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Interventions for improving modifiable risk factor control in the secondary prevention of stroke

  1. Kate E Lager1,*,
  2. Amit K Mistri2,
  3. Kamlesh Khunti1,
  4. Victoria J Haunton2,
  5. Aung K Sett2,
  6. Andrew D Wilson1

Editorial Group: Cochrane Stroke Group

Published Online: 2 MAY 2014

Assessed as up-to-date: 9 APR 2013

DOI: 10.1002/14651858.CD009103.pub2


How to Cite

Lager KE, Mistri AK, Khunti K, Haunton VJ, Sett AK, Wilson AD. Interventions for improving modifiable risk factor control in the secondary prevention of stroke. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD009103. DOI: 10.1002/14651858.CD009103.pub2.

Author Information

  1. 1

    University of Leicester, Department of Health Sciences, Leicester, UK

  2. 2

    University of Leicester, Department of Cardiovascular Sciences, Leicester, UK

*Kate E Lager, Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP, UK. katelager@gmail.com.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 2 MAY 2014

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Description of the condition

Stroke is defined as a rapidly developing neurological deficit, of presumed vascular origin, lasting for over 24 hours or leading to death (WHO 1978). Transient ischaemic attack (TIA) is an expression traditionally used to describe comparable neurological deficits lasting for less than 24 hours (Albers 2002; Easton 2009). More recently a new definition of TIA has been proposed, omitting the arbitrary 24 hour time frame and identifying TIA as a "transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischaemia, without acute infarction" (Easton 2009).

The World Health Organization has reported that cerebrovascular disease (stroke) is the second leading cause of mortality and disease burden among adults aged 60 years and over (WHO 2003). Stroke survivors are 15 times more likely to have a stroke in the year following the primary event compared with the general population (Burn 1994). Furthermore, TIA patients constitute a high risk group for subsequent stroke with an early risk of 9.9%, 13.4% and 17.3% at two, 30 and 90 days, respectively (Wu 2007). Long-term cohort studies have demonstrated that the risk of cardiovascular events remains high for at least 10 years after stroke or TIA (Touze 2005; Van Wijk 2005). Secondary prevention strategies aim to prevent recurrent events by improving modifiable risk factor control. National stroke guidelines identify clinical conditions (hypertension, hyperlipidaemia, atrial fibrillation, diabetes and obesity) and lifestyle factors (smoking, physical inactivity, unhealthy diet and excess alcohol consumption) as significant modifiable risk factors that should be targeted for secondary prevention (ESO 2008; Furie 2011; Lindsay 2010; National Stroke Foundation 2010; RCP 2012; SIGN 2008).

 

Description of the intervention

For the purposes of this review, stroke services are considered to include all services responsible for providing acute and follow-up care to stroke and TIA patients. Stroke services exist as part of diverse healthcare systems, with specific treatment goals varying according to national clinical guidelines. Acute stroke services include organised inpatient (stroke unit) care and specialist TIA clinics (RCP 2012; Stroke Unit Trialists' Collaboration 2013). Recommendations for secondary prevention can be initiated as part of a co-ordinated treatment programme during acute hospitalisation (Ovbiagele 2004). However, primary care services are well placed to monitor patient risk factors, encourage lifestyle change and review secondary prevention medications on an ongoing basis (RCP 2012). Primary care aims to be characterised by person-centredness, comprehensiveness, continuity of care and community participation (Starfield 2002; WHO 2008). Social care services and voluntary sector organisations can also work in partnership with primary care to deliver healthy living support (NAO 2005). Stroke service interventions are termed complex interventions since they often contain several interacting components and may require complex behaviours, organisational change or the assessment of numerous outcome measures (Craig 2008; Redfern 2008).

 

How the intervention might work

Stroke services addressing secondary prevention aim to improve patient compliance with medication regimens and lifestyle advice. Several classes of medication reduce stroke incidence by modifying cardiovascular risk. For example, long-term antiplatelet medication in those with a history of stroke or TIA is associated with a significant 25% reduction in secondary vascular events (Antithrombotic Trialists' Collaboration 2002). Similarly, antihypertensive and statin medications are associated with improvements in secondary prevention (Manktelow 2009; Rashid 2003). Meta-analyses report that moderate to high physical activity (Lee 2003), moderate alcohol consumption (Reynolds 2003), reduction of salt intake (He 2004) and specific dietary changes (He 2004a; He 2006) can also facilitate stroke prevention and cardiovascular risk reduction. An international case-control study identified five modifiable risk factors accounting for 83% of the population attributable risk (PAR) for stroke (O'Donnell 2010). Targeting multiple risk factors may have additive benefits for secondary prevention; a modelling study predicted that an 80% cumulative risk reduction in recurrent vascular events could be achieved by combining dietary modification, exercise, aspirin, a statin, and an antihypertensive agent (Hackam 2007).

 

Why it is important to do this review

Most stroke patients have at least one cardiovascular risk factor and hypertension, hyperlipidaemia, diabetes, smoking and obesity are often inadequately managed during follow-up (Alvarez-Sabin 2009; Li 2008; Mouradian 2002). Although the effectiveness of secondary prevention medications is well-established, non-treatment rates for antithrombotic, antihypertensive and statin therapies remain high after stroke (Raine 2009) and TIA (Lager 2012). Only 31% of stroke patients and 35% of TIA patients receive combination treatment with all three medication classes (Ramsay 2007). Adherence to secondary prevention medications falls progressively as time since the primary stroke elapses (Glader 2010). As strategies for stroke prevention are not optimally implemented, substantial benefits stand to be gained from improving the use of evidence-based interventions (Goldstein 2008).

Several studies have revealed inequalities in the provision of stroke care with older patients being less likely to receive or adhere to secondary prevention medication (De Schryver 2005; Raine 2009; Ramsay 2007). Similarly, stroke patients with more severe disability (Barthel scores of 14 or less) are less likely to receive appropriate secondary prevention than those with mild disability (Barthel score 15 to 20) (Rudd 2004). Ethnic groups are also reported to differ with respect to patterns in behavioural risk factors for stroke (Dundas 2001). These subgroups of patients may require targeted interventions in order to improve risk factor control.

Service interventions used for other conditions, particularly secondary prevention of ischaemic heart disease, may be relevant to the secondary prevention of stroke (Buckley 2010). However, more direct evidence is needed to guide improvements in follow-up care after stroke or TIA. For example, stroke commonly results in cognitive impairments or physical disabilities that are likely to influence both intervention design and outcomes. To date, there are no systematic reviews that have considered the impact of stroke service interventions on cardiovascular risk factor control or adherence to secondary prevention medications. An assessment of the quality and outcomes of previous studies in this field will inform the development of new interventions.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

The objective of this review was to assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including poor adherence to prescribed medications, and the occurrence of secondary cardiovascular events.

Poor adherence can compromise secondary prevention by reducing the clinical benefits of long-term therapies (WHO 2003a). In the context of this review, 'modifiable risk factors' therefore refer to:

  • clinical conditions (hypertension, hyperlipidaemia, atrial fibrillation, diabetes and obesity);
  • patient non-adherence to secondary prevention medications.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included published or unpublished randomised controlled trials (RCTs) with a minimum follow-up of three months after the start of the intervention. Parallel group trials, cluster-randomised trials and cross-over trials were eligible for inclusion in the review.

 

Types of participants

We included in this review adults (aged 18 years and over) with a confirmed diagnosis of ischaemic stroke, haemorrhagic stroke or TIA.

 

Types of interventions

For the purposes of this review, we defined stroke service interventions as alternative models of care that are implemented in order to improve patient outcomes following stroke or TIA. We included stroke service interventions that were intended to improve modifiable risk factor control. We focused on interventions that aimed to improve modifiable risk factor control through increased adherence to existing recommendations for secondary stroke prevention (for example recommendations in international stroke guidelines).

We considered the following intervention categories (pre-specified in the review protocol).

  • Educational and behavioural interventions for patients.
  • Educational and behavioural interventions for stroke service providers.
  • Organisational interventions (subdivided into the following categories developed by Wensing 2006):

    • revision of professional roles, e.g. involvement of non-physician staff in prevention clinics;
    • collaboration between multidisciplinary teams, e.g. interventions promoting effective liaison between primary and secondary care teams;
    • integrated care services, e.g. disease and case management programs where patient care follows protocols for screening, education and treatment or monitoring;
    • knowledge management systems, e.g. computerised decision support on medication prescribing, shared medical records;
    • quality management, e.g. guideline and protocol development;
    • financial incentives, e.g. the UK Quality and Outcomes Framework (NHS 2009).

We excluded interventions that were intended to improve physical rehabilitation or knowledge of stroke in general, surgical interventions, and interventions testing new pharmacological therapies. We have also excluded exercise training programs for stroke or TIA patients as these are the subject of other Cochrane reviews (MacKay-Lyons 2010; Saunders 2009).

 

Types of outcome measures

 

Primary outcomes

  • Quantitative between-group differences (or target achievement) for blood pressure, lipid profile (total cholesterol, high density lipoprotein (HDL), low density lipoprotein (LDL), triglycerides), glycaemic control in diabetes mellitus (HbA1c), body mass index (BMI) or validated cardiovascular risk score.

  • Any indicator of patient adherence to secondary prevention medications, e.g. self-reported medication adherence or medication persistence, medication possession, individual patient data on prescriptions, pharmacy claims, electronic monitoring, drug tracers in blood or urine.

 

Secondary outcomes

  • Secondary cardiovascular events: stroke, myocardial infarction, or vascular death.

 

Search methods for identification of studies

See the 'Specialised register' section in the Cochrane Stroke Group module. We searched for trials in all languages and arranged for translation of relevant papers published in languages other than English.

 

Electronic searches

We searched the following electronic databases to identify relevant trials:

  • Cochrane Stroke Group Trials Register (April 2013);
  • Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2013);
  • Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (2013, Issue 3) (Appendix 1);
  • MEDLINE in Ovid (1950 to April 2013) (Appendix 2);
  • EMBASE in Ovid (1981 to April 2013) (Appendix 3);
  • CINAHL in EBSCO (1981 to April 2013) (Appendix 4);
  • AMED in Ovid (1985 to April 2013) (Appendix 5);
  • British Nursing Index (BNI) in Ovid (1985 to April 2013) (Appendix 6);
  • Web of Science Conference Proceedings Citation Index - Science (1970 to April 2013) (Appendix 7);
  • Index to UK theses (April 2013) (http://www.theses.com/);
  • BiblioMap (health promotion research) (April 2013) (http://eppi.ioe.ac.uk/webdatabases/Intro.aspx?ID=7).

In addition, we searched the following databases of ongoing trials and grants registers:

We developed the search strategy with the help of Brenda Thomas (Cochrane Stroke Group Trials Search Co-ordinator) and Dr Brian Buckley of the National University of Ireland (Buckley 2010). We adapted the MEDLINE search strategy (Appendix 2) to search other databases.

 

Searching other resources

We used the Science Citation Index Cited Reference Search to search for studies citing included trials. We also checked the reference lists of included trials, relevant systematic reviews and relevant meta-analyses. We contacted authors and trialists involved in included trials in order to facilitate identification of ongoing trials and unpublished studies.

 

Data collection and analysis

 

Selection of studies

Two review authors (KL and a second review author) independently assessed the titles, abstracts and keywords of all records retrieved from the electronic searches and excluded obviously irrelevant studies. We obtained the full texts of the remaining studies and two authors independently selected studies for inclusion based on the following criteria. The study:

  1. was an RCT;
  2. restricted participants to TIA or stroke patients, or reported outcomes separately for TIA or stroke patient subgroups;
  3. evaluated a stroke service intervention;
  4. stated or clearly implied that the intention of an intervention was to improve modifiable risk factor control;
  5. assessed one or more of the defined outcome measures;
  6. did not include physical rehabilitation programs, new pharmacological therapies, surgical procedures, exercise training programmes, or educational programmes intended to improve knowledge of stroke in general.

We resolved any disagreements regarding study eligibility by discussion between all review authors.

 

Data extraction and management

Two review authors independently extracted outcome data for each eligible trial using a pre-specified data extraction form. One review author extracted data for all eligible studies (KL) and a second review author (AKS, VH) independently repeated data extraction for each study. We resolved disagreements by discussion to reach consensus, with review authors referring back to the original article.

We recorded the following information for each study.

  1. General information: published or unpublished, title, authors, journal or source, publication date, country of origin, publication language.
  2. Study methods: unit of randomisation (and method), allocation concealment (and method), blinding (outcome assessors), validation of questionnaires.
  3. Participants: sampling (random or convenience), place of recruitment, total sample size, numbers randomised, inclusion criteria, exclusion criteria, demographic characteristics (age, gender, ethnicity, socioeconomic or sociodemographic status), disability (modified Rankin score, Barthel score), co-morbidities, similarity between groups at baseline, dropout and withdrawal rates.
  4. Intervention details: components, length, frequency, location, mode of delivery, personnel responsible for delivery, timing post-stroke, details of control protocol.
  5. Outcomes: pre-specified outcomes defined above, follow-up intervals from start of intervention, units of measurement, missing data.
  6. Results: results for pre-specified outcomes, number of participants assessed, method of analysis (intention-to-treat analysis, per protocol analysis).
  7. Intervention category: pre-specified in the review protocol.

 

Assessment of risk of bias in included studies

One review author (KL) assessed the quality of all eligible trials. The review author was not blinded to study details (for example author, journal, results) when assessing the methods. We assessed the quality of each RCT according to the Cochrane Collaboration's tool for assessing risk of bias. We excluded the blinding of participants and healthcare providers from the assessment since these criteria were unlikely to be met given the nature of the interventions under consideration. We assessed the risk of bias across six domains (sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, selective outcome reporting and other sources of bias) and summarised the results narratively. We contacted study authors to retrieve missing information. If study authors did not provide the requested information, we recorded the relevant items on the risk of bias assessment as 'unclear'. We have summarised the risk of bias according to the following criteria (Higgins 2011).

  1. Low risk of bias: low risk of bias for all domains.
  2. Unclear risk of bias: unclear risk of bias for one or more domains.
  3. High risk of bias: high risk of bias for one or more domains.

 

Measures of treatment effect

A mixture of continuous outcomes and dichotomous outcomes were reported by studies included in this review. Where possible, we have reported data in terms of mean difference (MD) and 95% confidence interval (CI) for continuous data. For dichotomous data, we have reported risk ratios (RR) or odds ratios (OR) and 95% CIs. If individual studies reported continuous and dichotomous data for the same outcome, we have included both variables in the review. We used RevMan 5.2 to carry out statistical analyses (RevMan 2012).

 

Unit of analysis issues

We analysed cluster-RCTs by reporting effect estimates from analyses that accounted for the cluster design. Where necessary, we calculated effective sample sizes for cluster-RCTs and combined these with parallel RCTs in meta-analyses (Higgins 2011a). Where studies included repeated measurements for participants at several time points, we have reported the outcomes recorded at the end of the study per protocol.

 

Dealing with missing data

We contacted authors of included studies in order to request missing data. We planned to perform sensitivity analyses, where appropriate, to explore the effects of including or excluding studies with incomplete data. We imputed missing summary data (for example standard deviations) based on recommendations in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011a). We used sensitivity analyses, where appropriate, to investigate the effect of entering assumed values.

 

Assessment of heterogeneity

We identified heterogeneity from forest plots using the Chi2 test and a significance level of alpha = 0.1. We also quantified heterogeneity using the I2 statistic, where I2 values of 50% or more indicate a substantial level of heterogeneity (Higgins 2002; Higgins 2003). Where appropriate, we assessed possible sources of heterogeneity using sensitivity analyses.

 

Assessment of reporting biases

We used funnel plots to assess publication bias. Visual inspection suggested no asymmetry.

 

Data synthesis

Studies identified by the review were heterogeneous in terms of interventions, settings, patient characteristics and outcome measurements. We used consensus methods to decide whether meta-analysis of study results was appropriate. Where there were sufficient comparable data, we combined results for each outcome to give an overall estimate of treatment effect. We conducted meta-analyses separately for each intervention category, in order to reduce clinical heterogeneity among the studies that were combined to produce pooled estimates. We pre-specified intervention categories in the review protocol. Where meta-analysis was not possible or appropriate, we have presented a qualitative synthesis of intervention effects.

 

Subgroup analysis and investigation of heterogeneity

We planned to analyse outcomes according to the following subgroups:

  • patient age (under 65 years, 65 years and over);
  • condition (ischaemic stroke, haemorrhagic stroke or TIA);
  • stroke severity (e.g. according to the National Institute of Health Stroke Scale (NIHSS)) or disability (e.g. according to the Barthel score or modified Rankin Score (mRS));
  • specific risk factor management strategy (e.g. blood pressure lowering interventions).

However, subgroup analyses were not possible since relevant data were not available from included studies.

 

Sensitivity analysis

We planned to carry out sensitivity analyses if the results of meta-analysis were significant. Where appropriate, we used the following sensitivity analyses to consider whether identified factors were associated with different effect sizes:

  1. repeating analyses excluding unpublished studies;
  2. repeating analyses excluding studies at high or unclear risk of bias;
  3. repeating analyses excluding very large studies to investigate the extent to which they dominated the results;
  4. repeating analyses using different measures of effect size (risk difference, odds ratio etc) and different statistical models (fixed-effect and random-effects models);
  5. repeating analyses to investigate whether the conclusions were affected by assumptions made when dealing with missing data.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of studies awaiting classification; Characteristics of ongoing studies

 

Results of the search

We carried out searches in April 2013 and identified a total of 7757 records after the removal of duplicates (see Figure 1). Title and abstract screening identified 82 studies (211 records) that were potentially eligible for this review.

 FigureFigure 1. Study flow diagram.

Eight potentially eligible studies reported collective outcome data for participants with a broad range of cardiovascular diseases (Amariles 2012; Brotons 2011; Evans 2010; Goessens 2006; Ma 2009; Palanco 2011; Strandberg 2006; Vernooij 2012). We contacted study authors to request outcome data separately for stroke and TIA patients. Two study authors provided unpublished outcome data for stroke and TIA patients and we included these studies in the review (Brotons 2011; Evans 2010). Two study authors reported that separate outcome data for stroke and TIA patients were unavailable (Amariles 2012; Vernooij 2012). The remaining study authors did not respond to requests for additional data and we subsequently excluded four studies from the review (Goessens 2006; Ma 2009; Palanco 2011; Strandberg 2006).

