nurse-care-management group were 42 % more likely to have met the primary endpoint ( n = 18 ; 61 % nurse-managed patients ) compared with 33 % ( n = 18 ) of patients undergoing usual care ( P = 0.09 ) . There was no significant reduction in minor risk factors for either patient group . Patients in the prevention group had greater reductions in low-density lipoprotein cholesterol levels ( −38 vs −4 ; P = 0.0083 ) , changes in cardiovascular risk score ( −5.2 vs 1.3 ; P = 0.0033 ) , and had a greater reductions in systolic blood pressure ( −12.2 vs −0.105 ; P = 0.07 ) than their usual-care counterparts ( changes shown respectively ) . Patients in the prevention group were more likely to follow a prescribed diet than those in the usual-care group ( 50 % ) vs 7 % , respectively ; P = 0.0070 ) and maintain an exercise program ( 83 % vs 33 % , respectively ; P = 0.0018 ) . Summary : A physician-directed , nurse case-management system for patients post-hospitalization for cerebral ischemia is feasible and may help improve long-term control of major patient risk factors for stroke . A larger trial is needed to verify trends noted in our study BACKGROUND Although some studies have demonstrated that pharmacist intervention can improve drug therapy among patients with cardiovascular disease ( CVD ) , more evidence derived from r and omized controlled trials ( RCTs ) is needed , including assessment of the effect of community pharmacist interventions in patients with CVD . OBJECTIVE To assess the effectiveness of the Dader Method for pharmaceutical care on achieving therapeutic goals for blood pressure ( BP ) , total cholesterol ( TC ) , and both BP and TC ( BP/TC ) in patients with CVD and /or high or intermediate cardiovascular ( CV ) risk attending community pharmacies in Spain . METHODS Patients aged 25 to 74 years attending community pharmacies with a prescription for at least 1 drug indicated for CVD or CV risk factors were r and omized to 2 groups : an intervention group that received pharmaceutical care , which was provided by specially trained pharmacists working in collaboration with physicians , and a control group that received usual care ( routine dispensing counseling ) and verbal and written counseling regarding CVD prevention .  Patients were recruited from December 2005 to September 2006 , and both groups were followed for 8 months . Study outcomes were assessed at baseline and at 16 and 32 weeks after r and omization . The primary outcome measures were the proportions of patients achieving BP , TC , and BP/TC therapeutic goals ( BP lower than 140/90 mm Hg for patients with uncomplicated hypertension and lower than 130/80 mm Hg for patients with diabetes , chronic kidney disease , or history of myocardial infa rct ion or stroke ; TC lower than 200 mg per dL for patients without CVD and lower than 175 mg per dL for patients with CVD ) . Secondary outcomes were mean BP and TC values . BP was assessed manually by the pharmacist after a 10-minute rest in the supine position . This measurement was performed twice for every participant , and the average of the 2 measurements was calculated . TC was measured by the pharmacist during the study visit using the enzymatic dry method . Statistical analyses were performed using 2-tailed McNemar tests , Pearson chi-square tests , and Student 's t-tests ; P < 0.05 was considered statistically significant . RESULTS 714 patients were included in the study ( 356 intervention , 358 control ) , and the mean [ SD ] age was 62.8 [ 8.1 ] years . The 2 groups were similar at baseline in clinical and demographic characteristics , including the proportion of patients at therapeutic goals for BP , TC , and BP/TC . After 8 months of follow-up , there were statistically significant differences in favor of pharmaceutical care in the proportions of patients who achieved therapeutic goals for BP ( 52.5 % vs. 43.0 % , P=0.017 ) , TC ( 56.5 % vs. 44.1 % , P=0.001 ) , and BP/TC ( 37.1 % vs. 21.8 % , P < 0.001 ) . CONCLUSION Compared with usual care plus written education , pharmaceutical care focused on patient evaluation and follow-up in collaboration with physicians improved the achievement of BP , TC , and BP/TC treatment goals in patients with CVD and /or high or intermediate CV risk attending community pharmacies in Spain OBJECTIVE To evaluate the adequacy of management of modifiable risk factors ( MRF ) in a group of ischemic stroke out patients and the value of pharmacist intervention in a r and omized controlled study in a tertiary referral hospital . METHODS 160 ischemic stroke out patients from the same catchment area and with the same financial arrangements for healthcare , went through a 6-month equal allocation stratified r and omized study . Routine practice was not altered except for a monthly 1-hour pharmacist-intervention education programme . We evaluated the differences in blood pressure ( BP ) , blood glucose and lipid profiles before and after study . The proportion of patients with adequate management of MRF  was studied . RESULTS There were no differences in the demographic characteristics , MRF and medications prescribed throughout the study . Before the study , the proportions of adequate control of BP in the control and intervention groups were 43 % vs. 40 % ( P = 0.64 ) , lipid 27 % vs. 13 % ( P = 0.09 ) and glucose 