Adherence to Guidelines at a Stroke Prevention Clinic: A Follow-up Study

Abstract

BackgroundIn 2010, we published our stroke prevention clinic’s performance as compared to Canadian stroke prevention guidelines. We now compare our clinic’s adherence with guidelines to our previous results, following the implementation of an electronic documentation form.MethodsAll new patients referred to our clinic (McGill University Health Center) for recent transient ischemic attack (TIA) or ischemic stroke between 2014 and 2017 were included. We compared adherence to guidelines to our previous report (N=408 patients for period 2008–2010) regarding vascular risk management and treatment.ResultsThree hundred and ninety-two patients were included, of which 36% had a TIA and 64% had an ischemic stroke, with a mean age of 70 years and 43% female. Although the more recent cohort has shown a higher proportion of cardioembolic stroke compared to previous (19.1% vs. 14.7%) following new guidelines regarding prolonged cardiac monitoring, increased popularity in CT angiography has not translated into greater proportion of large-artery stroke subtype (26.3% vs. 26.2%). Blood pressure (BP) targets were achieved in 83% compared with 70% in our previous report (p<0.01). Attainment of low-density lipoprotein cholesterol target was also improved in our recent study (66% vs. 46%, p<0.01). No significant difference was found in the consistency of antithrombotic use (97.7% vs. 99.8%, p=0.08). However, there was a decline in smoking cessation (35% vs. 73%, p=0.02). Overall, optimal therapy status was better attained in the present cohort compared to the previous one (52% vs. 22%, p<0.01). The male sex was associated with better attainment of optimal therapy status (odds ratio, 1.61; 95% confidence interval, 1.04–2.51). The number of follow-up visits and the length of follow-up were not associated with attainment of stroke prevention targets.ConclusionsOur study shows improvement in attainment of therapeutic goals as recommended by Canadian stroke prevention guidelines, possibly attributed in part to the implementation of electronic medical recording in our clinic. Areas for improvement include smoking cessation counseling and diabetes screening.

A Gap in Post-Stroke Blood Pressure Target Attainment at Entry to Cardiac Rehabilitation

“…Similarly, Chen et al reported that in their multivariate logistic regression analysis a diagnosis of diabetes was independently associated with failing to meet BP targets. 12 When we examined DBP target attainment in patients with diabetes using the non-diabetes DBP target, there was no longer a significant difference between subjects with diabetes compared to those without. Thus, the greater proportion of people with diabetes not meeting the DBP target in this study is due, at least in part, to target levels that recommend tighter control.…”

“…Our finding that 64.3% of patients met SBP and DBP targets is consistent with previously published Canadian studies that reported 46% to 83% of stroke patients meet target. [10][11][12] Two studies of patients attending an initial visit at a stroke prevention clinic described 83% and 76% BP target attainment, respectively. 10,12 A lower proportion of target attainment (46%) was reported in an outpatient study of patients with stroke or transient ischemic attack (TIA).…”

“…[10][11][12] Two studies of patients attending an initial visit at a stroke prevention clinic described 83% and 76% BP target attainment, respectively. 10,12 A lower proportion of target attainment (46%) was reported in an outpatient study of patients with stroke or transient ischemic attack (TIA). 11 Unfortunately, none of these studies reported time since stroke, making a comparison to our cohort of patients who were a median of 210 days post-stroke challenging.…”

“…Canadian cohort studies of patients with stroke in primary care and stroke prevention clinics have reported 46% to 83% of patients meet target for both systolic BP (SBP) and DBP. [10][11][12] Thus, there remains a significant gap between guideline recommendations and real-world attainment.…”