A further 40 studies of potential relevance to this review were not associated with any manuscripts containing outcome data. We therefore attempted to obtain information about the status of these studies by emailing the main study contacts. Five authors supplied unpublished data and we included these studies in the review (Eames 2013; Flemming 2013; Lowrie 2010; O'Carroll 2011; Slark 2013). There were 14 completed trials for which further study information was unavailable (see Characteristics of studies awaiting classification). Correspondence with study contacts confirmed the status of 15 ongoing trials and a further six studies have been classified as ongoing due to their status on clinical trial registers (see Characteristics of ongoing studies).

We excluded a total of 21 studies from this review (see Characteristics of excluded studies for a list of excluded studies and the reasons for exclusion).

 

Included studies

Twenty-six RCTs met the inclusion criteria for this review, of which 23 used a parallel group design (Adie 2010; Allen 2002; Allen 2009; Boter 2004; Boysen 2009; Chanruengvanich 2006; Chiu 2008; Eames 2013; Ellis 2005; Evans 2010; Flemming 2013; Hornnes 2011; Joubert 2009; Kerry 2013; Kim 2013; Lowe 2007; Maasland 2007; MacKenzie 2013; Markle-Reid 2011; O'Carroll 2011; Slark 2013; Wang 2005; Welin 2010) and three used a cluster design (Brotons 2011; Johnston 2010; Lowrie 2010). Detailed information on each can be found in the Characteristics of included studies table.

 

Participants

The trials included a total of 8021 participants with cerebrovascular disease. The mean or median age of participants ranged from 60 to 73 years. Six studies included participants with a diagnosis of ischaemic stroke (Allen 2009; Boysen 2009; Chiu 2008; Johnston 2010; Kim 2013; Slark 2013) whereas three studies included participants with either ischaemic or haemorrhagic stroke (Lowe 2007; Welin 2010) or did not specify stroke subtype (Wang 2005). Ten trials included a broader range of participants with a diagnosis of either stroke or TIA (Allen 2002; Boter 2004; Eames 2013; Ellis 2005; Flemming 2013; Hornnes 2011; Joubert 2009; MacKenzie 2013; Markle-Reid 2011; O'Carroll 2011), with the proportion of TIA patients ranging from 1% (Eames 2013) to 46% (Flemming 2013). Four studies focused only on individuals with minor stroke or TIA (Adie 2010; Chanruengvanich 2006; Kerry 2013; Maasland 2007). Other studies included participants with a history of cardiovascular disease or elevated cardiovascular risk factors, and provided separate unpublished data for stroke and TIA patients (Brotons 2011; Evans 2010; Lowrie 2010).

 

Location

Four of the included trials were conducted in the USA (Allen 2002; Allen 2009; Flemming 2013; Johnston 2010), three in Canada (Evans 2010; MacKenzie 2013; Markle-Reid 2011), 12 in Europe (Adie 2010; Boter 2004; Brotons 2011; Ellis 2005; Hornnes 2011; Kerry 2013; Lowe 2007; Lowrie 2010; Maasland 2007; O'Carroll 2011; Slark 2013; Welin 2010), two in Australia (Eames 2013; Joubert 2009) and four in Asia (Chanruengvanich 2006; Chiu 2008; Kim 2013; Wang 2005). One study was a multi-centre trial conducted in five centres in China and Europe (Boysen 2009).

 

Setting

The majority of studies were set in primary care or community settings (Adie 2010; Allen 2002; Allen 2009; Boter 2004; Boysen 2009; Brotons 2011; Chanruengvanich 2006; Evans 2010; Hornnes 2011; Kerry 2013; Kim 2013; Lowrie 2010; MacKenzie 2013; Markle-Reid 2011; O'Carroll 2011; Wang 2005). Four studies were set in outpatient clinics (Chiu 2008; Ellis 2005; Flemming 2013; Welin 2010) and one was incorporated into a TIA service that provided screening and diagnostic work-up in a single day (Maasland 2007). Another two interventions were performed during hospitalisation for acute stroke (Johnston 2010; Slark 2013). Three further studies were initiated in the hospital setting (Eames 2013; Joubert 2009; Lowe 2007) with two subsequently continuing the intervention in the community (Eames 2013; Joubert 2009).

 

Interventions

See the Characteristics of included studies table for details of interventions (components, length, frequency).

 
Intervention categories

To facilitate analysis and interpretation of study results, we have described interventions according to categories pre-specified in the review protocol (educational and behavioural interventions for patients; educational and behavioural interventions for healthcare providers; organisational interventions as defined according to the taxonomy developed by Wensing 2006). We have summarised the categorisation of interventions in  Table 1. All but three studies included educational or behavioural interventions for patients. Fifty per cent of the studies included integrated care services where patient care was delivered according to protocols for screening, education and treatment or monitoring. Thirty five per cent of studies included educational or behavioural interventions for healthcare providers, which usually involved the provision of guidelines or specification of individual patient targets. Less common intervention elements included revision of professional roles (changes in the tasks carried out by pharmacists), collaboration between multidisciplinary teams, knowledge management systems and quality management. No studies included financial interventions.

The majority of interventions were multifaceted and contained components that were associated with more than one category. However, in order to summarise evidence effectively we categorised interventions according to their predominant components. We decided final category assignments through discussion between review authors to reach consensus. We identified two broad categories of interventions: educational or behavioural interventions for patients and organisational interventions. Predominant intervention categories are highlighted in  Table 1. Several interventions included organisational elements with varying amounts of education (directed towards patients or healthcare professionals). We have categorised these as predominantly organisational interventions since organisational elements were considered to have facilitated or permitted the delivery of education (for example patient education is often a component of integrated care services (Wensing 2006)). Conversely, we classified interventions as predominantly educational or behavioural interventions if they were implemented without changes to the organisation of patient care. A summary of the interventions in each category is provided below.

 
Educational or behavioural interventions for patients

Eleven studies involved educational and behavioural interventions for patients (Adie 2010; Boysen 2009; Chanruengvanich 2006; Chiu 2008; Eames 2013; Kim 2013; Lowe 2007; Maasland 2007; MacKenzie 2013; O'Carroll 2011; Slark 2013). None of these interventions incorporated organisational elements. The content of nine interventions was largely focused on modifiable risk factors for stroke (Adie 2010; Boysen 2009; Chanruengvanich 2006; Chiu 2008; Kim 2013; Maasland 2007; MacKenzie 2013; O'Carroll 2011; Slark 2013). Two interventions delivered education about secondary stroke prevention as part of broader stroke education programmes (Eames 2013; Lowe 2007).

 
Organisational interventions

Fifteen studies involved predominantly organisational interventions. Five interventions addressed secondary stroke prevention as part of a wider set of study aims encompassing post-stroke rehabilitation (interventions with a broad focus) (Allen 2002; Allen 2009; Boter 2004; Markle-Reid 2011; Welin 2010). Although these organisational interventions generally provided some patient education about secondary stroke prevention, this appeared to be delivered on only one occasion (Allen 2002; Allen 2009) or on an opportunistic basis (Boter 2004; Welin 2010). Conversely, secondary prevention was the main aim of the remaining 10 organisational interventions (interventions specifically targeting secondary prevention). Eight of these interventions included an element of patient education or behavioural counselling directed towards secondary stroke prevention (Brotons 2011; Ellis 2005; Evans 2010; Flemming 2013; Hornnes 2011; Joubert 2009; Kerry 2013; Wang 2005). The two remaining interventions did not specify the inclusion of patient education elements but instead directed secondary prevention education towards healthcare professionals (Johnston 2010; Lowrie 2010).

 
Timing

Fifteen studies recruited participants immediately following diagnosis of acute stoke or TIA. These studies initiated interventions prior to hospital discharge (Eames 2013; Johnston 2010; Joubert 2009; Lowe 2007; Maasland 2007; Slark 2013), within one week post-discharge (Allen 2002; Allen 2009; Boter 2004; Wang 2005), within one month post-discharge (Adie 2010; Hornnes 2011) or within three months post-discharge (Boysen 2009; Chanruengvanich 2006; Ellis 2005; Flemming 2013; O'Carroll 2011; Welin 2010). Six studies recruited participants from primary care, outpatient or community settings. Four of these studies initiated interventions within nine months (Kerry 2013), 12 months (Brotons 2011; Kim 2013) or 18 months (Markle-Reid 2011) of stroke or TIA diagnosis; one study initiated the intervention when participants had been attending an outpatient clinic for at least 12 months (Chiu 2008) and two studies did not specify intervention timing (Evans 2010; Lowrie 2010).

Four studies involved interventions that were delivered on a single occasion (Lowe 2007; Maasland 2007; Slark 2013) or on two occasions (O'Carroll 2011). The remaining studies implemented interventions over a time frame ranging from three to 36 months. The majority of interventions had a duration of between three and 12 months.

 
Outcomes

Details of outcomes are provided in the Characteristics of included studies table.

 

Excluded studies

Reasons for excluding studies are provided in the Characteristics of excluded studies table.

 

Risk of bias in included studies

We assessed the risk of bias according to the Cochrane Collaboration's tool for assessing risk of bias. For each study we extracted information about methods of randomisation and allocation concealment, blinding of outcome assessors, incomplete outcome data, selective outcome reporting and any other potential sources of bias. We have presented a detailed assessment of the risk of bias for individual studies in the Characteristics of included studies table. Summary assessments are shown in Figure 2.

 FigureFigure 2. Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

 

Allocation

Inclusion criteria for this review required studies to be randomised. All but three studies reported adequate generation of allocation sequence. Two studies were reported as RCTs but did not provide details of randomisation methods (Chanruengvanich 2006; Chiu 2008). One study reported that participants were "randomly divided into intervention group (146 cases) and control group (52 cases)" (Wang 2005). Although the use of randomised methods can be inferred from this statement, the large imbalances in group size were not explained and this study has therefore been included but considered at high risk of bias.

Criteria for adequate allocation concealment were met by all but five studies. Three trials failing to report randomisation methods also provided no information about allocation concealment (Chanruengvanich 2006; Chiu 2008; Wang 2005). Another two studies with adequate sequence generation contained no information about allocation concealment (Allen 2002; Kim 2013).

 

Blinding

Ten studies reported blinding of outcome assessors for all outcomes (Allen 2009; Boter 2004; Boysen 2009; Chanruengvanich 2006; Eames 2013; Ellis 2005; Hornnes 2011; Kerry 2013; Markle-Reid 2011). A further three studies reported blinding during assessment of selected outcomes (Allen 2002; Johnston 2010; Welin 2010). There were thus 16 studies for which at least some data were collected by unblinded outcome assessors (Adie 2010; Allen 2002; Brotons 2011; Chiu 2008; Evans 2010; Flemming 2013; Johnston 2010; Joubert 2009; Kim 2013; Lowrie 2010; Maasland 2007; MacKenzie 2013; O'Carroll 2011; Slark 2013; Wang 2005; Welin 2010). Following consideration of these 16 studies, the review authors judged that non-blinding of outcome assessors was unlikely to affect the measurement of objective outcomes such as physiological data (for example blood pressure), information extracted from medical records or information measured through validated questionnaires (Adie 2010; Brotons 2011; Chiu 2008; Evans 2010; Flemming 2013; Kim 2013; Lowrie 2010; MacKenzie 2013; O'Carroll 2011; Slark 2013; Wang 2005; Welin 2010). However, it was unclear whether non-blinding could have affected outcomes obtained from participants via self-report (for example adherence to medication and self-reported cardiovascular events) (Flemming 2013; Joubert 2009; Kim 2013; Maasland 2007; MacKenzie 2013; Slark 2013).

 

Incomplete outcome data

The proportion of study participants completing follow-up ranged from 70% (Brotons 2011) to 100% (Adie 2010; MacKenzie 2013). Two studies did not report the proportion of participants completing follow-up (Chiu 2008; Wang 2005) and in one study information was only available for those participants with baseline and follow-up data (Lowrie 2010). Two studies reported no missing outcome data (Adie 2010; MacKenzie 2013). Nineteen studies reported the reasons for missing outcome data and the review authors judged that reasons were unlikely to be related to the study outcomes (Boter 2004; Boysen 2009; Brotons 2011; Chanruengvanich 2006; Eames 2013; Ellis 2005; Evans 2010; Flemming 2013; Hornnes 2011; Johnston 2010; Joubert 2009; Kerry 2013; Kim 2013; Lowe 2007; Maasland 2007; Markle-Reid 2011; O'Carroll 2011; Slark 2013; Welin 2010). The five remaining studies did not provide enough information about missing outcome data to permit judgement (Allen 2002; Allen 2009; Chiu 2008; Lowrie 2010; Wang 2005).

 

Selective reporting

Protocols were available for 18 of the 26 studies, and 17 appeared to be free of selective outcome reporting (Adie 2010; Allen 2009; Boter 2004; Boysen 2009; Brotons 2011; Chanruengvanich 2006; Eames 2013; Evans 2010; Flemming 2013; Hornnes 2011; Kerry 2013; Lowrie 2010; Maasland 2007; MacKenzie 2013; O'Carroll 2011; Slark 2013; Welin 2010). One study reported the primary outcomes in the pre-specified way, although some secondary outcomes were not reported (Johnston 2010). Protocols could not be obtained for the remaining eight studies (Allen 2002; Chiu 2008; Ellis 2005; Joubert 2009; Kim 2013; Lowe 2007; Markle-Reid 2011; Wang 2005).

 

Other potential sources of bias

We identified no other potential sources of bias.

 

Effects of interventions

 

Blood pressure

Twenty studies reported data on blood pressure, of which eight evaluated educational or behavioural interventions for participants (Adie 2010; Chanruengvanich 2006; Chiu 2008; Lowe 2007; Maasland 2007; MacKenzie 2013; O'Carroll 2011; Slark 2013) and 12 evaluated organisational interventions (Allen 2002; Allen 2009; Brotons 2011; Ellis 2005; Evans 2010; Flemming 2013; Hornnes 2011; Johnston 2010; Joubert 2009; Kerry 2013; Wang 2005; Welin 2010).

 
Educational and behavioural interventions for patients

Pooled data from eight studies (Adie 2010; Chanruengvanich 2006; Chiu 2008; Lowe 2007; Maasland 2007; MacKenzie 2013; O'Carroll 2011; Slark 2013) indicated that educational and behavioural interventions for participants were not associated with significant changes in mean systolic blood pressure ( Analysis 1.1) or mean diastolic blood pressure ( Analysis 1.2). However, the analyses included one large study that was independently associated with reductions in systolic and diastolic blood pressure (Chiu 2008) and consequently the pooled results were associated with a substantial level of statistical heterogeneity ( Analysis 1.1;  Analysis 1.2). Chiu 2008 only reported outcome data for a subgroup of participants with hypertension, so that baseline blood pressure levels were higher and therefore easier to improve upon. When this study was removed from the analyses, pooled data from the remaining studies did not indicate any intervention effects and statistical heterogeneity was reduced. The three studies that reported data on the achievement of blood pressure targets (< 140/90 mmHg or < 130/80 mmHg) indicated that educational and behavioural interventions for patients were not associated with a significant change in the proportion of participants who attained adequate blood pressure control (Adie 2010; Chiu 2008; MacKenzie 2013) ( Analysis 1.3).

 
Organisational interventions

Pooled data from nine studies (Allen 2002; Brotons 2011; Ellis 2005; Evans 2010; Flemming 2013; Hornnes 2011; Joubert 2009; Kerry 2013; Welin 2010) indicated that organisational interventions were associated with a trend towards mean systolic blood pressure reduction, although this did not reach statistical significance (MD -2.57; 95% CI -5.46 to 0.31) ( Analysis 2.1). Pooled data from seven studies (Brotons 2011; Ellis 2005; Evans 2010; Hornnes 2011; Joubert 2009; Kerry 2013; Welin 2010) indicated that organisational interventions were also associated with a non-significant trend towards mean diastolic blood pressure reduction (MD -0.90; 95% CI -2.49 to 0.68) ( Analysis 2.2). The three studies (Ellis 2005; Flemming 2013; Joubert 2009) that were associated with the greatest reductions in systolic blood pressure (values ranging from -6.00 mmHg to -12.09 mmHg) combined integrated care with comprehensive patient education (involving promotion and tracking of adherence to medications and healthy lifestyle behaviours for secondary stroke prevention). These studies focused specifically on secondary stroke prevention and involved regular patient appointments (with a nurse or general practitioner (GP)) and review of multiple stroke risk factors (by a nurse case manager). Nurse case managers informed participants (Ellis 2005) or their GPs (Flemming 2013; Joubert 2009) if risk factors deviated from recommended targets (although nurses themselves did not influence medication prescribing). Consideration of other studies included in the meta-analysis of systolic blood pressure data showed that most evaluated interventions were not focused specifically on secondary stroke prevention due to wider study aims (Allen 2002; Welin 2010) or the inclusion of participants with a range of other cardiovascular diseases (Brotons 2011; Evans 2010). Two other studies that did focus specifically on secondary stroke prevention had a more narrow objective since they focused largely on blood pressure control rather than multiple risk factor reduction (Hornnes 2011; Kerry 2013).

Seven studies evaluating organisational interventions reported data on blood pressure control (Allen 2009; Brotons 2011; Flemming 2013; Hornnes 2011; Johnston 2010; Joubert 2009; Wang 2005). Blood pressure targets varied by study and according to participant co-morbidities, with the majority of studies specifying a blood pressure target of ≤ 140/90 mmHg or ≤ 130/80 mmHg for participants with diabetes. Pooled data indicated that organisational interventions were associated with a borderline significant increase in the proportion of patients who attained blood pressure targets (OR 1.24; 95% CI 0.94 to 1.64) ( Analysis 2.3). However, one study included in the meta-analysis independently demonstrated that a larger proportion of intervention group participants attained a target systolic blood pressure of < 140 mmHg at follow-up when compared with control group participants (OR 2.19; 95% CI 1.16 to 4.15) (Joubert 2009).