36 % vs. 21 % ( P = 0.15 ) . At the end of the study , the corresponding proportions were for BP 43 % vs. 83 % ( P = 0.00 ) , lipid 27 % vs. 40 % ( P = 0.16 ) and glucose 46 % vs. 35 % ( P = 0.40 ) . CONCLUSION Pharmacist intervention was associated with improved BP control but not with the other MRF . Earlier initiation and longer duration of intervention may improve the outcome further , and whether targeting of high-risk subjects may be particularly rewarding is worthy of investigation STUDY OBJECTIVE To evaluate whether a simple pharmacist protocol , consisting of patient screening and cardiovascular risk stratification , identification and reminders about uncontrolled risk factors , and drug adherence support , can significantly reduce cardiovascular risk . DESIGN Prospect i ve , r and omized , controlled pilot study . SETTING Large primary care medical clinic in Saskatoon , Saskatchewan , Canada . PATIENTS One hundred seventy-six adult patients ( mean age 60 yrs ) who exhibited a 10-year Framingham risk score of 15 % or greater , or a coronary artery disease risk equivalent ( coronary artery disease , peripheral artery disease , cerebrovascular disease , or diabetes mellitus ) . INTERVENTION Eligible patients initially met with the pharmacist to receive general counselling about cardiovascular disease and were then r and omly assigned to receive ongoing follow-up by the pharmacist ( follow-up group [ 88 patients ] ) or to return to usual care ( single-contact group [ 88 patients ] ) for a minimum of 6 months . MEASUREMENTS AND MAIN RESULTS The primary end point was mean reduction in the 10-year Framingham risk score . Secondary end points included individual modifiable risk factors ( systolic and diastolic blood pressures ; total cholesterol , low-density lipoprotein cholesterol , high-density lipoprotein cholesterol [ HDL ] , and triglyceride levels ; total cholesterol : HDL ratio ; and hemoglobin A(1c ) value ) , as well as statin utilization , initiation , and adherence rates . Baseline characteristics were similar across both groups . Neither the mean reduction in 10-year risk ( -2.68 for the follow-up group and -1.25 for the single-contact group , one-tailed p=0.098 ) nor individual risk factors were significantly different between groups . The proportion of patients exhibiting statin adherence of 80 % or greater did not significantly differ between groups at study end ( 73.1 % [ 57/78 ] and 80.0 % [ 52/65 ] , respectively , p=0.333 ) . However , 85.2 % ( 75/88 ) in the follow-up group continued with statin therapy at the end of the study compared with 67.0 % ( 59/88 ) in the single-contact group ( p=0.005 ) . Statin initiations were more frequent in the follow-up group than in the single-contact group ( 75.0 % [ 30/40 ) vs 48.9 % [ 22/45 ] , p=0.013 ) . CONCLUSION This simple cardiovascular care protocol for nonspecialist pharmacists did not result in a clear improvement to cardiovascular risk reduction success among patients in a primary care medical clinic . The intervention did , however , appear to improve statin utilization Background and Purpose — Stroke recurrence rates are high ( 20%–25 % ) and have not declined over past 3 decades . This study tested effectiveness of motivational interviewing ( MI ) for reducing stroke recurrence , measured by improving adherence to recommended medication and lifestyle changes compared with usual care . Methods — Single-blind , prospect i ve phase III r and omized controlled trial of 386 people with stroke assigned to either  MI treatment ( 4 sessions at 28 days , 3 , 6 , and 9 months post stroke ) or usual care ; with outcomes assessed at 28 days , 3 , 6 , 9 , and 12 months post stroke . Primary outcomes were change in systolic blood pressure and low-density lipoprotein cholesterol levels as indicators of adherence at 12 months . Secondary outcomes included self-reported adherence , new stroke , or coronary heart disease events ( both fatal and nonfatal ) ; quality of life ( Short Form-36 ) ; and mood ( Hospital Anxiety and Depression Scale ) . Results — MI did not significantly change measures of blood pressure ( mean difference in change , −0.2.35 [ 95 % confidence interval , −6.16 to 1.47 ] ) or cholesterol ( mean difference in change , −0.0.12 [ 95 % confidence interval , −0.30 to 0.06 ] ) . However , it had positive effects on self-reported medication adherence at 6 months ( 1.979 ; 95 % confidence interval , 0.98–3.98 ; P=0.0557 ) and 9 months ( 4.295 ; 95 % confidence interval , 1.56–11.84 ; P=0.0049 ) post stroke . Improvement across other measures was also observed , but the differences between MI and usual care groups were not statistically significant . Conclusions — MI improved self-reported medication adherence . All other effects were nonsignificant , though in the direction of a treatment effect . Further study is required to determine whether MI leads to improvement in other important areas of functioning ( eg , caregiver burden ) . Clinical Trial Registration — URL : http://www.anzctr.org.au . Unique identifier : ACTRN-12610000715077 How do you obtain a valid assessment of subjective outcomes in a trial in which the participants can not be blinded to the intervention ? Bias is inevitable from unblinded patients , but trials that have not told patients about treatment in all arms have been