Implementation of a Structured Guideline–Based Program for the Secondary Prevention of Ischemic Stroke in China

Abstract

Background and Purpose— High rates of ischemic stroke and poor adherence to secondary prevention measures are observed in the Chinese population. Methods— We used a national, multicenter, cluster-randomized controlled trial in which 47 hospitals were randomized to either a structured care program group (n=23) or a usual care group (n=24). The structured care program consisted of a specialist-administered, guideline-recommended pharmaceutical treatment and a lifestyle modification algorithm associated with written and Internet-accessed educational material for patients for the secondary prevention of ischemic stroke. The primary efficacy outcome was the proportion of patients who adhered to the recommended measures at 12-month postdischarge. This trial is registered with ClinicalTrial.gov (NCT00664846). Results— At 12 months, 1287 (72.1%) patients in the Standard Medical Management in Secondary Prevention of Ischemic Stroke in China (SMART) group and 1430 (72%) patients in the usual care group had completed the 12-month follow-up ( P =0.342). Compared with the usual care group, those in the SMART group showed higher adherence to statins (56% versus 33%; P =0.006) but no difference in adherence to antiplatelet (81% versus 75%; P =0.088), antihypertensive (67% versus 69%; P =0.661), or diabetes mellitus drugs (73% versus 67%; P =0.297). No significant difference in the composite end point (new-onset ischemic stroke, hemorrhagic stroke, acute coronary syndrome, and all-cause death) was observed (3.56% versus 3.59%; P =0.921). Conclusions— The implementation of a program to improve adherence to secondary ischemic stroke prevention efforts in China is feasible, but these programs had only a limited impact on adherence and no impact on 1-year outcomes. Further development of a structured program to reduce vascular events after stroke is needed. Clinical Trial Registration—URL: http://www.clinicaltrials.gov . Unique identifier: NCT00664846.

Fixed-Dose Combination Treatment After Stroke for Secondary Prevention in China

“…20 A recent randomized clinical trial among stroke patients in China showed that intensive patient education had no effect on adherence to combination treatment using separate medications. 22 The reasons may include the complexity of treatment with different drugs for both physicians in community hospitals and stroke patients. Use of a polypill is a possible solution, and there is evidence that this can lead to a reduction in risk factors and increased adherence rates.…”

Effectiveness of Goal-Setting Telephone Follow-Up on Health Behaviors of Patients with Ischemic Stroke: A Randomized Controlled Trial

“…First, patients and physicians pay more attention to in-hospital treatment during the acute phase of stroke than to long-term prevention after hospital discharge. 12 Second, the separation of health systems into hospital-based and community care in China is a major barrier to optimal secondary prevention as recommendations provided in hospitals are frequently not adhered to by community physicians, a situation similar to that in Germany. 3 Third, in our experience, many stroke patients do not visit outpatient clinics for long-term secondary prevention programs.…”

Cardiovascular surgery experience does not significantly improve patients' response to stroke

“…Studies have demonstrated poor control of cardiovascular risk factors and low adherence to stroke secondary prevention efforts in China (Gao et al, 2013;Lu et al, 2017;Pan et al, 2016;Peng et al, 2014;Qin et al, 2016). Even for patients with a history of cardiovascular surgeries, therapy compliance was still unimproved (Halle et al, 2018).We assume that they may be unaware of, and underestimate the importance of, controlling risk factors to reduce stroke incidence (O'Donnell et al, 2016;Soroush et al, 2017).…”