 

Cholesterol

 

Total cholesterol

Thirteen studies reported cholesterol data, of which six included educational and behavioural interventions for patients (Adie 2010; Chanruengvanich 2006; Chiu 2008; Kim 2013; Maasland 2007; Slark 2013) and seven included predominantly organisational interventions (Allen 2009; Brotons 2011; Ellis 2005; Evans 2010; Joubert 2009; Lowrie 2010; Wang 2005).

 
Educational and behavioural interventions for patients

Pooled data from six studies indicated that educational and behavioural interventions for patients were not associated with changes in mean total cholesterol levels (Adie 2010; Chanruengvanich 2006; Chiu 2008; Kim 2013; Maasland 2007; Slark 2013) ( Analysis 1.4). Only one study reported achievement of total cholesterol targets (total cholesterol ≤ 4 mmol/L) and found no significant difference between the intervention and control groups (Adie 2010) ( Analysis 1.5).

 
Organisational interventions

Organisational interventions were not associated with changes in mean total cholesterol levels (Brotons 2011; Ellis 2005; Evans 2010; Joubert 2009; Lowrie 2010) ( Analysis 2.4). Pooled data from four studies (Allen 2009; Joubert 2009; Lowrie 2010; Wang 2005) indicated that organisational interventions were not associated with changes in the achievement of total cholesterol targets, although the substantial level of statistical heterogeneity observed in this analysis (I2 = 85%) meant that results should be interpreted with caution. It should be noted in this meta-analysis that the outlying study with the largest effect sizewas considered at high risk of bias due to concerns about the adequacy of the randomisation procedures (Wang 2005). Furthermore, the authors of this trial did not specify risk factor targets, stating instead that the results of blood fat tests were either classified as qualified or disqualified. When we removed this study from the meta-analysis, we saw no changes in the achievement of total cholesterol targets (varying from < 4.0 to < 5.0 mmol/L) when the data from the remaining three studies were pooled, and statistical heterogeneity was reduced (I2 = 15%).

 

Low density lipoprotein (LDL)

Five studies reported LDL data, of which two evaluated educational and behavioural interventions for patients (Chiu 2008; Maasland 2007) and three evaluated organisational interventions (Brotons 2011; Evans 2010; Flemming 2013).

 
Educational and behavioural interventions for patients

Pooled data from two studies (Chiu 2008; Maasland 2007) indicated that educational and behavioural interventions for patients were not associated with changes in mean LDL levels, although a substantial level of statistical heterogeneity was observed in this analysis (I2 = 61%) ( Analysis 1.6). One of the two studies included in the analysis was individually associated with improvements in LDL levels (MD -0.39 mmol/L; 95% CI -0.73 to -0.05). However, data were only presented for a subgroup of study participants with hypercholesterolaemia (i.e. those with the greatest potential for improvement) (Chiu 2008). Maasland 2007 reported significant reductions in LDL during the course of the study for both the intervention and control groups, with no significant differences between the groups. Only Chiu 2008 presented data on the achievement of LDL targets (LDL < 2.6 mmol/L or, if LDL not available, TC < 4.1 mmol/L) and no significant improvements were reported (Chiu 2008).

 
Organisational interventions

There were no significant effects of organisational interventions on mean LDL levels (Brotons 2011; Evans 2010; Flemming 2013) ( Analysis 2.6). Flemming 2013 reported data on the achievement of LDL targets (fasting LDL <  2.6 mmol/L; optional goal < 1.8 mmol/L) and no significant differences were observed between the intervention and control groups ( Analysis 2.7).

 

High density lipoprotein (HDL)

Four studies reported data on HDL, of which one evaluated an educational or behavioural intervention for patients (Chanruengvanich 2006) and three evaluated organisational interventions (Brotons 2011; Evans 2010; Flemming 2013).

 
Educational and behavioural interventions for patients

One study reported mean HDL levels and no significant intervention effect was observed (Chanruengvanich 2006) ( Analysis 1.7). No studies reported data on HDL target achievement.

 
Organisational interventions

No significant intervention effects on mean HDL levels were observed when data from three studies were pooled (Brotons 2011; Evans 2010; Flemming 2013) ( Analysis 2.8). Flemming 2013 reported data on HDL target achievement (fasting HDL > 1.0 mmol/L in men; > 1.3 mmol/L in women) and no significant differences were observed between the intervention and control groups.

 

Triglycerides

Six studies reported data on triglycerides. Three studies involved educational and behavioural interventions for patients (Chiu 2008; Kim 2013; Maasland 2007) and three involved organisational interventions (Brotons 2011; Evans 2010; Flemming 2013).

 
Educational and behavioural interventions for patients

There were no effects of patient educational and behavioural interventions on mean triglyceride levels (Chiu 2008; Kim 2013; Maasland 2007) ( Analysis 1.8). No studies reported data on triglyceride target achievement.

 
Organisational interventions

There were no effects of organisational interventions on mean triglyceride levels (Brotons 2011; Evans 2010; Flemming 2013) ( Analysis 2.10). Flemming 2013 reported data on the achievement of triglyceride targets (fasting triglycerides < 1.7 mmol/L) and no significant differences were observed between the intervention and control groups ( Analysis 2.11).

 

HbA1c

Six studies reported data on HbA1c outcomes. These outcomes were not restricted to individuals with diabetes. One study evaluated a patient educational or behavioural intervention (Chiu 2008) while five studies evaluated organisational interventions (Allen 2009; Ellis 2005; Evans 2010; Flemming 2013; Wang 2005).

 
Educational and behavioural interventions for patients

No studies reported mean HbA1c levels. One study reported an outcome relating to HbA1c target achievement (HbA1c < 7% or fasting blood glucose < 7.0 mmol/L or random postprandial blood glucose < 11.1 mmol/L) and no significant differences between the intervention and control groups were observed (Chiu 2008) ( Analysis 1.9).

 
Organisational interventions

Pooled data from three studies (Ellis 2005; Evans 2010; Flemming 2013) indicated that there were no effects of organisational interventions on mean HbA1c levels ( Analysis 2.12). Data from three studies (Allen 2009; Flemming 2013; Wang 2005) could be pooled for achievement of HbA1c targets and no significant intervention effect was observed, although a considerable level of statistical heterogeneity was present (I2 = 96%) ( Analysis 2.13). The outlying study in this analysis was considered to be at high risk of bias due to concerns about the adequacy of randomisation procedures (Wang 2005). When the data reported by Wang 2005 were removed from the meta-analysis, no significant differences in the achievement of HbA1c targets (varying from ≤ 6.5% to ≤ 7.0%) were observed between the intervention and control groups and statistical heterogeneity was reduced (I2 = 38%).

 

Body mass index (BMI)

Five studies reported BMI results, of which one evaluated a patient educational or behavioural intervention (Maasland 2007) and four evaluated organisational interventions (Brotons 2011; Flemming 2013; Joubert 2009; Wang 2005).

 
Educational and behavioural interventions for patients

One study reported data on mean BMI and no significant intervention effects were observed (Maasland 2007) ( Analysis 1.10). No data were available on BMI target achievement.

 
Organisational interventions

Pooled data from three studies (Brotons 2011; Flemming 2013; Joubert 2009) indicated a trend towards a reduction in mean BMI levels (MD -0.68 kg/m2; 95% CI -1.46 to 0.11) ( Analysis 2.14) although this did not reach statistical significance. Two studies measured the achievement of BMI targets (Flemming 2013; Wang 2005) ( Analysis 2.15). In one study, the intervention was associated with improvements in BMI target achievement that bordered on statistical significance (OR 1.73; 95% CI 0.93 to 3.25). However, the study was considered at high risk of bias and the BMI target was not specified (Wang 2005). In the second study no significant differences in the achievement of the specified BMI target (< 25 kg/m2) were observed between the intervention and control groups (Flemming 2013).

 

Cardiovascular risk score

 
Organisational interventions

One study involving an organisational intervention reported data on the Framingham cardiovascular risk scores (Flemming 2013). The Framingham point score can be translated to provide an estimate of an individuals's 10-year risk of developing cardiovascular disease (Anderson 1991; Wilson 1998). Flemming 2013 reported that the intervention group demonstrated a significantly greater reduction in Framingham cardiovascular risk score when compared with the control group (MD -6.50; 95% CI -10.22 to -2.78) ( Analysis 2.16), although it was not possible from the available study data to discern the magnitude of cardiovascular risk reduction.

 

Adherence to secondary prevention medications

Thirteen studies measured adherence to secondary prevention medications, of which six involved educational and behavioural interventions for patients (Eames 2013; Kim 2013; Maasland 2007; MacKenzie 2013; O'Carroll 2011; Slark 2013) and seven involved organisational interventions (Allen 2009; Boter 2004; Ellis 2005; Flemming 2013; Hornnes 2011; Johnston 2010; Joubert 2009).

 
Educational and behavioural interventions for patients

Six studies reported the effects of patient education on adherence to secondary prevention medications (Eames 2013; Kim 2013; Maasland 2007; MacKenzie 2013; O'Carroll 2011; Slark 2013). These data could not be pooled due to methodological heterogeneity (differences in outcome measurements). It should be noted that only Eames 2013 reported adequate blinding of outcome assessors. It was judged that non-blinding of outcome assessors may have influenced the data collected by four studies that assessed participants' self-reported medication adherence during face-to-face or telephone interviews with outcome assessors (Kim 2013; Maasland 2007; MacKenzie 2013; Slark 2013). However, it was judged that non-blinding of outcome assessors was unlikely to affect the adherence outcome data collected by O'Carroll 2011 since this was obtained using: (1) a previously validated questionnaire that was administered to patients, and (2) electronic pill containers. Similarly, it was judged that non-blinding of outcome assessors was unlikely to affect adherence outcome data obtained via a pharmacist review of prescription renewal patterns (MacKenzie 2013). Please see the Characteristics of included studies table for full evaluations of the risk of bias for the included studies.

The majority of studies measuring medication adherence outcomes found no significant differences between the intervention and control groups on any indicator of adherence. The studies by Eames 2013, Kim 2013, Maasland 2007 and Slark 2013 found no significant differences between the intervention and control groups in participants' self-reported adherence to secondary prevention medications. MacKenzie 2013 evaluated adherence to antihypertensive medication through participants' self-reported missed medication doses and a pharmacist-led review of participants' prescription renewal patterns: no significant differences in the number of missed pills or prescription renewals were observed between the intervention and control groups.

Only one study (O'Carroll 2011) reported significant differences in medication adherence between the participants in the intervention and control groups. O'Carroll 2011 conducted a repeated measures analysis of self-reported adherence to antihypertensive medication over a time frame of three months, assessed using the Medication Adherence Report Scale (Horne 2006), and reported a "significantly greater improvement in the intervention group" with regards to total medication adherence (P = 0.027), although the clinical implications of this effect could not be discerned from the available study data. Conversely, this study found no significant differences between groups in terms of non-intentional non-adherence and intentional non-adherence. O'Carroll 2011 also evaluated antihypertensive medication adherence by obtaining data from electronic pill containers to determine the "percentage of doses taken", "percentage of days on which the correct dose was taken" and "percentage of doses taken on schedule". The trialists reported that "the intervention group had higher adherence on all measures than the control group, although this was only significant for percentage doses taken on schedule (P = 0.048)”. More specifically, it was reported that the intervention group took 9.79% (SD 16.59) more doses on schedule when compared with the control group (O'Carroll 2011).

 
Organisational interventions

Four studies reported data on the proportion of participants compliant with warfarin therapy (Johnston 2010; Joubert 2009), anticoagulants (Allen 2009) or antithrombotic medication (Flemming 2013). Two studies measured compliance with antihypertensive medication (Hornnes 2011; Johnston 2010) and two measured compliance with statin medication (Flemming 2013; Johnston 2010). Two further studies reported the proportion of participants using secondary prevention medications as prescribed (Boter 2004; Ellis 2005). Medication compliance was either measured through participant self-report (Allen 2009; Boter 2004; Ellis 2005; Flemming 2013; Hornnes 2011; Joubert 2009) or through an analysis of filled prescription data and International Normalised ratio (INR) blood test records (Johnston 2010). Four of the five studies reported blinding of outcome assessors when collecting data on medication compliance (Boter 2004; Ellis 2005; Hornnes 2011; Johnston 2010; Joubert 2009), whereas Joubert et al did not provide any information regarding this (Joubert 2009). Data were not pooled since there was substantial heterogeneity in the methods that were used to obtain outcome data. No individual study reported significant differences in medication compliance between the intervention and control groups.

 

Secondary cardiovascular events

Eleven studies reported data on secondary cardiovascular events. Of these, eight evaluated organisational interventions (Allen 2002; Boysen 2009; Brotons 2011; Ellis 2005; Hornnes 2011; Markle-Reid 2011; Wang 2005; Welin 2010) and two evaluated educational and behavioural interventions for patients (MacKenzie 2013; Slark 2013).

 

Secondary stroke

 
Educational and behavioural interventions for patients

Two studies reported data on the proportion of participants who experienced at least one recurrent stroke (MacKenzie 2013; Slark 2013) ( Analysis 1.11). Blinding of outcome assessors was not reported in either study. MacKenzie 2013 observed no significant difference in the number of recurrent strokes (assessed via a clinical record review) between the intervention and control groups. Slark 2013 observed no recurrent strokes in either the intervention group nor the control group for the duration of the study follow-up.

 
Organisational interventions

Four studies recorded the proportion of participants who experienced at least one recurrent stroke (Allen 2002; Kerry 2013; Wang 2005; Welin 2010). In three of these studies, data on the incidence of recurrent stroke were obtained by blinded outcome assessors via clinical record review (Allen 2002; Welin 2010) or administration of patient questionnaires (Kerry 2013). One study did not specify the method used to determine recurrent stroke events and no blinding of outcome assessors was reported (Wang 2005). Pooled data from all four studies suggested that organisational interventions were not associated with changes in the proportion of participants who experienced at least one recurrent stroke ( Analysis 2.21). However, the analysis was associated with substantial statistical heterogeneity (I2 = 77%) due to an outlying study that was considered at high risk of bias (Wang 2005). When the study by Wang et al was removed from the analysis no intervention effect was observed among the three remaining studies.

Three studies provided data on the number of secondary strokes (Boysen 2009; Hornnes 2011; Markle-Reid 2011) that occurred during follow-up (measured at end of study per protocol). Data on secondary stroke events were obtained by blinded outcome assessors following a review of clinical records (Boysen 2009; Hornnes 2011) or face-to-face interviews with study participants (Markle-Reid 2011). Data were pooled as rate ratios (Deeks 2011) and no significant intervention effect was observed ( Analysis 2.18). In one further study, an additional follow-up was conducted by blinded outcome assessors after a mean duration of 3.6 years (Ellis 2005). The study found that the number of self-reported secondary strokes were similar between groups (OR 0.72; 95% CI 0.12 to 4.32) ( Analysis 2.19) but a significantly higher number of TIAs were reported in the intervention group (OR 2.49; 95% CI 1.18 to 5.22) ( Analysis 2.20). The trialists state that "one patient in the intervention group reported 10 possible transient ischaemic attacks in the interval between studies" and that "no objective confirmation of these reported symptoms was possible" (Ellis 2005).

 

Secondary cardiovascular events

 
Organisational interventions

One study reported data on the proportion of participants who experienced at least one secondary cardiovascular event during follow-up (Brotons 2011). The data were collected by non-blinded outcome assessors following a review of clinical records and interviews with study participants. No significant intervention effect was observed ( Analysis 2.21).

Two studies reported data on the number of secondary cardiovascular events that occurred before the end of the study per protocol (Flemming 2013; Hornnes 2011). Secondary events were documented by blinded (Hornnes 2011) or non-blinded (Flemming 2013) outcome assessors following clinical record review. Flemming 2013 observed no secondary cardiovascular events in the intervention group nor the control group. Similarly, Hornnes 2011 observed no significant differences between groups in the number of cardiovascular events ( Analysis 2.22). In an additional follow-up interview with study participants, conducted by blinded outcome assessors after a mean duration of 3.6 years, Ellis 2005 observed a significantly higher number of self-reported cardiovascular events in the intervention group (OR 2.08; 95% CI 1.06 to 4.06) ( Analysis 2.22). However, this finding was likely to reflect the increased number of TIAs observed (discussed in the previous section).

 

Myocardial infarction and ischaemic heart disease

 
Organisational interventions

Two studies reported the number of myocardial infarctions that occurred during follow-up (Boysen 2009; Hornnes 2011) and no significant intervention effect was seen ( Analysis 2.23). Ellis 2005 observed no significant differences in the number of ischaemic heart disease events after a mean follow-up duration of 3.6 years ( Analysis 2.23). Data were collected by blinded outcome assessors in all three studies following clinical record review (Boysen 2009; Hornnes 2011) or interviews with study participants (Ellis 2005).

 

Vascular death

 
Organisational interventions

Two studies reported data on vascular death that were obtained by blinded (Boysen 2009) and non-blinded (Brotons 2011) outcome assessors following clinical record review. Boysen 2009 observed no significant differences in the number of vascular deaths occurring in the intervention and control groups ( Analysis 2.24). Similarly, Brotons 2011 observed no significant differences between intervention and control groups in the proportion of patients experiencing vascular death ( Analysis 2.25).

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Summary of main results

This review produced mixed findings regarding the effectiveness of stroke service interventions for the secondary prevention of stroke. We performed meta-analyses (where appropriate) for the outcomes of blood pressure, lipid profile, HbA1c, BMI and recurrent cardiovascular events. We carried out a qualitative analysis for medication adherence outcomes.

Educational and behavioural interventions for patients were not generally associated with clear differences in any of the review outcomes, with only two exceptions. The pharmacist education program evaluated by Chiu 2008 was associated with significant improvements in mean systolic blood pressure, mean diastolic blood pressure and mean LDL levels. However, this study only presented data for a subgroup of participants with hypertension or hypercholesterolaemia who therefore had the greatest potential for improvement. It may be that educational interventions are more effective for participants with uncontrolled risk factors, and these participants could be targeted in future studies. The studies currently included in this review do not contain sufficient data to evaluate this. Additionally, O'Carroll 2011 was the only study included in the review to demonstrate significant differences between the intervention and control groups in adherence to secondary prevention medications. Although this study demonstrated improvements in two indicators of participant adherence to antihypertensive therapy, further research is required to determine the clinical impact of these findings.