heavily criticised . Asking participants to consent to postponed information could be a solution The most powerful tool for study ing the effectiveness of a medical treatment is a r and omised controlled clinical trial with blinded assessment of outcomes . However , blinding is not always possible — for example , in a trial comparing a surgical intervention with non-surgical treatment or the effectiveness of supplemental care compared with conventional care . Blinding needs special attention in such studies in order to prevent bias . When outcomes are assessed by doctors , it is often easy for the assessment to be done by doctors other than those who performed the procedure . However , when studies measure patients ' assessment of outcomes , blinding is much more complicated or even impossible . ! [ ] [ 1 ] Credit : PETER GRAY Unblinded patients who assess outcomes after being informed about the different treatment options during recruitment might bias the results of a study . The likelihood of bias increases when patients have a preference for one of the treatment options . For example , patients may have been told during recruitment that the new or supplemental strategy has been developed because the current strategy has disadvantages . The best way to obtain valid assessment s in such studies remains unclear . Intense debate was generated when research ers tried to mask patients … [ 1 ] : SIR— Interventions with an educational or counselling component have been reported to be effective in a variety of patient groups to encourage smoking cessation [ 1 ] , lower blood pressure ( BP ) [ 2 , 3 ] , achieve modest reductions in cholesterol [ 4 ] , and promote weight loss [ 5 ] . Evaluation of the impact of education on physical outcomes is lacking in stroke disease , despite evidence that inadequate provision of information may adversely affect compliance with secondary prevention and psychosocial outcomes [ 6 ] . We describe a single-blind r and omised controlled trial of health education and counselling for patients with stroke or transient ischaemic attack ( TIA ) , and its effects on risk factors , satisfaction , mood and perceived health status Background Small subcortical strokes , also known as lacunar strokes , comprise more than 25 % of brain infa rcts , and the underlying vasculopathy is the most common cause of vascular cognitive impairment . How to optimally prevent stroke recurrence and cognitive decline in S3 patients is unclear . The aim of the Secondary Prevention of Small Subcortical Strokes study ( Trial registration : NCT00059306 ) is to define strategies for reducing stroke recurrence , cognitive decline , and major vascular events . Methods Secondary Prevention of Small Subcortical Strokes is a r and omised , multicentre clinical trial ( n=3000 ) being conducted in seven countries , and sponsored by the US NINDS/NIH . Patients with symptomatic small subcortical strokes in the six-months before and an eligible lesion on magnetic resonance imaging are simultaneously r and omised , in a 2 × 2 factorial design , to antiplatelet therapy – 325 mg aspirin daily plus 75 mg clopidogrel daily , vs. 325 mg aspirin daily plus placebo , double-blind – and to one of two levels of systolic blood pressure targets –‘intensive ’ ( < 130 mmHg ) vs. ‘ usual ’ ( 130–149 mmHg ) . Participants are followed for an average of four-years . Time to recurrent stroke ( ischaemic or haemorrhagic ) is the primary outcome and will be analysed separately for each intervention . The secondary outcomes are the rate of cognitive decline and major vascular events . The primary and most secondary outcomes are adjudicated central ly by those unaware of treatment assignment . Conclusions Secondary Prevention of Small Subcortical Strokes will address several important clinical and scientific questions by testing two interventions in patients with recent magnetic resonance imaging-defined lacunar infa rcts , which are likely due to small vessel disease . The results will inform the management of millions of patients with this common vascular disorder OBJECTIVE We aim ed to examine whether better use of preventive methods and treatments of cardiovascular disease would reduce recurrent events in home-dwelling patients 75 years or older . METHODS This was a r and omized , controlled trial ( a practical clinical trial , the DEBATE ) , conducted in 2000 to 2003 in Helsinki , Finl and . We recruited 400 vascular patients with mean age of 80 years from the community , and they were r and omly assigned to the intervention group ( n = 199 ) where both nonpharmacological and pharmacological cardiovascular treatments were optimized by a geriatrician according to current guidelines . The control group ( n = 201 ) received the usual care . Main outcome measures were major cardiovascular disease events and total mortality and changes in risk factors and medications . RESULTS The groups were balanced at baseline . Mean duration of follow-up was 3.4 years . At 3 years , drug treatments had become more evidence -based in the intervention group . Consequently , total and low-density lipoprotein cholesterol levels ( P < .0001 ) and systolic ( P = .005 ) and diastolic ( P = .009 ) blood pressure were significantly improved in the intervention group . However , neither primary end points ( 52 and 53 events in