The estimated effects of organisational interventions were compatible with improvements and no differences in mean systolic blood pressure (MD -2.57 mmHg; 95% CI -5.46 to 0.31), mean diastolic blood pressure (MD -0.90 mmHg; 95% CI -2.49 to 0.68) and blood pressure target achievement (OR 1.24; 95% CI 0.94 to 1.64). Blood pressure reductions of this magnitude may be associated with improved clinical outcomes since the Post-stroke Antihypertensive Treatment Study (PATS) provided evidence that blood pressure lowering of 5/2 mmHg with indapamide treatment reduced the incidence of secondary stroke by 29% (PATS Collaborating Group 1995). Additionally, a meta-analysis of individual patient data from 61 prospective studies concluded that a 2 mmHg reduction in usual systolic blood pressure could reduce stroke mortality by approximately 10% (Lewington 2002). In the meta-analysis of systolic blood pressure data presented in this review, the largest blood pressure reductions were associated with three interventions that contained common elements of integrated care and comprehensive patient education (involving promotion and tracking of behaviours for secondary stroke prevention). Another finding from this review is that the effects of organisational interventions (including common elements of integrated care and patient education) on BMI were compatible with a small clinical benefit (MD -0.68 kg/m2; 95% CI -1.46 to 0.11), although the imprecision of this estimate means that an absence of improvement could not be ruled out.

 

Overall completeness and applicability of evidence

A limitation of the included studies was the lack of consistently used outcome measures (for example some studies measured mean blood pressure whereas some measured target achievement with a variety of acceptable ranges). Combining all results in meta-analyses was therefore problematic. A second limitation was related to variations in study follow-up duration. This review pooled data collected at the end of the study per protocol. However, follow-up duration varied from three to 36 months. The results should therefore be interpreted with some caution since shorter studies may not allow enough time for the interventions to produce an impact on modifiable risk factors.

Intervention intensity is a poorly defined concept (Francis 2011; Greaves 2011), although it may incorporate factors such as "total number of contacts, total contact time, duration of the intervention and the number of behaviour change techniques used" (Greaves 2011). Differences in intervention intensity are considered to represent a potential source of heterogeneity in the context of complex interventions (O'Connor 2011). Correspondingly, the stroke service interventions included in this review were found to differ considerably in terms of aims (for example degree of focus on secondary stroke prevention), duration, components and mode of delivery. Pre-determined strategies for categorising intervention intensity may therefore facilitate the synthesis of future research findings (Baker 2011). However, systematic reviews of complex interventions have to date failed to demonstrate consistent associations between intervention intensity and effectiveness (Baker 2011; Beswick 2008; Greaves 2011). It has been asserted that methods for adequately describing and understanding complex interventions need to be "further developed and tested with the expectation that they will complement existing systematic review methodology" (Shepperd 2009).

 

Quality of the evidence

We analysed data from 26 trials involving 8021 participants with stroke or TIA. All 26 trials were conducted over the previous 10 years. One study did not report randomisation methods and had unequal group sizes, which raised questions about the validity of the findings (Wang 2005).

 

Potential biases in the review process

We have attempted to identify all RCTs of potential relevance to the review. In addition to a comprehensive search strategy, we attempted to contact the authors of all included trials in order to identify further published, unpublished and ongoing studies. Visual inspection of funnel plots did not raise any concerns regarding publication bias. We have included all eligible RCTs regardless of publication language (we arranged for the full translation of one study not published in English).

 

Agreements and disagreements with other studies or reviews

Buckley 2010 conducted a systematic review of the effects of service organisation interventions for the secondary prevention of ischaemic heart disease. Only interventions delivered in primary care were included. The review found that interventions involving certain elements (regular planned patient appointments, patient education and monitoring of medication and risk factors) may be associated with improved control of total cholesterol and blood pressure levels. However, the authors recommend that the results should be interpreted with caution due to significant clinical and statistical heterogeneity. In contrast to Buckley 2010, this systematic review included interventions that were not delivered in primary care, and therefore different types of interventions were included (for example implementation of discharge orders). However, the conclusions of this review are in accordance with Buckley 2010 since organisational interventions including elements of integrated care and patient education were associated with the greatest improvements in blood pressure control.

The positive effects of integrated care services in this review are also supported by the findings of another review of organisational interventions. Wensing 2006 reported that "integrated care services are particularly promising" when considering strategies to improve patient care. This is attributed to the typical multifaceted nature of these interventions. The authors suggested that the incorporation of numerous intervention components may "address a wide range of potential barriers for change". They also stated that "further work should focus on analysing the contributions of the specific components in integrated care services, to identify which particularly contribute to their effectiveness" (Wensing 2006).

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

 

Implications for practice

This review has highlighted potential benefits of organisational interventions on mean systolic blood pressure, mean diastolic blood pressure, blood pressure target achievement and mean BMI (analysis of the effects of organisational interventions on these outcomes were imprecise and compatible with improvements and no differences). However, the conclusions of this review do not provide any clear evidence that organisational interventions can improve other modifiable risk factors (lipid profile, HbA1c, medication adherence) or reduce the incidence of recurrent cardiovascular events. Results also suggest that interventions including patient education alone are unlikely to lead to improvements in modifiable risk factor control or the prevention of recurrent cardiovascular events.

 
Implications for research

Future research should focus on the development of more effective interventions to translate secondary prevention recommendations into practice. The findings from this review suggest that educational and behavioural interventions for patients delivered in the absence of organisational change may not be the most effective means of achieving this. Instead, future research should evaluate the effects of organisational interventions (including common elements of integrated care and patient education). We have identified 21 ongoing studies and 14 studies that are awaiting assessment, so a future review update may lead to more robust conclusions.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

We would like to thank all of the authors who kindly provided us with additional data about their studies. We are grateful to Brenda Thomas, Janette Camosso-Stefinovic and Dr Brian Buckley for their contributions to the search strategies. We are also grateful for the important contributions made by Phi-Anh Tonnu and Chokanan Thaitirarot to study selection and data collection.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
Download statistical data

 
Comparison 1. Educational or behavioural interventions for patients versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mean systolic blood pressure8621Mean Difference (IV, Random, 95% CI)-2.06 [-7.40, 3.28]

 2 Mean diastolic blood pressure8621Mean Difference (IV, Random, 95% CI)0.35 [-2.38, 3.08]

 3 Blood pressure target achievement3266Odds Ratio (M-H, Random, 95% CI)1.34 [0.70, 2.59]

 4 Mean total cholesterol6405Mean Difference (IV, Random, 95% CI)0.17 [-0.31, 0.65]

 5 Total cholesterol target achievement156Odds Ratio (M-H, Random, 95% CI)0.56 [0.19, 1.68]

 6 Mean low density lipoprotein2139Mean Difference (IV, Random, 95% CI)-0.15 [-0.76, 0.47]

 7 Mean high density lipoprotein162Mean Difference (IV, Random, 95% CI)0.0 [-0.15, 0.15]

 8 Mean triglycerides3182Mean Difference (IV, Random, 95% CI)-0.08 [-0.38, 0.23]

 9 HbA1C target achievement167Odds Ratio (M-H, Random, 95% CI)0.65 [0.25, 1.75]

 10 Mean BMI157Mean Difference (IV, Random, 95% CI)-0.24 [-0.80, 0.32]

 11 Proporation of participants with secondary stroke156Odds Ratio (M-H, Random, 95% CI)5.0 [0.23, 109.01]

 
Comparison 2. Organisational interventions versus usual care

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Mean systolic blood pressure91514Mean Difference (IV, Random, 95% CI)-2.57 [-5.46, 0.31]

 2 Mean diastolic blood pressure71384Mean Difference (IV, Random, 95% CI)-0.90 [-2.49, 0.68]

 3 Blood pressure target achievement71346Odds Ratio (M-H, Random, 95% CI)1.24 [0.94, 1.64]

 4 Mean total cholesterol5648Mean Difference (IV, Random, 95% CI)-0.08 [-0.37, 0.20]

 5 Total cholesterol target achievement4757Odds Ratio (M-H, Random, 95% CI)1.56 [0.67, 3.66]

 6 Mean low density lipoprotein3245Mean Difference (IV, Random, 95% CI)-0.42 [-1.12, 0.28]

 7 Low density lipoprotein target achievement136Odds Ratio (M-H, Random, 95% CI)1.0 [0.27, 3.72]

 8 Mean high density lipoprotein3247Mean Difference (IV, Random, 95% CI)0.06 [-0.06, 0.19]

 9 High density lipoprotein target achievement136Odds Ratio (M-H, Random, 95% CI)1.27 [0.33, 4.97]

 10 Mean triglycerides3246Mean Difference (IV, Random, 95% CI)-0.05 [-0.26, 0.16]

 11 Triglyceride target achievement136Odds Ratio (M-H, Random, 95% CI)0.25 [0.05, 1.18]

 12 Mean HbA1C3234Mean Difference (IV, Random, 95% CI)-0.13 [-1.33, 1.08]

 13 HbA1C target achievement3553Odds Ratio (M-H, Random, 95% CI)3.93 [0.30, 51.33]

 14 Mean BMI3423Mean Difference (IV, Random, 95% CI)-0.68 [-1.46, 0.11]

 15 BMI target achievement2234Odds Ratio (M-H, Random, 95% CI)1.73 [0.93, 3.25]

 16 Mean Framingham cardiovascular risk score136Mean Difference (IV, Random, 95% CI)-6.5 [-10.22, -2.78]

 17 Proportion of participants with secondary stroke or TIA4791Odds Ratio (M-H, Random, 95% CI)0.66 [0.23, 1.86]

 18 Number of secondary strokes3Odds Ratio (Random, 95% CI)1.19 [0.70, 2.03]

 19 Number of secondary strokes1Odds Ratio (Random, 95% CI)0.72 [0.12, 4.32]

 20 Number of secondary TIAs1Odds Ratio (Random, 95% CI)2.49 [1.18, 5.22]

 21 Proportion of participants with secondary cardiovascular events1324Odds Ratio (M-H, Random, 95% CI)1.48 [0.79, 2.77]

 22 Number of secondary cardiovascular events2Odds Ratio (Random, 95% CI)1.24 [0.40, 3.84]

 23 Number of myocardial infarctions3Odds Ratio (Random, 95% CI)0.47 [0.15, 1.48]

 24 Number of vascular deaths1Odds Ratio (Random, 95% CI)0.75 [0.17, 3.35]

 25 Proportion of participants with vascular death1324Odds Ratio (M-H, Random, 95% CI)1.75 [0.41, 7.46]

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Appendix 1. CENTRAL search strategy

1. MeSH descriptor Cerebrovascular Disorders explode tree 1

2. ((cva or stroke or poststroke or (post NEXT stroke) or (transient NEXT isch*mic NEXT attack) or TIA or ministroke or (mini NEXT stroke)) NEAR/6 (people or patient or outpatient or adult or survivor or victim or individual or client or population or community or subject)):ti,ab,kw

3. (cerebrovascular* or cerebral vascular):ti,ab,kw

4. (cerebral or cerebellar or brain* or vertebrobasilar):ti,ab,kw

5. (infarct* or isch*mi* or thrombo* or apoplexy or emboli*):ti,ab,kw

6. (#4 AND #5)

7. (cerebral or intracerebral or intracranial or brain* or cerebellar or subarachnoid):ti,ab,kw

8. (accident* or h*morrhag*):ti,ab,kw

9. (#7 AND #8)

10. (#1 OR #2 OR #3 OR #6 OR #9)

11. MeSH descriptor Child, this term only

12. MeSH descriptor Infant explode all trees

13. MeSH descriptor Pediatrics explode all trees

14. (child* or neonat* or p?ediatric* or infant*):ti,ab,kw

15. (#11 OR #12 OR #13 OR #14)

16. MeSH descriptor Patient Care Management, this term only

17. MeSH descriptor Comprehensive Health Care, this term only

18. MeSH descriptor Nursing Process, this term only

19. MeSH descriptor Nursing Assessment explode all trees

20. MeSH descriptor Patient Care Planning, this term only

21. MeSH descriptor Case Management, this term only

22. MeSH descriptor Delivery of Health Care, this term only

23. MeSH descriptor Delivery of Health Care, Integrated, this term only

24. MeSH descriptor Managed Care Programs explode tree 2

25. MeSH descriptor Disease Management, this term only

26. MeSH descriptor Patient Care Team explode all trees

27. MeSH descriptor Primary Health Care explode all trees

28. MeSH descriptor Reminder Systems, this term only

29. MeSH descriptor Guideline Adherence, this term only

30. MeSH descriptor Home Care Services, this term only

31. MeSH descriptor Home Nursing, this term only

32. MeSH descriptor Nursing Services explode all trees

33. MeSH descriptor Professional Role explode all trees

34. MeSH descriptor Community Health Services, this term only

35. MeSH descriptor Medical Records, this term only

36. MeSH descriptor Medical Records Systems, Computerized, this term only

37. MeSH descriptor Patient Education as Topic, this term only

38. MeSH descriptor Patient Compliance explode tree 1

39. MeSH descriptor Life Style, this term only

40. MeSH descriptor Health Promotion, this term only

41. MeSH descriptor Health Services Administration, this term only

42. MeSH descriptor Education, Medical, Continuing, this term only

43. MeSH descriptor Marketing of Health Services, this term only

44. MeSH descriptor Patient Participation, this term only

45. MeSH descriptor Quality of Health Care, this term only

46. MeSH descriptor Quality Assurance, Health Care, this term only

47. MeSH descriptor Exercise, this term only

48. MeSH descriptor Physical Fitness, this term only

49. MeSH descriptor Smoking Cessation, this term only

50. MeSH descriptor Diet, this term only

51. MeSH descriptor Diet, Fat-Restricted, this term only

52. MeSH descriptor Diet, Carbohydrate-Restricted, this term only

53. MeSH descriptor Diet, Reducing, this term only

54. MeSH descriptor Caloric Restriction, this term only

55. MeSH descriptor Alcohol Drinking, this term only with qualifier: PC

56. MeSH descriptor Health Education, this term only

57. MeSH descriptor Community Health Planning, this term only

58. MeSH descriptor Communication, this term only

59. MeSH descriptor Communication Barriers, this term only

60. MeSH descriptor Information Dissemination, this term only

61. MeSH descriptor Interdisciplinary Communication, this term only

62. MeSH descriptor Nurse Clinicians, this term only

63. MeSH descriptor Nurse Practitioners, this term only

64. MeSH descriptor Risk Reduction Behavior, this term only

65. MeSH descriptor Pamphlets, this term only

66. MeSH descriptor Health Behavior, this term only

67. MeSH descriptor Health Knowledge, Attitudes, Practice, this term only

68. MeSH descriptor Secondary Prevention, this term only

69. MeSH descriptor Preventive Health Services, this term only

70. (manag* NEAR/3 care):ti,ab,kw

71. (management NEAR/3 program*):ti,ab,kw

72. (case NEAR/3 manag*):ti,ab,kw

73. (patient NEAR/3 management):ti,ab,kw

74. (home NEAR/3 intervention):ti,ab,kw

75. (home NEXT visit*):ti,ab,kw

76. (discharg* NEAR/3 program*):ti,ab,kw

77. (practice NEXT guideline*):ti,ab,kw

78. (discharg* NEAR/3 plan*):ti,ab,kw

79. (comprehensive NEAR/3 care):ti,ab,kw

80. (treatment NEAR/3 plan*):ti,ab,kw

81. (nurse NEAR/3 led):ti,ab,kw

82. (disease NEXT management):ti,ab,kw

83. (multi NEXT disciplin*):ti,ab,kw

84. (multidisciplin*):ti,ab,kw

85. (secondary NEXT prevention NEXT clinic):ti,ab,kw

86. (reminder):ti,ab,kw

87. (recall*):ti,ab,kw

88. (nurse NEAR/3 clinic):ti,ab,kw

89. (secondary NEXT prevention NEAR/3 intervention):ti,ab,kw

90. (secondary NEXT prevention NEAR/3 program*):ti,ab,kw

91. MeSH descriptor Appointments and Schedules, this term only

92. (appointment):ti,ab,kw

93. (outreach NEXT nurs*):ti,ab,kw

94. (outreach NEXT visit*):ti,ab,kw

95. (lifestyle NEAR/3 intervention*):ti,ab,kw

96. (physical NEXT (activity or exercise)):ti,ab,kw

97. (aerobic):ti,ab,kw

98. (fitness):ti,ab,kw

99. (exercise NEAR/3 (train* or intervention or program* or activity or regim*)):ti,ab,kw

100. (nurs* NEXT intervention*):ti,ab,kw

101. (education* NEXT program*):ti,ab,kw

102. ((risk NEXT factor*) NEAR/5 (modif* or reduc* or manage* or monitor* or self-manage*)):ti,ab,kw

103. (#16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36 OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46 OR #47 OR #48 OR #49 OR #50 OR #51 OR #52 OR #53 OR #54 OR #55 OR #56 OR #57 OR #58 OR #59 OR #60 OR #61 OR #62 OR #63 OR #64 OR #65 OR #66 OR #67 OR #68 OR #69 OR #70 OR #71 OR #72 OR #73 OR #74 OR #75 OR #76 OR #77 OR #78 OR #79 OR #80 OR #81 OR #82 OR #83 OR #84 OR #85 OR #86 OR #87 OR #88 OR #89 OR #90 OR #91 OR #92 OR #93 OR #94 OR #95 OR #96 OR #97 OR #98 OR #99 OR #100 OR #101 OR #102)

104. (#10 NOT #15)

105. (#103 AND #104)

 

Appendix 2. MEDLINE (Ovid) search strategy

1. exp Cerebrovascular Disorders/

2. ((cva$ or stroke$ or poststroke$ or post-stroke$ or post stroke$ or transient isch?emic attack$ or TIA$ or ministroke$ or mini-stroke$ or mini stroke$) adj6 (people or patient$ or inpatient$ or outpatient$ or adult$ or survivor$ or victim$ or individual$ or client$ or population$ or community or subject$)).tw.

3. (cerebrovascular$ or cerebral vascular).tw.

4. (cerebral or cerebellar or brain$ or vertebrobasilar).tw.

5. (infarct$ or isch?emi$ or thrombo$ or apoplexy or emboli$).tw.

6. 4 and 5

7. (cerebral or intracerebral or intracranial or brain$ or cerebellar or subarachnoid).tw.

8. (accident$ or h?emorrhag$).tw.

9. 7 and 8

10. 1 or 2 or 3 or 6 or 9

11. Child/

12. exp Infant/

13. exp pediatrics/

14. (child$ or neonat$ or p?ediatric$ or infant$).tw.

15. 11 or 12 or 13 or 14

16. 10 not 15

17. Patient Care Management/

18. Comprehensive Health Care/

19. Nursing Process/

20. exp Nursing Assessment/

21. Patient Care Planning/

22. Case Management/

23. delivery of health care/

24. "Delivery of Health Care, Integrated"/

25. exp Managed Care Programs/

26. Disease Management/

27. exp Patient Care Team/

28. exp Primary Health Care/

29. Reminder Systems/

30. Guideline Adherence/

31. Home Care Services/

32. Home Nursing/

33. exp Nursing Services/

34. exp Professional Role/

35. Community Health Services/

36. Medical Records/ or Medical Records Systems, Computerized/

37. Patient Education as Topic/

38. exp Patient Compliance/

39. Life Style/

40. Health Promotion/

41. Health Services Administration/

42. Education, Medical, Continuing/

43. Marketing of Health Services/

44. Patient Participation/

45. Quality of Health Care/

46. Quality Assurance, Health Care/

47. Exercise/ or Physical Fitness/

48. Smoking Cessation/

49. Diet/ or Diet, Fat-Restricted/ or Diet, Carbohydrate-Restricted/ or Diet, Reducing/ or Caloric Restriction/

50. Alcohol, Drinking/pc

51. Health Education/

52. Community Health Planning/

53. Communication/ or Communication Barriers/ or Information Dissemination/ or Interdisciplinary Communication/

54. Nurse Clinicians/

55. Nurse Practitioners/

56. Risk Reduction Behavior/

57. Pamphlets/

58. Health Behavior/

59. Health Knowledge, Attitudes, Practice/

60. Secondary Prevention/

61. Preventive Health Services/

62. (manag$ adj3 care).tw.

63. (management adj3 program$).tw.

64. (case adj3 manag$).tw.

65. (patient adj3 management).tw.

66. (home adj3 intervention$).tw.

67. (home adj visit$).tw.

68. (discharg$ adj3 program$).tw.

69. (practice adj guideline$).tw.

70. (discharg$ adj3 plan$).tw.

71. (comprehensive adj3 care).tw.

72. (treatment adj3 plan$).tw.

73. (nurse$ adj3 led).tw.

74. (disease adj management).tw.

75. multi-disciplin$.tw.

76. multidisciplin$.tw.

77. secondary prevention clinic$.tw.

78. reminder$.tw.

79. recall$.tw.

80. (nurse adj3 clinic$).tw.

81. (secondary prevention adj3 intervention$).tw.

82. (secondary prevention adj3 program$).tw.

83. "Appointments and Schedules"/

84. appointment$.tw.

85. (outreach adj nurs$).tw.

86. (outreach adj visit$).tw.

87. (lifestyle adj3 intervention$).tw.

88. (nurs$ adj intervention$).tw.

89. (education$ adj program$).tw.

90. (physical adj (activit$ or exercise$)).tw.

91. (exercise adj3 (train$ or intervention$ or program$ or activit$ or regim$)).tw.

92. aerobic.tw.

93. fitness.tw.

94. (risk factor$ adj5 (modif$ or reduc$ or manage$ or monitor$ or self-manage$)).tw.

95. 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50 or 51 or 52 or 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 or 62 or 63 or 64 or 65 or 66 or 67 or 68 or 69 or 70 or 71 or 72 or 73 or 74 or 75 or 76 or 77 or 78 or 79 or 80 or 81 or 82 or 83 or 84 or 85 or 86 or 87 or 88 or 89 or 90 or 91 or 92 or 93 or 94

96. randomized controlled trial.pt.

97. controlled clinical trial.pt.

98. randomized.ab.

99. randomised.ab.

100. placebo.ab.

101. clinical trials as topic.sh.

102. randomly.ab.

103. trial.ti.

104. 96 or 97 or 98 or 99 or 100 or 101 or 102 or 103

105. 16 and 95 and 104

106. exp animals/ not humans.sh.

107. 105 not 106

 

Appendix 3. EMBASE (Ovid) search strategy

1. exp *cerebrovascular disease/

2. ((cva$ or stroke$ or poststroke$ or post-stroke$ or post stroke$ or transient isch?emic attack$ or TIA$ or ministroke$ or mini-stroke$ or mini stroke$) adj6 (people or patient$ or inpatient$ or outpatient$ or adult$ or survivor$ or victim$ or individual$ or client$ or population$ or community or subject$)).tw.

3. (cerebrovascular$ or cerebral vascular).tw.

4. (cerebral or cerebellar or brain$ or vertebrobasilar).tw.

5. (infarct$ or isch?emi$ or thrombo$ or apoplexy or emboli$).tw.

6. 4 and 5

7. (cerebral or intracerebral or intracranial or brain$ or cerebellar or subarachnoid).tw.

8. (accident$ or h?emorrhag$).tw.

9. 7 and 8

10. 1 or 2 or 3 or 6 or 9

11. child/

12. exp infant/

13. exp pediatrics/

14. (child$ or neonat$ or p?ediatric$ or infant$).tw.

15. 11 or 12 or 13 or 14

16. 10 not 15

17. (child$ or neonate$ or p?ediatric$ or infant$).tw.

18. 16 not 17

19. patient care planning/

20. case management/

21. health care delivery/

22. integrated health care system/

23. disease management/

24. reminder system/

25. *medical record/

26. health education/

27. patient education/

28. *patient compliance/

29. lifestyle modification/ or lifestyle/

30. health promotion/

31. medical education/

32. patient participation/

33. *exercise/ or aerobic exercise/ or fitness/ or *physical activity/

34. *smoking cessation/

35. *diet/ or low calory diet/ or low carbohydrate diet/ or low fat diet/ or diet restriction/

36. alcohol consumption/

37. health care planning/

38. interdisciplinary communication/

39. information dissemination/

40. risk reduction/

41. health behavior/

42. secondary prevention/

43. preventive medicine/

44. risk management/

45. medical specialist/

46. medical information/

47. (manag$ adj3 care).tw.

48. (management adj3 program$).tw.

49. (case adj3 manag$).tw.

50. (patient adj3 management).tw.

51. (home adj3 intervention$).tw.

52. (home adj visit$).tw.

53. (discharg$ adj3 program$).tw.

54. (practice adj guideline$).tw.

55. (discharg$ adj3 plan$).tw.

56. (comprehensive adj3 care).tw.

57. (treatment adj3 plan$).tw.

58. (nurse$ adj3 led).tw.

59. (disease adj management).tw.

60. multi-disciplin$.tw.

61. multidisciplin$.tw.

62. secondary prevention clinic$.tw.

63. reminder$.tw.

64. recall$.tw.

65. (nurse adj3 clinic$).tw.

66. (secondary prevention adj3 intervention$).tw.

67. (secondary prevention adj3 program$).tw.

68. appointment$.tw.

69. (outreach adj nurs$).tw.

70. (outreach adj visit$).tw.

71. (lifestyle adj3 intervention$).tw.

72. (nurs$ adj intervention$).tw.

73. (education$ adj program$).tw.

74. (physical adj (activit$ or exercise$)).tw.

75. (exercise adj3 (train$ or intervention$ or program$ or activit$ or regim$)).tw.

76. aerobic.tw.

77. fitness.tw.

78. (risk factor$ adj5 (modif$ or reduc$ or manage$ or monitor$ or self-manage$)).tw.

79. 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27 or 28 or 29 or 30 or 31 or 32 or 33 or 34 or 35 or 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45 or 46 or 47 or 48 or 49 or 50 or 51 or 52 or 53 or 54 or 55 or 56 or 57 or 58 or 59 or 60 or 61 or 62 or 63 or 64 or 65 or 66 or 67 or 68 or 69 or 70 or 71 or 72 or 73 or 74 or 75 or 76 or 77 or 78

80. random$.tw.

81. placebo$.tw.

82. placebo/

83. double-blind$.tw.

84. randomized controlled trial/

85. randomization/

86. double blind procedure/

87. single blind procedure/

88. triple blind procedure/

89. 80 or 81 or 82 or 83 or 84 or 85 or 86 or 87 or 88

90. 18 and 79 and 89

 

Appendix 4. CINAHL (EBSCO) search strategy

1. exp CEREBRAL ISCHEMIA/ OR exp INTRACRANIAL HEMORRHAGE/ OR *STROKE/

2. *STROKE PATIENTS/

3. (cva* OR stroke* OR poststroke* OR post-stroke* OR "transient ischemic attack*" OR "transient ischaemic attack*" OR TIA* OR ministroke* OR mini-stroke*).ti,ab

4. (cerebrovascular* OR "cerebral vascular").ti,ab

5. (cerebral OR cerebellar OR brain* OR vertebrobasilar).ti,ab

6. (infarct* OR ischemi* OR ischaemi* OR thrombo* OR apoplexy OR emboli*).ti,ab

7. 5 AND 6

8. (cerebral OR intracerebral OR intracranial OR brain* OR cerebellar OR subarachnoid).ti,ab

9. (accident* OR hemorrhag* OR haemorrhag*).ti,ab

10. 8 AND 9

11. 1 OR 2 OR 3 OR 4 OR 7 OR 10

12. NURSING INTERVENTIONS/

13. NURSING PRACTICE/

14. ADVANCED NURSING PRACTICE/

15. HEALTH CARE DELIVERY/

16. HEALTH CARE DELIVERY, INTEGRATED/

17. DISEASE MANAGEMENT/

18. CASE MANAGEMENT/

19. MULTIDISCIPLINARY CARE TEAM/

20. exp CONTINUITY OF PATIENT CARE/

21. PATIENT EDUCATION/

22. LIFE STYLE CHANGES/

23. BEHAVIOR MODIFICATION/

24. exp PATIENT COMPLIANCE/

25. EDUCATION, MEDICAL, CONTINUING/

26. EDUCATION, NURSING, CONTINUING/

27. (manag* ADJ3 care).ti,ab

28. (management ADJ3 program*).ti,ab

29. (case ADJ3 manag*).ti,ab

30. (patient ADJ3 management).ti,ab

31. (home ADJ3 intervention*).ti,ab

32. "home visit*".ti,ab

33. (discharg* ADJ3 program*).ti,ab

34. "practice guideline*".ti,ab

35. (discharg* ADJ3 planning).ti,ab

36. (comprehensive ADJ3 care).ti,ab

37. (treatment ADJ3 plan*).ti,ab

38. (nurse* ADJ3 led).ti,ab

39. "disease management".ti,ab

40. multi-disciplin*.ti,ab

41. multidisciplin*.ti,ab

42. "secondary prevention clinic*".ti,ab

43. reminder*.ti,ab

44. recall*.ti,ab

45. (nurse ADJ3 clinic*).ti,ab

46. ("secondary prevention" ADJ3 intervention*).ti,ab

47. ("secondary prevention" ADJ3 program*).ti,ab

48. appointment*.ti,ab

49. "outreach nurs*".ti,ab

50. "outreach visit*".ti,ab

51. (lifestyle ADJ3 intervention*).ti,ab

52. "nurs* intervention*".ti,ab

53. "education* program*".ti,ab

54. ("physical activit*" OR "physical exercise*").ti,ab

55. (exercise ADJ3 train*).ti,ab

56. (exercise ADJ3 intervention*).ti,ab

57. (exercise ADJ3 program*).ti,ab

58. (exercise ADJ3 activit*).ti,ab

59. (exercise ADJ3 regim*).ti,ab

60. aerobic.ti,ab

61. fitness.ti,ab

62. ("risk factor*" ADJ5 modif*).ti,ab

63. ("risk factor*" ADJ5 reduc*).ti,ab

64. ("risk factor*" ADJ5 manage*).ti,ab

65. ("risk factor*" ADJ5 monitor*).ti,ab

66. ("risk factor*" ADJ5 self-manage*).ti,ab

67. 12 OR 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33 OR 34 OR 35 OR 36 OR 37 OR 38 OR 39 OR 40 OR 41 OR 42 OR 43 OR 44 OR 45 OR 46 OR 47 OR 48 OR 49 OR 50 OR 51 OR 52 OR 53 OR 54 OR 55 OR 56 OR 57 OR 58 OR 59 OR 60 OR 61 OR 62 OR 63 OR 64 OR 65 OR 66

68. CLINICAL TRIALS/

69. RANDOM ASSIGNMENT/

70. PLACEBOS/

71. DOUBLE-BLIND STUDIES/ OR SINGLE-BLIND STUDIES/ OR TRIPLE-BLIND STUDIES/

72. random*.ti,ab

73. placebo.ti,ab

74. 68 OR 69 OR 70 OR 71 OR 72 OR 73

75. 11 AND 67 AND 74

 

Appendix 5. AMED (Ovid) search strategy

1. CEREBRAL HEMORRHAGE/ OR CEREBRAL INFARCTION/ OR CEREBRAL ISCHEMIA/ OR CEREBROVASCULAR ACCIDENT/ OR STROKE/

2. (cva* OR stroke* OR poststroke* OR post-stroke* OR "transient ischemic attack*" OR "transient ischaemic attack*" OR TIA* OR ministroke* OR mini-stroke*).ti,ab

3. (people OR patient* OR outpatient* OR inpatient* OR adult* OR survivor* OR victim* OR individual* OR client* OR population* OR community OR subject*).ti,ab

4. 2 AND 3

5. (cerebrovascular* OR "cerebral vascular").ti,ab

6. (cerebral OR cerebellar OR brain* OR vertebrobasilar).ti,ab

7. (infarct* OR ischemi* OR ischaemi* OR thrombo* OR apoplexy OR emboli*).ti,ab

8. 6 AND 7

9. (cerebral OR intracerebral OR intracranial OR brain* OR cerebellar OR subarachnoid).ti,ab

10. (accident* OR hemorrhag* OR haemorrhag*).ti,ab

11. 9 AND 10

12. 1 OR 4 OR 5 OR 8 OR 11

13. "DELIVERY OF HEALTH CARE"/

14. PATIENT CARE MANAGEMENT/

15. PROGRAM EVALUATION/

16. PATIENT EDUCATION/

17. LIFE STYLE/

18. PREVENTION/

19. PATIENT COMPLIANCE/

20. PATIENT CARE TEAM/

21. COMMUNITY HEALTH SERVICES/

22. HEALTH PROMOTION/

23. EXERCISE/

24. DIET/

25. SMOKING CESSATION/

26. HEALTH BEHAVIOR/

27. (manag* ADJ3 care).ti,ab

28. (management ADJ3 program*).ti,ab

29. (case ADJ3 manag*).ti,ab

30. (patient ADJ3 management).ti,ab

31. (home ADJ3 intervention*).ti,ab

32. "home visit*".ti,ab

33. (discharg* ADJ3 program*).ti,ab

34. "practice guideline*".ti,ab

35. (discharg* ADJ3 planning).ti,ab

36. (comprehensive ADJ3 care).ti,ab

37. (treatment ADJ3 plan*).ti,ab

38. (nurse* ADJ3 led).ti,ab

39. "disease management".ti,ab

40. multi-disciplin*.ti,ab

41. multidisciplin*.ti,ab

42. "secondary prevention clinic*".ti,ab

43. reminder*.ti,ab

44. recall*.ti,ab

45. (nurse ADJ3 clinic*).ti,ab

46. ("secondary prevention" ADJ3 intervention*).ti,ab

47. ("secondary prevention" ADJ3 program*).ti,ab

48. appointment*.ti,ab

49. "outreach nurs*".ti,ab

50. "outreach visit*".ti,ab

51. (lifestyle ADJ3 intervention*).ti,ab

52. "nurs* intervention*".ti,ab

53. "education* program*".ti,ab

54. ("physical activit*" OR "physical exercise*").ti,ab

55. (exercise ADJ3 train*).ti,ab

56. (exercise ADJ3 intervention*).ti,ab

57. (exercise ADJ3 program*).ti,ab

58. (exercise ADJ3 activit*).ti,ab

59. (exercise ADJ3 regim*).ti,ab

60. aerobic.ti,ab

61. fitness.ti,ab

62. ("risk factor*" ADJ5 modif*).ti,ab

63. ("risk factor*" ADJ5 reduc*).ti,ab

64. ("risk factor*" ADJ5 manage*).ti,ab

65. ("risk factor*" ADJ5 monitor*).ti,ab

66. ("risk factor*" ADJ5 self-manage*).ti,ab

67. 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33 OR 34 OR 35 OR 36 OR 37 OR 38 OR 39 OR 40 OR 41 OR 42 OR 43 OR 44 OR 45 OR 46 OR 47 OR 48 OR 49 OR 50 OR 51 OR 52 OR 53 OR 54 OR 55 OR 56 OR 57 OR 58 OR 59 OR 60 OR 61 OR 62 OR 63 OR 64 OR 65 OR 66

68. RANDOMIZED CONTROLLED TRIALS/

69. CLINICAL TRIALS/

70. PLACEBOS/

71. DOUBLE BLIND METHOD/

72. random*.ti,ab

73. placebo*.ti,ab

74. 68 OR 69 OR 70 OR 71 OR 72 OR 73

75. 12 AND 67 AND 74

 

Appendix 6. BNI (Ovid) search strategy

1. BNI STROKE/

2. BNI (cva* OR stroke* OR poststroke* OR post-stroke* OR "transient ischemic attack*" OR "transient ischaemic attack*" OR TIA* OR ministroke* OR mini-stroke*).ti,ab

3. BNI (people OR patient* OR outpatient* OR inpatient* OR adult* OR survivor* OR victim* OR individual* OR client* OR population* OR community OR subject*).ti,ab