the intervention and control groups , respectively ) nor total mortality ( 36 and 35 deaths ) were significantly different between the two groups . No special adverse effects were encountered . CONCLUSION It was possible and safe to institute evidence -based cardiovascular treatments and improve risk factors in patients 75 years or older in a pragmatic setting . During 3.4 years , however , this was not converted to clinical benefits Objectives . Ethnic minority groups are at a higher risk of stroke and heart disease . However , design ing effective prevention strategies requires responding to the needs of different ethnic groups . The aims of this study were to estimate the prevalence of four behavioural risk factors ( smoking , drinking , exercise and weight ) for stroke among Black Caribbeans , Black Africans and Whites , and also to examined reported willingness to change these behaviours . Design . A r and om sample of 311 Black Caribbean , 300 White , and 105 Black Africans aged 45 - 74 registered with 16 practice s in south London were surveyed in 1995 . Information was obtained on smoking , drinking and exercise patterns , body mass index and perceptions of being at risk of stroke , and willingness to change risk behaviour . Results . White respondents ( 31 % age and sex st and ardised prevalence ) were more likely to smoke than Black Caribbeans ( 23 % ) and Black Africans ( 10 % ) ( p < 0.001 ) . Self-reported rates of drinking were higher than the government 's ' sensible drinking levels ' for 19 % of Whites , 11 % of Black Caribbeans and 4 % Black Africans ( p < 0.001 ) . In contrast , fewer Whites ( 51 % ) were overweight ( BMI > 27 ) than Black Caribbeans ( 60 % ) and Black Africans ( 68 % ) ( p = 0.001 ) . A high proportion of smokers wished to give up ( 89 % Black African ; 83 % Black Caribbean ; 74 % White ) . A higher proportion of Black Caribbeans ( 35 % ) reported a willingness to reduce their alcohol intake compared to only 15 % of Whites ( p = 0.040 ) . There was a difference between groups in attitudes to weight reduction with 69 % Black Caribbean women expressing a desire to be thinner compared to 86 % Whites and 82 % Black Africans ( p = 0.051 ) . Conclusion . Strategies to reduce behavioural risk factors for heart attack and stroke need to emphasise different risk factors among ethnic groups , especially in relation to alcohol use in the White population and weight in the Black Caribbean population . Influencing the change of these behaviours requires working in partnership with local community groups BACKGROUND 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 . Underst and ing 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 . METHODS The Adherence eValuation After Ischemic Stroke Longitudinal ( AVAIL ) registry is a prospect i ve 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 . RESULTS 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 . CONCLUSIONS 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 BACKGROUND Survivors of ischemic stroke/transient ischemic attack ( TIA ) are at high risk for other vascular events . We evaluated the impact of 2 types of case management ( hard touch with pharmacist or soft touch with nurse ) added to usual care on global vascular risk . METHODS This is a prespecified secondary analysis of a 6-month trial conducted in out patients with recent stroke/TIA who received usual care  and were r and omized to additional monthly visits with either nurse case managers ( who counseled patients , monitored risk factors , and communicated results to primary care physicians ) or pharmacist case managers ( who were also able to independently prescribe according to treatment algorithms ) . The Framingham Risk Score [ FRS ] ) and the Cardiovascular Disease Life Expectancy Model ( CDLEM ) were used to estimate 10-year risk of any vascular event at baseline , 6 months ( trial conclusion ) , and 12 months ( 6 months after last trial visit ) . RESULTS Mean age of the 275 evaluable patients was 67.6 years . Both study arms were well balanced at baseline and exhibited reductions in absolute global vascular risk estimates at 6 months : median 4.8 % ( Interquartile range ( IQR ) 0.3%-11.3 % ) for the pharmacist arm versus 5.1 % ( IQR 1.9%-12.5 % ) for the nurse arm on the FRS ( P = .44 between arms ) and median 10.0 % ( 0.1%-31.6 % ) versus 12.5 % ( 2.1%-30.5 % ) on the CDLEM ( P = .37 ) . These reductions persisted at 12 months : median 6.4 % ( 1.2%-11.6 % ) versus 5.5 % ( 2.0%-12.0 % ) for the FRS ( P = .83 ) and median 8.4 % ( 0.1%-28.3 % ) versus 13.1 % ( 1.6%-31.6 % ) on the CDLEM ( P = .20 ) . CONCLUSIONS Case management by nonphysician providers is associated with improved global vascular risk in patients with recent stroke/TIA . Reductions achieved during the active phase of the trial persisted after trial conclusion Proven strategies to reduce risk of stroke recurrence are under‐utilized . We sought to evaluate the impact of st and ardized stroke discharge orders on treatment practice s in a cluster‐r and omized trial
target: There were no significant effects of organisational  interventions on lipid profile , HbA1c , medication adherence or recurrent cardiovascular events .
  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 .
background: 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 .