4. BNI 2 AND 3

5. BNI (cerebrovascular* OR "cerebral vascular").ti,ab

6. BNI (cerebral OR cerebellar OR brain* OR vertebrobasilar).ti,ab

7. BNI (infarct* OR ischemi* OR ischaemi* OR thrombo* OR apoplexy OR emboli*).ti,ab

8. BNI 6 AND 7

9. BNI (cerebral OR intracerebral OR intracranial OR brain* OR cerebellar OR subarachnoid).ti,ab

10. BNI (accident* OR hemorrhag* OR haemorrhag*).ti,ab

11. BNI 9 AND 10

12. BNI 1 OR 4 OR 5 OR 8 OR 11

13. BNI PATIENTS : EDUCATION/

14. BNI NURSING : ROLE/

15. BNI CARE PLANS AND PLANNING/

16. BNI EVIDENCE BASED PRACTICE/

17. BNI MULTIDISCIPLINARY TEAMS/

18. BNI CONTINUITY OF CARE/

19. BNI PATIENTS : COMPLIANCE/

20. BNI (manag* ADJ3 care).ti,ab

21. BNI (management ADJ3 program*).ti,ab

22. BNI (case ADJ3 manag*).ti,ab

23. BNI (patient ADJ3 management).ti,ab

24. BNI (home ADJ3 intervention*).ti,ab

25. BNI "home visit*".ti,ab

26. BNI (discharg* ADJ3 program*).ti,ab

27. BNI "practice guideline*".ti,ab

28. BNI (discharg* ADJ3 planning).ti,ab

29. BNI (comprehensive ADJ3 care).ti,ab

30. BNI (treatment ADJ3 plan*).ti,ab

31. BNI (nurse* ADJ3 led).ti,ab

32. BNI "disease management".ti,ab

33. BNI multi-disciplin*.ti,ab

34. BNI multidisciplin*.ti,ab

35. BNI "secondary prevention clinic*".ti,ab

36. BNI reminder*.ti,ab

37. BNI recall*.ti,ab

38. BNI (nurse ADJ3 clinic*).ti,ab

39. BNI ("secondary prevention" ADJ3 intervention*).ti,ab

40. BNI ("secondary prevention" ADJ3 program*).ti,ab

41. BNI appointment*.ti,ab

42. BNI "outreach nurs*".ti,ab

43. BNI "outreach visit*".ti,ab

44. BNI (lifestyle ADJ3 intervention*).ti,ab

45. BNI "nurs* intervention*".ti,ab

46. BNI "education* program*".ti,ab

47. BNI ("physical activit*" OR "physical exercise*").ti,ab

48. BNI (exercise ADJ3 train*).ti,ab

49. BNI (exercise ADJ3 intervention*).ti,ab

50. BNI (exercise ADJ3 program*).ti,ab

51. BNI (exercise ADJ3 activit*).ti,ab

52. BNI (exercise ADJ3 regim*).ti,ab

53. BNI aerobic.ti,ab

54. BNI fitness.ti,ab

55. BNI ("risk factor*" ADJ5 modif*).ti,ab

56. BNI ("risk factor*" ADJ5 reduc*).ti,ab

57. BNI ("risk factor*" ADJ5 manage*).ti,ab

58. BNI ("risk factor*" ADJ5 monitor*).ti,ab

59. BNI ("risk factor*" ADJ5 self-manage*).ti,ab

60. BNI 13 OR 14 OR 15 OR 16 OR 17 OR 18 OR 19 OR 20 OR 21 OR 22 OR 23 OR 24 OR 25 OR 26 OR 27 OR 28 OR 29 OR 30 OR 31 OR 32 OR 33 OR 34 OR 35 OR 36 OR 37 OR 38 OR 39 OR 40 OR 41 OR 42 OR 43 OR 44 OR 45 OR 46 OR 47 OR 48 OR 49 OR 50 OR 51 OR 52 OR 53 OR 54 OR 55 OR 56 OR 57 OR 58 OR 59

61. BNI random*.ti,ab

62. BNI placebo*.ti,ab

63. BNI trial.ti,ab

64. BNI 61 OR 62 OR 63

65. BNI 12 AND 60 AND 64

 

Appendix 7. Web of Science Conference Proceedings Citation Index - Science search strategy

Stroke* OR TIA OR "transient isch*mic attack" OR "cerebral infarct*" OR "brain infarct*" OR cerebrovascular IN TITLE

AND

("secondary SAME prevention") OR ("recurrent stroke") OR (risk SAME reduc*) IN TOPIC

AND

intervention or program or service* or management IN TOPIC

AND

Proceedings paper IN DOCUMENT TYPE

 

What's new

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Last assessed as up-to-date: 9 April 2013.


DateEventDescription

2 May 2014AmendedAn updated 'Declaration of Interest' statement has been added for one author.



 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Dr Kate Lager contributed to the conception and design of the review. She was principally responsible for data collection, analysis of data, interpretation of data and writing the review.

Professor Andrew Wilson guided the conception and design of the review. He contributed to data collection, interpretation of data and revising the review.

Dr Amit Mistri guided protocol development, and also contributed to data collection, interpretation of data and revising the review.

Professor Kamlesh Khunti guided protocol development, and contributed to interpretation of the data and revising the review.

Dr Victoria Haunton and Dr Aung K Sett selected studies according to the review criteria, and contributed to data extraction and revising the review.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Dr Amit Mistri has received speaker fees for talks on stroke from various companies manufacturing drugs for vascular disease including Boehringer-Ingelheim, Bayer, Bristol-Myers Squibb, Astellas Pharma, Pfizer and Astra Zeneca, and a travel grant for conference attendance from Boehringer-Ingelheim.

Professor Kamlesh Khunti has acted as a consultant and speaker for Novartis, Novo Nordisk, Sanofi-Aventis, Lilly and Merck Sharp & Dohme. He has received grants in support of investigator and investigator initiated trials from Novartis, Novo Nordisk, Sanofi-Aventis, Lilly, Pfizer, Boehringer Ingelheim and Merck Sharp & Dohme. He has received funds for research, honoraria for speaking at meetings and has served on advisory boards for Lilly, Sanofi-Aventis, Merck Sharp & Dohme and Novo Nordisk.

Professor Andrew Wilson: none known.

Dr Kate Lager: none known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Internal sources

  • Department of Health Sciences, University of Leicester, UK.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. What's new
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

The following authors have contributed to the review but were not authors of the review protocol: Dr Victoria J Haunton and Dr Aung K Sett.

The title for the review has been changed following recommendations made by the Cochrane Stroke Group Editorial Team.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. References to ongoing studies
  22. Additional references
Adie 2010 {published and unpublished data}
  • Adie K, James MA. Does telephone follow up improve blood pressure after stroke/TIA?. Hypertension 2008;52(4):760.
  • Adie K, James MA. Does telephone follow up improve blood pressure in patients after stroke or TIA?. Proceedings of the 3rd Stroke Forum Conference. Harrogate, UK: The Stroke Association, 2008:5.
  • Adie K, James MA. Does telephone follow-up improve blood pressure after minor stroke or TIA?. Age and Ageing 2010;39:598-603.
Allen 2002 {published data only}
  • Allen KR, Hazelett S, Jarjoura D, Wickstrom GC, Hue K, Weinhardt J, et al. Effectiveness of a postdischarge care management model for stroke and transient ischaemic attack: a randomised trial. Journal of Stroke and Cerebrovascular Disease 2002;11(2):88-98.
  • Allen KR, Hazelett SE, Jarjoura D, Wickstrom G, Hua K, Weinhardt JA, et al. A post-discharge care management model for stroke and transient ischaemic attack: a randomised controlled trial. Stroke 2002;33(1):417 (Abstract P306).
  • NCT00328471. A post discharge intervention to improve stroke outcomes. http://clinicaltrials.gov/ct2/show/NCT00328471 (accessed 05 July 2013).
  • Wright K, Allen K, Weinhardt J, Gareri M, Hua K, Hazelett S. Effectiveness of interdisciplinary post-stroke case management in improving patient outcomes: a pilot study. Journal of Stroke and Cerebrovascular Diseases 2000;9(4):205.
  • Wright K, Hazelett S, Weinhardt J, Jarjoura D, Hua K, Gareri M, et al. The role of the advanced practice nurse in post-stroke care management. Journal of Stroke and Cerebrovascular Diseases 2003;12(5):249 (Abstract 12).
Allen 2009 {published data only}
  • Allen K, Hazelett S, Jarjoura D, Hua K, Wright K, Weinhardt J, et al. A randomised trial testing the superiority of a postdischarge care management model for stroke survivors. Journal of Stroke and Cerebrovascular Disease 2009;18(6):443-52.
  • Allen K, Hazelett S, Jarjoura D, Wright K, Clough L, Weinhardt J. Improving stroke outcomes: implementation of a postdischarge care management model. Journal of Clinical Outcomes Management 2004;11(11):707-14.
  • Allen K, Hazelett S, Jarjoura D, Wright K, Weinhardt J. Randomized controlled trial of a post-stroke post-discharge care management intervention. Stroke 2008;39(2):531 (Abstract 14).
  • Allen K, Jarjoura D, Hazelett S, Wickstrom G, Wright K, Hua K. Effectiveness of care management for secondary prevention with TIA/non-disabled stroke survivors. Journal of the American Geriatrics Society 2002;50(4):483:S168.
  • Allen KR, Hazelett SE, Palmer RP, Jarjoura DG, Wickstrom GC, Weinhardt JA, et al. Developing a stroke unit using the acute care for elders intervention and model of care. Journal of the American Geriatrics Society 2003;51(11):1660-7.
  • NCT00328471. A post discharge intervention to improve stroke outcomes. http://clinicaltrials.gov/show/NCT00328471 (accessed 05 July 2013).
Boter 2004 {published and unpublished data}
  • Albrecht KW, Algra A, Boter H, Carpay HA, van Gijn J, de Haan R, et al. HESTIA: a randomised clinical trial of a nursing care program for recently discharged stroke patients. Proceedings of the 27th International Stroke Conference. Feb 7-9 2002. USA, San Antonio: The American Stroke Association, 2002:Abstract CTP365.
  • Albrecht KWJ. Home evaluation of stroke induced aid (HESTIA). Stroke 2000;31:2538-9.
  • Boter H. Effectiveness of outreach stroke care. Utrecht: University of Utrecht, 2003.
  • Boter H, Rinkel GJE, de Haan R, for the HESTIA study group. A multicentre, randomised controlled trial of an outreach nursing care programme for recently discharged stroke patients. Journal of Neurology 2003;250 Suppl 2:(Abstract 77).
  • Boter H, Rinkel JE, Haan R. Outreach nurse support after stroke: a descriptive study on patients' and carers' needs, and applied nursing interventions. Clinical Rehabilitation 2004;18:156-63.
  • Boter H, van Delden JJM, de Haan RJ, Rinkel GJE. A modified informed-consent procedure in which the complete information is given retrospectively: no objection from participating patients. Nederlands Tijdschrift voor Geneeskunde 2005;149(1):29-32.
  • Boter H, van Delden JJM, de Haan RJ, Rinkel GJE, for the home evaluation of stroke induced aid study group. Patients' evaluation of informed consent to postponed information: cohort study. BMJ 2004;329:86-7.
  • Boter H, van Delden JM, de Haan RJ, Rinkel GJE, for the home evaluation of stroke induced aid study group. Modified informed consent procedure: consent to postponed information. BMJ 2003;327:284-6.
  • Boter H, for the HESTIA Study Group. Multicenter randomised controlled trial of an outreach nursing support program for recently discharged stroke patients. Stroke 2004;35:2867-72.
  • HESTIA Study Group. Home evaluation of stroke induced aid (HESTIA). Stroke 2002;33:1732.
Boysen 2009 {published and unpublished data}
  • Boysen G, Krarup L, Zeng X, Oskedra A, Kõrv J, Andersen G, et al. ExStroke pilot trial of the effect of repeated instructions to improve physical activity after ischaemic stroke: a multinational randomised controlled trial. BMJ 2009;339:b2810.
  • Boysen G, Krarup LH, Zeng X, Oskedra A, Korv J, Andersen G, et al. Failure to promote physical activity after ischaemic stroke. The ExStroke pilot trial. International Journal of Stroke 2008;3 Suppl 1:72 (Abstract FC11-04).
  • Boysen G, Pedersen A, Meden P, Hansen L, Lindahl M, Zeng X, et al. Physical exercise after acute ischaemic stroke. Exstroke pilot trial. Proceedings of the 29th International Stroke Conference. 5-7 February 2004. California, USA: American Stroke Association, 2004.
  • Boysen G, Truelsen T, Pedersen A, Hansen L, Lindahl M, Zeng X. Physical activity and the risk of ischaemic stroke. European Journal of Neurology 2005;12 Suppl 2:311.
  • Krarup L, Gluud C, Truelsen T, Pedersen A, Lindahl M, Hansen L, et al. The ExStroke pilot trial: rationale, design, and baseline data of a randomized multicenter trial comparing physical training versus usual care after an ischaemic stroke. Contemporary Clinical Trials 2007;29:410-7.
  • Krarup LH, Truelsen T, Boysen G. Repeated encouragement to be physically active improves insulin sensitivity after ischaemic stroke. Cerebrovascular Diseases 2008;25 Suppl 2:7 (Abstract 2).
  • Krarup LH, Truelsen T, Gludd C, Andersen G, Zeng X, Oskedra A, et al. Prestroke physical activity is associated with severity and long-term outcome from first-ever stroke. Neurology 2008;71(17):1313-8.
  • Krarup LH, Lindhal M, Truelsen T, Gludd C, Boysen G. The risk of falling after stroke is associated with physical inactivity. Cerebrovascular Diseases 2010;29:72.
  • NCT00132483. ExStroke pilot trial: physical exercise after acute ischaemic stroke. http://www.clinicaltrials.gov/ct2/show/NCT00132483 (accessed 05 July 2013).
  • Truelsen T, Pedersen A, Schnohr P, Bousen G. The ExStroke Trial. Physical activity before ischaemic stroke. Cerebrovascular Diseases 2004;17 Suppl 5:30 (Abstract 5).
  • Truelsen T, Pedersen A, Schnohr P, Boysen G. The EXSTROKE trial. Physical activity before ischaemic stroke. European Journal of Neurology 2004;11 Suppl 2:16 (Abstract SC124).
  • Truelsen T, Pedersen A, Schnor P, Boysen G. The EXSTROKE trial. Physical activity before ischaemic stroke. Stroke 2004;35(6):e239 (Abstract 673).
Brotons 2011 {published and unpublished data}
  • Brotons C, Arino D, Borrás I, Buitrago F, González ML, Kloppe P, et al. Evaluation of the efficacy of a comprehensive programme of secondary prevention of cardiovascular disease in primary care: the PREseAP Study. Atencion Primaria 2006;37(5):295-8.
  • Brotons C, Soriano N, Moral I, Rodrigo MP, Kloppe P, Rodríguez AL, et al. Randomized clinical trial to assess the efficacy of a comprehensive programme of secondary prevention of cardiovascular disease in general practice: the PREseAP study. Revista Española de Cardiología 2011;64(1):13-20.
  • ISRCTN18578323. Randomised controlled trial to assess the efficacy of a comprehensive secondary prevention programme in primary care. http://www.controlled-trials.com/ISRCTN18578323 (accessed 05 July 2013).
  • Trialists. Individual patient data (as supplied on 16 July 2012). Unpublished data on file.
Chanruengvanich 2006 {published data only}
  • Chanruengvanich W, Kasemkitwattana S, Charoenyooth C, Towanabut S, Pongurgsorn C. Self-regulated exercise program in transient ischemic attack and minor stroke patients. Thai Journal of Nursing Research 2006;10(3):165-78.
Chiu 2008 {published data only}
Eames 2013 {published and unpublished data}
  • ACTRN12608000469314. Do stroke clients and carers provided with a post-discharge education and support package demonstrate better stroke knowledge as compared with those receiving usual care?. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12608000469314 (accessed 05 July 2013).
  • Eames S, Hoffman T, Worrall L, Read S, Wong A. Randomised controlled trial of a postdischarge education and support package for clients with stroke and their carers. Australian Occupational Therapy Journal 2011;58:51.
  • Eames S, Hoffman T, Worrall L, Read S, Wong A. Randomised controlled trial of an education and support package for stroke patients and their carers. BMJ Open 2013;3:e002538.
  • Eames S, Hoffmann T, Worrall L, Read S, Wong A. Randomised controlled trial of a post-discharge education and support package for clients with stroke and their carers. International Journal of Stroke 2011;6:8.
  • Eames S, Hoffmann T, Worrall L, Wong A, Read S. Evaluation of an innovative post-discharge education and support package for patients with stroke and their carers. International Journal of Stroke 2010;5 Suppl 2:190 (Abstract PO10411).
  • UK trialists. Individual patient data (as supplied 21 July 2012). Unpublished data on file.
Ellis 2005 {published and unpublished data}
  • Ellis G, Rodger J, McAlpine C, Langhorne P. Patient-centered education lowers blood pressure. Stroke 2004;35(1):257 (Abstract P25).
  • Ellis G, Rodger J, McAlpine C, Langhorne P. The impact of a stroke nurse specialist on risk factor modification in a TIA clinic: a randomised controlled trial. Age and Ageing 2004;33 Suppl 1:10.
  • Ellis G, Rodger J, McAlpine C, Langhorne P. The impact of stroke nurse specialist input on risk factor modification: a randomised controlled trial. Age and Ageing 2005;34(4):389-92.
  • McManus J, Craig A, McAlpine C, Langhorne P, Ellis G. Does behaviour modification affect post-stroke risk factor control? Three-year follow-up of a randomized controlled trial. Clinical Rehabilitation 2009;23:99-105.
  • McManus JA, Craig A, Ellis G, McAlpine C, Langhorne P. 3 years on: does behaviour modification affect post stroke risk factor control?. Age and Ageing 2006;35 Suppl 3:i72.
  • McManus JA, Craig A, Ellis G, McAlpine C, Langhorne P. 3 years on: does behaviour modification affect post stroke risk factor control?. Cerebrovascular Diseases 2006;21 Suppl 4:92 (Abstract 12).
Evans 2010 {published and unpublished data}
  • Evans CD, Eurich DT, Taylor JG, Blackburn DF. The collaborative cardiovascular risk reduction in primary care (CCARP) study. Pharmacotherapy 2010;30(8):766-75.
Flemming 2013 {published and unpublished data}
  • Flemming K, Brown R. Utility of a physician directed, nurse based stroke prevention program. Neurology 2012;78 (Meeting Abstracts 1):P07.022.
  • Flemming KD, Allison T, Covalt J, Herzig D, Brown RD. The utility of a nurse case managed ischemic stroke post hospitalization prevention program (as supplied 13 May 2013). Unpublished report.
Hornnes 2011 {published and unpublished data}
  • Hornnes AN, Boysen G, Larsen K. The post stroke preventive trial (PREVENT). A randomised controlled trial nested in a cohort. Proceedings of the 17th European Stroke Conference. 13-16 May 2008. Nice, France, 2008 (Abstract 9).
  • Hornnes N, Larsen K, Boysen G. Blood pressure 1 year after stroke: the need to optimise secondary prevention. Journal of Stroke and Cerebrovascular Diseases 2011;20(1):16-23.
  • Hornnes N, Larsen K, Boysen G. Little change of modifiable risk factors 1 year after stroke: a pilot study. International Journal of Stroke 2010;5:157-62.
  • NCT00253097. The post stroke preventive trial (PREVENT). A RCT nested in a cohort study. http://www.clinicaltrials.gov/ct2/show/NCT00253097 (accessed 05 July 2013).
Johnston 2010 {published and unpublished data}
  • Hills NK, Nguyen-Huynh M, Grosvenor D, Sidney S, Kingman J, Bernstein A, et al. Race and blood pressure control six months after ischemic stroke. Stroke 2008;39(2):622-23 (Abstract P213).
  • Johnston SC, Sidney S, Hills NK, Grosvenor D, Klingman JG, Bernstein A, Levin E. Standardised discharge orders after stroke: results of the quality improvement in stroke prevention (QUISP) cluster randomised trial. Annals of Neurology 2010;67:579-89.
  • Johnston SC, Sidney S, Hills NK, Grosvenor D, Klingman JG, Bernstein A, et al. Standardised discharge orders after stroke: results of the quality improvement in stroke prevention (QUISP) trial. Stroke 2010;41(4):e289 (Abstract 130).
  • Kwan J, Johnston SC. The impact of standardised stroke orders on adherence to best practices. Neurology 2006;66:1130.
  • NCT00328640. Quality improvement in stroke prevention (QUISP). http://www.clinicaltrials.gov/ct2/show/NCT00328640 (accessed 05 July 2013).
  • Navi BB, Kamel H, Sidney S, Hills NK, Nguyen-Huynh MN, Johnston SC. Statin cessation after ischaemic stroke. Stroke 2010;41(4):E244 (Abstract 157).
Joubert 2009 {published data only}
  • ACTRN12611000264987. Reducing disability in older Australians through secondary stroke prevention. ICARUSS. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12611000264987 (accessed 05 July 2013).
  • Joubert J. Shared care in stroke survivors - translation of research into service. Journal of the Neurological Sciences 2005;238 Suppl 1:S63 (Abstract OPL069).
  • Joubert J, Joubert L, Jackson D, Wilson A, Pearce C, Reid C, et al. Improvement in risk factor management stroke survivors exposed to an integrated model of care. International Journal of Stroke 2010;5:27.
  • Joubert J, Joubert L, Reid C, Barton D, Cumming T, Mitchell P, et al. The positive effect of integrated care on depressive symptoms in stroke survivors. Cerebrovascular Diseases 2008;26(2):199-205.
  • Joubert J, Joubert LB, Reid C, Barton D, Cumming T, Mitchell P, et al. The positive effect of integrated care on depressive symptoms in stroke survivors. International Journal of Stroke 2008;3 Suppl 1:144 (Abstract 3).
  • Joubert J, Reid C, Barton D, Cumming T, McLean A, Joubert L, et al. Integrated care improves risk-factor modification after stroke: initial results of the integrated care for the reduction of secondary stroke model. Journal of Neurology, Neurosurgery and Psychiatry 2009;80:279-84.
  • Joubert J, Reid C, Joubert L, Barton D, Ruth D. Effective detection and secondary intervention for post-stroke depression in a high-risk group: results of a shared care model. Cerebrovascular Diseases 2004; Vol. 17 Suppl 1.
  • Joubert J, Reid C, Joubet L, Barton D, Ruth D, Jackson D, et al. Risk factor management and depression post-stroke: the value of an integrated model of care. Journal of Clinical Neuroscience 2006;13:84-100.
Kerry 2013 {published data only}
  • Kerry S, Cloud G, Markus H, Khong T, Oakeshott P. Does self monitoring improve blood pressure control in hypertensive stroke patients - first results of a randomised trial. International Journal of Stroke 2010;5 Suppl 3:6.
  • Kerry S, Markus H, Khong T, Doshi R, Conroy R, Oakeshott P. Community based trial of home blood pressure monitoring with nurse-led telephone support in patients with stroke or transient ischaemic attack recently discharged from hospital. Trials 2008;9:15.
  • Kerry S, Markus H, Oakeshott P, Khong T. Community based trial of home blood pressure monitoring of recently discharge stroke patients. The Stroke Association Funded Research 2007 (www.stroke.org.uk).
  • Kerry SM, Markus HS, Khong TK, Cloud GC, Tulloch J, Coster D, et al. Home blood pressure monitoring with nurse-led telephone support among patients with hypertension and a history of stroke: a community-based randomized controlled trial. Canadian Medical Association Journal 2013;185(1):23-31.
Kim 2013 {published data only}
  • Kim JI, Lee S, Kim JH. Effects of a web-based stroke education program on recurrence prevention behaviors among stroke patients: a pilot study. Health Education Research 2013;28(3):488-501.
Lowe 2007 {published and unpublished data}
  • ISRCTN55373356. The CareFile project: an assessment of the impact of individualised information booklets in patients post stroke. http://www.controlled-trials.com/ISRCTN55373356 (accessed 05 July 2013).
  • Lowe D, Leathley M, Sharma A. Patient education following stroke: the CareFile project. Cerebrovascular Diseases 2002;13 Suppl 3:81.
  • Lowe D, Leathley M, Sharma A. The effects of an individualised booklet in post stroke patients: the care file project. Cerebrovascular Diseases 2003;16 Suppl 4:95 (Abstract P404).
  • Lowe D, Leathley MJ, Sharma AK. An assessment of the utility of an individualised information booklet in patients after stroke: the CAREFILE project. Age and Ageing 2005;34 Suppl 1:i38.
  • Lowe DB, Leathley MJ, Sharma AK. Assessment of stroke knowledge. Age and Ageing 2002;31 Suppl 1:42.
  • Lowe DB, Sharma AK, Leathley MJ. The CareFile project: a feasibility study to examine the effects of an individualised information booklet on patients after stroke. Age and Ageing 2007;36:83-9.
Lowrie 2010 {published and unpublished data}
  • Lowrie R, Morrison J, McConachie A. A cluster randomised controlled trial of pharmacist led statin outreach support (SOS) in primary care: design and baseline characteristics. Contemporary Clinical Trials 2010;31:303-11.
  • UK trialists. Summary patient data (as supplied on 08 July 2013). Unpublished data on file.
Maasland 2007 {published and unpublished data}
MacKenzie 2013 {published data only}
  • MacKenzie G, Ireland S, Sahlas D, Oczkowski W, Gould L, LeBlanc K, et al. Tailored interventions to improve hypertension in management after stroke. Stroke 2011;42(11):e599.
  • Mackenzie G, Ireland S, Moore S, Heinz I, Johnson R, Oczkowski W, et al. Tailored interventions to improve hypertension management after stroke or TIA - phase II (TIMS II). Canadian Journal of Neuroscience Nursing 2013;35(1):27-34.
Markle-Reid 2011 {published and unpublished data}
  • Markle-Reid M, Orridge C, Weir R, Browne G, Gafni A, Lewis M, et al. Interprofessional stroke rehabilitation for stroke survivors using home care. Canadian Journal of Neurological Sciences 2011;38:317-34.
  • NCT00463229. Interdisciplinary team approach to stroke rehabilitation in home care. http://clinicaltrials.gov/ct2/show/NCT00463229 (accessed 05 July 2013).
O'Carroll 2011 {published and unpublished data}
  • ISRCTN38274953. Improving adherence to medication in stroke survivors: a single centre randomised controlled pilot study. http://www.controlled-trials.com/ISRCTN38274953 (accessed 05 July 2013).
  • O'Carroll R. Improving adherence to medication in stroke survivors (IAMSS): a randomised controlled trial: study protocol. BMC Neurology 2010;10:15.
  • O'Carroll R, Whittaker J, Hamilton B, Johnston M, Sudlow C, Dennis M. Predictors of adherence to secondary preventive medication in stroke patients. Annals of Behavioral Medicine 2011;41(3):383-90.
  • UK trialists. IAMSS Final Report (as supplied 18 April 2013). Unpublished report.
Slark 2013 {published and unpublished data}
  • ISRCTN67999605. Individual risk awareness intervention in stroke. http://www.controlled-trials.com/ISRCTN67999605 (accessed 05 July 2013).
  • Slark J, Khan MS, Bentley P, Sharma P. Individual risk awareness intervention in stroke (IRAIS): a randomised controlled trial (as supplied 17 June 2013). Unpublished report.
  • Slark JS. Risk awareness in secondary stroke prevention. London, UK: Imperial College London, 2012.
Wang 2005 {published data only}
  • Wang L. Neurologist participates in the community intervention for the functional prognosis of convalescent patients with stroke. Chinese Journal of Clinical Rehabilitation 2005;9(17):4-5.
Welin 2010 {published and unpublished data}
  • NCT00976001. Follow-up pilot study after a first stroke. http://clinicaltrials.gov/ct2/show/NCT00976001 (accessed 05 July 2013).
  • Welin L, Bjälkefur K, Roland I. Open, randomized pilot study after first stroke: a 3.5 year follow-up. Stroke 2010;41:1555-7.

References to studies excluded from this review

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. References to ongoing studies
  22. Additional references
Amariles 2012 {published data only}
  • Amariles P, Sabater-Hernandez D, Garcia-Jimenez E, Rodriguez-Chamorro MA, Prats-Mas R, Marin-Magan F, et al. Effectiveness of Dader method for pharmaceutical care on control of blood pressure and total cholesterol in outpatients with cardiovascular disease or cardiovascular risk: EMDADER-CV randomized controlled trial. Journal of Managed Care Pharmacy 2012;18(4):311-23.
Banet 1997 {published data only}
  • Banet GA, Felchlia MA. The potential utility of a shared medical record in a "first-time" stroke population. Journal of Vascular Nursing 1997;15(1):29-33.
Bokemark 1996 {published data only}
  • Bokemark L, Blomstrand C, Fagerberg B. Considerable differences in the management of stroke. A study of structured vs. conventional care. Lakartidningen 1996;93(8):681-5.
Gillham 2010 {published data only}
  • Gillham S, Endacott R. Impact of enhanced secondary prevention on health behaviour in patients following minor stroke and transient ischaemic attack: a randomised controlled trial. Clinical Rehabilitation 2010;24(9):822-30.
  • Gillham SD. Does enhanced secondary prevention intervention after minor stroke and transient ischaemic attack (TIA) affect readiness to change health behaviour?. Conference: 4th UK Forum Stroke Conference. Glasgow, United Kingdom, 2009. International Journal of Stroke 2009;4:27.
Goessens 2006 {published data only}
  • *Goessens BMB, Visseren FLJ, Sol BGM, de Man-van Ginkel JM, van der Graaf Y. A randomised, controlled trial for risk factor reduction in patients with symptomatic vascular disease: the multidisciplinary vascular prevention by nurses study (VENUS). European Journal of Cardiovascular Prevention and Rehabilitation 2006;13:996-1003.
  • Sol BG, van der Graaf Y, van der Bijl JJ, Goessens BM, Visserten FL. The role of self-efficacy in vascular risk factor management: a randomised controlled trial. Patient Education and Counseling 2008;71(2):191-7.
Green 2007 {published data only}
  • Green T, Haley E, Eliasziw M. Patient education in stroke prevention. Stroke 2006;37(2):688 (Abstract P211).
  • Green T, Haley E, Eliasziw M, Hoyte K. Education in stroke prevention: efficacy of an educational counselling intervention to increase knowledge in stroke survivors. Canadian Journal of Neuroscience Nursing 2007;29(2):13-20.
Harrington 2007 {published data only}
  • Harrington R, Taylor G, Duggan A, Reed M, Wood V. The evaluation of a community-based stroke scheme. Disability and Rehabilitation 2007;29(20-21):1636-7.
Johnston 2000 {published data only}
Joshi 2012 {published data only}
  • Chow CK, Joshi R, Gottumukkala AK, Raju K, Raju R, Reddy S, et al. Rationale and design of the rural Andhra Pradesh cardiovascular prevention study (RAPCAPS): a factorial, cluster-randomised trial of 2 practical cardiovascular disease prevention strategies developed for rural Andhra Pradesh, India. American Heart Journal 2009;158:349-55.
  • Joshi R, Chow C, Raju K, Raju R, Gottumukkala AK, Reddy S, et al. The rural Andhra Pradesh cardiovascular prevention study (RAPCAPS): a cluster randomised trial. Journal of the American College of Cardiology 2012;59(13):1188-96.
  • NCT00263393. Rural Andhra Pradesh cardiovascular prevention study (RAPCAPS). http://clinicaltrials.gov/show/NCT00263393 (accessed 05 July 2013).
Ma 2009 {published data only}
  • Ma J, Berra K, Haskell WL, Klieman L, Hyde S, Smith MW, et al. Case management to reduce cardiovascular risk in a county healthcare system. Archives of Internal Medicine 2009;169(21):1988-95.
  • Ma J, Lee K, Berra K, Stafford RS. Implementation of case management to reduce cardiovascular disease risk in the Stanford and San Mateo heart to heart randomised controlled trial: study protocol and baseline characteristics. Implementation Science 2006;1:21.
  • NCT00127751. Heart disease on the mend. http://clinicaltrials.gov/show/NCT00127751 (accessed 05 July 2013).
Middleton 2004 {published data only}
  • Middleton S, Donnelly N, Harris J, Ward J. Nursing intervention after carotid endarterectomy: a randomised trial of co-ordinated care post-discharge. Issues and Innovations in Nursing Practice 2004;52(3):250-61.
Nir 2006 {published data only}
  • Nir Z, Weisel-Eichler A. Improving knowledge and skills for use of medication by patients after stroke: Evaluation of a nursing intervention. American Journal of Physical Medicine and Rehabilitation 2006;85(7):582-92.
Ornstein 2004 {published data only}
  • Ornstein S, Jenkins RG, Nietert PJ, Feifer C, Roylance LF, Nemeth L, et al. A multimethod quality improvement intervention to improve preventive cardiovascular care: a cluster randomised trial. Annals of Internal Medicine 2004;141(7):523-32.
  • Ornstein SM. Translating research into practice using electronic medical records the PPRNet-TRIP project: primary and secondary prevention of coronary heart disease and stroke. Topics in Health Information Management 2001;22:52-8.
Palanco 2011 {published data only}
  • ISRCTN93700442. Impact of comprehensive and intensive treatment of risk factors concerning cardiovascular mortality in secondary prevention: MIRVAS study. http://www.controlled-trials.com/ISRCTN93700442 (accessed 05 July 2013).
  • Moreno-Palanco MA, Ibanez-Sanz P, Ciria-de, Pablo C, Pizarro-Portillo A, Rodriquez-Salvanes F, Suarez-Fernandez C. Impact of comprehensive and intensive treatment of risk factors concerning cardiovascular mortality in secondary prevention: MIRVAS study. Revista Española de Cardiología 2011;64(3):179-85.
  • Palanco MAM, de Pablo CC, Sanz IP, Luis SC, Portillo AP, Fernandez C. Cardiovascular morbimortality reduction after an acute cardiovascular event through multifactorial and intensive cardiovascular risk factors management (MIRVAS project). Medicina Clinica 2007;129(7):241-6.
Powers 2011 {published data only}
  • NCT01134458. Personalised cardiovascular risk information to initiate and maintain behavior changes (FIMDM_CVD). http://clinicaltrials.gov/show/NCT01134458 (accessed 05 July 2013).
  • Powers BJ, Danus S, Grubber JM, Olsen MK, Oddone EZ, Bosworth HB. The effectiveness of personalised coronary heart disease and stroke risk communication. American Heart Journal 2011;161(4):673-80.
Rimmer 2000 {published data only}
  • Rimmer JH, Braunschweig C, Silverman K, Riley B, Creviston T, Nicola T. Effects of a short-term health promotion intervention for a predominantly African-American group of stroke survivors. American Journal of Preventive Medicine 2000;18(4):332-8.
Ross 2007 {published data only}
  • Ross MA, Compton S, Medado P, Fitzgerald M, Kilanowski P, O'Neil BJ. An emergency department diagnostic protocol for patients with transient ischaemic attack: a randomized controlled trial. Annals of Emergency Medicine 2007;50(2):109-19.
Sides 2012 {published data only}
  • Bushnell C, Zimmer L, Schwamm L, Goldstein LB, Clapp-Channing N, Harding T, et al. The adherence evaluation after ischaemic stroke longitudinal (AVAIL) registry: design, rationale, and baseline patient characteristics. American Heart Journal 2009;157(3):428-35.
  • NCT01115660. Stroke education intervention trial - pilot AVAIL II. http://clinicaltrials.gov/show/NCT01115660 (accessed 05 July 2013).
  • Sides EG, O Zimmer L, Wilson L, Pan W, Olson DM, Peterson ED, et al. Medication coaching program for patients with minor stroke or TIA: a pilot study. BMC Public Health 2012;12:549.
Strandberg 2006 {published data only}
  • Strandberg TE, Pitkala K, Berglind S, Nieminen MS, Tilvis RS. Multifactorial cardiovascular disease prevention in patients aged 75 years and older: a randomised controlled trial: drugs and evidence based medicine in the elderly (DEBATE) study. American Heart Journal 2001;142(6):945-51.
  • Strandberg TE, Pitkala K, Berglind S, Nieminen MS, Tilvis RS. Multifactorial cardiovascular prevention in patients aged 75 and over: design and baseline results of a randomised controlled trial (DEBATE Study). European Heart Journal 2001;22:460 (Abstract P2408).
  • Strandberg TE, Pitkala K, Berglind S, Nieminen MS, Tilvis RS. Possibilities of multifactorial cardiovascular disease prevention in patients aged 75 and older: a randomised controlled trial. Drugs and evidence based medicine in the elderly (DEBATE) study. European Heart Journal 2003;24:1216-22.
  • Strandberg TE, Pitkala KH, Berglind S, Nieminen MS, Tilvis RS. Multifactorial intervention to prevent recurrent cardiovascular events in patients 75 years or older: the drugs and evidence-based medicine in the elderly (DEBATE) study: a randomised, controlled trial. American Heart Journal 2006;152:585-92.
UMIN000001865 {published and unpublished data}
  • UMIN000001865. Lifestyle intervention for prevention of stroke recurrence in mild stroke - a randomised controlled trial. http://apps.who.int/trialsearch/Trial.aspx?TrialID=UMIN000001865 (accessed 05 July 2013).
Vernooij 2012 {published data only}
  • Vernooij JW, Kaasjager HA, van der Graaf Y, Wierdsma J, Grandjean HM, Hovens MM, et al. Internet based vascular risk factor management for patients with clinically manifest vascular disease: randomised controlled trial. BMJ 2012;344:e3750.

References to studies awaiting assessment

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. References to ongoing studies
  22. Additional references
Feld-Glazman 2012 {published data only}
  • Feld-Glazman R, Bushnik T, Van Lew S, Sheikovitz L. The impact of a stroke education program on Patient's stroke knowledge and their change of stroke risk behaviors. Archives of Physical Medicine and Rehabilitation 2012;93(10):E39.
ISRCTN23868518 {published data only}
  • ISRCTN23868518. Secondary preventive, nurse based, telephone follow-up for risk factor control after stroke. http://www.controlled-trials.com/ISRCTN23868518/ (accessed 05 July 2013).
  • Mooe T, Bergstrom L, Irewall A-L, Ogren J. The NAILED stroke risk factor trial (Nurse based Age independent Intervention to Limit Evolution of Disease after stroke): Study protocol for a randomized controlled trial. Trials 2013;14:5.
ISRCTN63816609 {published data only}
  • ISRCTN63816609. Improving the prevention of vascular events after stroke or transient ischemic attack: a randomised controlled pilot trial of nurse independent prescriber-led care pathway-based risk factor management. http://www.controlled-trials.com/ISRCTN63816609 (accessed 05 July 2013).
ISRCTN95662526 {published and unpublished data}
  • ISRCTN95662526. The you call - we call trial: impact of a multimodal support intervention after a "mild" stroke. http://www.controlled-trials.com/ISRCTN95662526 (accessed 05 July 2013).
  • Rochette A, Korner-Bitensky N, Bishop D, Teasell R, White C, Bravo G, et al. Study protocol of the you call - we call trial: impact of a multimodal support intervention after a "mild" stroke. BMC Neurology 2010;10:3.
  • Rochette A, Korner-Bitensky N, White C, Bravo G, Côté R, Green T, et al. You all - we call trial: impact of a multimodal support intervention after a "mild" stroke. Stroke 2013;44:ANS13.
NCT00172484 {published data only}
  • NCT00172484. North Taiwan stroke center for prevention and treatment. http://clinicaltrials.gov/show/NCT00172484 (accessed 05 July 2013).
NCT00211731 {published and unpublished data}
  • Cowles C, Tuhrim S, Brust J, Koppel B, Weinberger J, Horowitz C, Chassin M. Participation in peer-led support groups improves use of secondary stroke prevention measures. Neurology 2008;70(11 Suppl 1):A203.
  • NCT00211731. Preventing recurrent stroke in minority populations. http://clinicaltrials.gov/ct2/show/NCT00211731 (accessed 05 July 2013).
NCT00664846 {published and unpublished data}
  • Cui L, Peng B, Ni J, Zhou L, Zhu Y, Yao M, et al. Standard medical management is associated with improved quality and outcome of secondary stroke prevention in China. Stroke 2012;43 (Meeting abstracts 2):A2587.
  • Cui L, Peng B, Zhu Y, Ni J, Xu W, Zhou L, et al. Standard medical management in secondary prevention of ischaemic stroke in China (Abstract CTP45). Proceedings of the International Stroke Conference. 24-26 February 2010. Texas, USA: American Heart Association and American Stroke Association, 2010.
  • NCT00664846. Standard medical management in secondary prevention of ischaemic stroke in China (SMART). http://clinicaltrials.gov/show/NCT00664846 (accessed 05 July 2013).
  • Peng B, Zhu Y, Cui L, Ni J, Xu W, Zhou L, et al. Standard medical management in secondary prevention of ischemic stroke in China (SMART). International Journal of Stroke 2011;6(5):461-5.
  • Peng B, Zhu Y, Ni J, Xu W, Zhou L, Yao M, et al. Interim analysis of a multi-center trial in secondary ischaemic stroke prevention in China (Abst. CTP47). Proceedings of the International Stroke Conference 2011. Los Angeles, USA: American Heart Association and American Stroke Association, 8-11 February 2011.
NCT00687869 {published and unpublished data}
  • NCT00687869. Participative rehabilitation in stroke patients (paReSiS). http://clinicaltrials.gov/show/NCT00687869 (accessed 05 July 2013).
NCT00703274 {published and unpublished data}
  • Dromerick AW, Gibbons C, Edwards DF, Farr D, Jayam-Trouth A, Shara NM, et al. A Phase II RCT of stroke navigators to improve compliance with secondary stroke prevention: PROTECT DC (Abst. CTP33). Proceedings of the International Stroke Conference 2011. Los Angeles, USA: American Heart Association and American Stroke Association, 8-11 February 2011.
  • Dromerick AW, Gibbons MC, Covington C, Farr D, Jayam-Trouth A, Shara NM, et al. A phase II RCT of stroke navigators to improve compliance with secondary stoke prevention. PROTECT DC (Abst. CT P23). Proceedings of the International Stroke Conference 2009. California, USA: American Heart Association and American Stroke Association, 18-20 February 2009.
  • Dromerick AW, Gibbons MC, Edwards DF, Farr D, Sanchez BN, Fokar A, et al. A Phase II RCT of stroke navigators to improve compliance with secondary stroke prevention: PROTECT DC (Abst. CT P26). Proceedings of the International Stroke Conference 2010. Texas, USA: American Heart Association and American Stroke Assocation, 24-26 February 2010.
  • Dromerick AW, Gibbons MC, Edwards DF, Farr DE, Giannetti M, Sanchez B, et al. Preventing recurrence of thromboembolic events through coordinated treatment in the district of Columbia (PROTECT DC). International Journal of Stroke 2011;6(5):454-60.
  • NCT00703274. Preventing recurrence of thromboembolic events through coordinated treatment in the district of Columbia (PROTECT DC). http://clinicaltrials.gov/show/NCT00703274 (accessed 05 July 2013).
NCT01027273 {published and unpublished data}
  • Goldfinger JZ, Kronish IM, Fei K, Graciani A, Rosenfeld P, Lorig K, et al. Peer education for secondary stroke prevention in inner-city minorities: design and methods of the prevent recurrence of all inner-city strokes through education randomized controlled trial. Contemporary Clinical Trials 2012;33(5):1065-73.
  • NCT01027273. Prevent return of stroke study. http://clinicaltrials.gov/ct2/show/NCT01027273 (accessed 05 July 2013).
NCT01071408 {published and unpublished data}
  • Cheng EM, Cunningham WE, Towfighi A, Sanossian N, Bryg RJ, Anderson TL, et al. Randomized, controlled trial of an intervention to enable stroke survivors throughout the Los Angeles County safety net to "stay with the guidelines". Circulation. Cardiovascular Quality and Outcomes 2011;4(2):229-34.
  • NCT01071408. Trial of a secondary stroke prevention program. http://clinicaltrials.gov/show/NCT01071408 (accessed 05 July 2013).
NCT01466907 {published and unpublished data}
  • NCT01466907. Detection and intervention of health problems after stroke: a randomised controlled trial of a structured nurse-led follow-up program. http://clinicaltrials.gov/ct2/show/NCT01466907 (accessed 05 July 2013).
Nguyen 2011 {published data only}
  • Nguyen P, Tokuda S, Wallis D. Pharmacist telephone interventions improve adherence to stroke preventive medications and reduce stroke risk factors: a randomised controlled trial. Stroke 2011;43(3):e244.
Wolfe 2010 {published data only}
  • ISRCTN10730637. The south London secondary prevention programme. http://www.controlled-trials.com/ISRCTN10730637 (accessed 05 July 2013).
  • Redfern J. The stop stroke secondary prevention trial: one year update. Proceedings of the The Stroke Association 9th Scientific Conference. 15-16 September 2004. Cambridge, UK: The Stroke Association, 2004.
  • Redfern J, McKevitt C, Frisby L, Montoute K, Rudd A, Wolfe C. Stop stroke: the south London secondary prevention programme. Evaluation of a multifaceted secondary prevention programme for stroke. Proceedings of the 13th European Stroke Conference (http://www.eurostroke.org/esc_ongoing_trials.asp). 13-15 May 2004. Mannheim-Heidelberg, Germany, 2004.
  • Redfern J, McKevitt C, Rudd AD, Heuschmann P, Grieve A, Wolfe CDA. Optimising secondary prevention post stroke - first results of the stop stroke study. Proceedings of the 3rd UK Stroke Forum Conference 2008. 2-4 December 2008. Harrogate, UK: The Stroke Association, 2008.
  • Redfern J, McKevitt C, Rudd AG, Heuschmann P, Grieve A, Wolfe CDA. Stop stroke: cluster randomised controlled trial of a patient/carer and general practitioner intervention to improve risk factor management after stroke. Cerebrovascular Diseases 2009;27:66.
  • Redfern J, Rudd AD, Wolfe CDA, McKevitt C. Stop stroke: development of an innovative intervention to improve risk factor management after stroke. Patient Education and Counseling 2008;72:201-9.
  • Redfern J, Wolfe C, McKevitt C. How does stop stroke work? Qualitative process evaluation of a multiple risk factor intervention to improve stroke secondary prevention. Cerebrovascular Diseases 2008;25 Suppl 2:189 (Abstract 7).
  • Refern J, McKevitt C, Rudd A, Wolfe C. Stop stroke. A new intervention to improve stroke secondary prevention (Abstract 18). Proceedings of the 12th European Stroke Conference. Valencia, Spain, 21-24 May 2003.
  • Refern JM. Methods for developing and evaluating randomised controlled trials of complex interventions - case study of stroke secondary prevention. London, UK: Guy's King's and St. Thomas's School of Medicine, 2007.
  • Wolfe C. The south London stroke secondary prevention programme. Proceedings of the UK Stroke Forum Conference 2007. 4-6 December 2007. Harrogate, UK: The Stroke Association, 2007.
  • Wolfe CD, Redfern J, Rudd AG, Grieve AP, Heuschmann PU, McKevitt C. Cluster randomized controlled trial of a patient and general practitioner intervention to improve the management of multiple risk factors after stroke: stop stroke. Stroke 2010;41:2470-6.

References to ongoing studies

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. References to ongoing studies
  22. Additional references
ACTRN12608000166370 {published and unpublished data}
  • ACTRN12608000166370. Shared team approach between nurses and doctors for improved risk factor management for stroke patients. http://apps.who.int/trialsearch/Trial.aspx?TrialID=ACTRN12608000166370 (accessed 05 July 2013).
  • Cadilhac DA, Thrift AG, Srikanth VK, Nelson MR, Kim J, Fitzgerald SM, et al. The standfirm trial: a double-blind, cluster randomised-controlled trial of long-term risk factor management in survivors of stroke. International Journal of Stroke 2012;7 Suppl 1:58.
  • Thayabaranathan T, Cadilhac DA, Srikanth VK, Nelson MR, Kim J, Fitzgerald SM, et al. Feasibility of a double-blind, cluster randomised-controlled trial of long-term risk factor management in survivors of stroke. International Journal of Stroke 2012;7 Suppl 1:8.
  • Thrift AG, Srikanth VK, Nelson MR, Kim J, Fitzgerald SM, Gerraty RP, et al. Risk factor management in survivors of stroke: a double-blind, cluster-randomized, controlled trial. International Journal of Stroke 2012 Dec 11. doi: 10.1111/j.1747-4949.2012.00933.x. [Epub ahead of print].
ACTRN12611000792921 {published and unpublished data}
  • ACTRN12611000792921. Multi-centre randomised controlled trial comparing the effect of general practitioner utilisation of a TIA electronic decision support tool in the management of TIA/minor stroke patients versus usual care on the subsequent 90 day stroke risk, degree of guideline adherence, and overall treatment costs. http://apps.who.int/trialsearch/Trial.aspx?TrialID=ACTRN12611000792921 (accessed 05 July 2013).
ChiCTR-TRC-12002127 {published and unpublished data}
  • ChiCTR-TRC-12002127. Effects of clinical pharmacist interventions on the secondary prevention in the ischemic stroke patients. http://apps.who.int/trialsearch/Trial.aspx?TrialID=ChiCTR-TRC-12002127 (accessed 05 July 2013).
ISRCTN07607027 {published and unpublished data}
  • ISRCTN07607027. Promoting adherence to a regimen of risk factor modification by trained non-medical personnel evaluated against regular practice study PARTNERS. http://www.controlled-trials.com/ISRCTN07607027 (accessed 05 July 2013).
  • Mayer C, Chan R, Hachinski V. Partners promoting adherence to regimen of risk factor modification by trained volunteers or nurses evaluated against regular practice study. International Journal of Stroke 2008;3 Suppl 1:321 (Abstract PO02-212).
ISRCTN08913646 {published and unpublished data}
  • ISRCTN08913646. The effect of a health empowerment intervention for stroke self-management (HEISS) on the self-management behaviour and health outcomes of stroke rehabilitation patients. http://www.controlled-trials.com/ISRCTN08913646 (accessed 05 July 2013).
ISRCTN35701810 {published and unpublished data}
  • Dregan A, Toschke MA, Wolfe CD, Rudd A, Ashworth M, Gulliford MC, et al. Utility of electronic patient records in primary care for stroke secondary prevention trials. BMC Public Health 2011;11:86.
  • Dregan A, van Staa T, McDermott L, McCann G, Ashworth M, Charlton J, et al. Cluster randomized trial in the general practice research database: 2. secondary prevention after first stroke (eCRT study): study protocol for a randomized controlled trial. Trials 2012;13:181.
  • ISRCTN35701810. Secondary prevention after first stroke. http://www.controlled-trials.com/ISRCTN35701810 (accessed 05 July 2013).
ISRCTN97412358 {published data only}
  • ISRCTN97412358. ECG monitoring to detect atrial fibrillation after stroke. http://www.controlled-trials.com/ISRCTN97412358 (accessed 05 July 2013).
JPRN-UMIN000007808 {published and unpublished data}
  • JPRN-UMIN000007808. Construction of a self-management patient education program and evidences for preventing recurrence of stroke in community settings. http://apps.who.int/trialsearch/Trial.aspx?TrialID=JPRN-UMIN000007808 (accessed 05 July 2013).
NCT00355147 {published data only}
  • Damush TM, Ofner S, Yu Z, Plue L, Nicholas G, Williams LS. Implementation of a stroke self-management program: a randomized controlled pilot study of veterans with stroke: a randomized controlled pilot study of veterans with stroke. Translational Behavioral Medicine 2011;1(4):561-72.
  • NCT00355147. Adapting tools to implement stroke risk management to veterans (TOOLS). http://clinicaltrials.gov/show/NCT00355147 (accessed 05 July 2013).
NCT00574808 {published and unpublished data}
  • Liddy C, Hogg W, Russell G, Wells G, Armstrong CD, Akbari A, et al. Improved delivery of cardiovascular care (IDOCC) through outreach facilitation: study protocol and implementation details of a cluster randomised controlled trial in primary care. Implementation Science 2011;6:110.
  • NCT00574808. Improved delivery of cardiovascular care through outreach facilitation (IDOCC). http://www.clinicaltrials.gov/ct2/show/NCT00574808 (accessed 05 July 2013).
NCT00861081 {published and unpublished data}
  • NCT00861081. Intervention to enable stroke survivors in Los Angeles county hospitals to "stay within the guidelines" SUSTAIN. http://clinicaltrials.gov/ct2/show/NCT00861081 (accessed 05 July 2013).
NCT00931788 {published and unpublished data}
  • NCT00931788. Preventing recurrent vascular events in patients with stroke or transient ischaemic attack (PREVENTION). http://clinicaltrials.gov/show/NCT00931788 (accessed 05 July 2013).
NCT01122394 {published data only}
  • NCT01122394. Reducing Risk of Recurrence (RRR). http://clinicaltrials.gov/show/NCT01122394 (accessed 05 July 2013).
NCT01517542 {published and unpublished data}
  • NCT01517542. Evaluation of effectiveness of nutritional counselling in patients after stroke. http://clinicaltrials.gov/show/NCT01517542 (accessed 05 July 2013).
NCT01550822 {published data only}
  • NCT01550822. HEALS (healthy eating and lifestyle after stroke). http://clinicaltrials.gov/show/NCT01550822 (accessed 05 July 2013).
NCT01586702 {published and unpublished data}
  • Leistner S, Benik S, Laumeier I, Ziegler A, Nieweler G, Nolte CH, et al. Secondary prevention after minor stroke and TIA - usual care and development of a support program. PLoS ONE 2012;7(12):e49985.
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NCT01684176 {published and unpublished data}
  • NCT01684176. Tailored intervention to improve patient adherence to secondary stroke prevention medication. http://clinicaltrials.gov/ct2/show/NCT01684176 (accessed 05 July 2013).
NCT01721538 {published data only}
  • NCT01721538. Secondary prevention of stroke through non-drug therapeutic weight reduction "SCENARIO". http://clinicaltrials.gov/ct2/show/NCT01721538 (accessed 05 July 2013).
NCT01763203 {published and unpublished data}
  • NCT01763203. The SUCCEED trial of secondary stroke prevention. http://clinicaltrials.gov/show/NCT01763203 (accessed 05 July 2013).
NCT01776034 {published data only}
  • NCT01776034. Health promotion and wellness program for stroke survivors. http://www.clinicaltrials.gov/ct2/show/NCT01776034 (accessed 05 July 2013).
NCT01807793 {published and unpublished data}
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Additional references

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. What's new
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. References to studies awaiting assessment
  21. References to ongoing studies
  22. Additional references
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