Standardized discharge orders after stroke: Results of the quality improvement in stroke prevention (QUISP) cluster randomized trial

Sidney, Stephen; Hills, Nancy K.; Grosvenor, David; Klingman, Jeffrey; Bernstein, Allan L.; Levin, Eleanor

doi:10.1002/ana.22019

Cited by 30 publications

(41 citation statements)

References 47 publications

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“…Another study used discharge orders at the end of the patient's stay in hospital to improve preventive care with modest evidence of effect. 25 A recent review, including 162 randomized trials, found that computer-delivered reminders generally had limited impact on practitioners' behavior, 26 consistent with our findings. Roshanov et al 26 found that interventions that required physicians to actively negate advice offered, before this could be disregarded, were more effective than other types of computer-delivered interventions.…”

Section: Comparison With Other Studiessupporting

confidence: 86%

Point-of-Care Cluster Randomized Trial in Stroke Secondary Prevention Using Electronic Health Records

Dregan

Staa

McDermott

et al. 2014

Stroke

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Stroke represents a long-term condition that requires ongoing preventive medical care to reduce the risk of recurrence of stroke. During the first 10 years after stroke, there is nearly 40% cumulative risk of recurrence.1 Secondary prevention after stroke should include interventions to manage and monitor vascular risk factors including blood pressure (BP), lipid-lowering drugs, and antithrombotic treatment where appropriate, as well as efforts to control overweight, increase exercise, and reduce alcohol and smoking.2 Audits have revealed major deficiencies in stroke secondary prevention with ≤40% subjects achieving a systolic BP of <140 mm Hg at 6 months poststroke.3 Failure to use effective treatments is associated with considerable morbidity, mortality, and healthcare costs. 4 There is a need for more effective intervention strategies to improve poststroke standards of care for secondary prevention that are relevant to routine clinical practice.Advances in electronic health records (EHRs) offer important opportunities for more efficient implementation of clinical and cluster trials.5 Using EHRs from a large clinical database as a sampling frame, and source of data to evaluate trial outcomes, might offer several potential advantages, enabling the recruitment of participants and assessment of Background and Purpose-The aim of this study was to evaluate whether the remote introduction of electronic decision support tools into family practices improves risk factor control after first stroke. This study also aimed to develop methods to implement cluster randomized trials in stroke using electronic health records. Methods-Family practices were recruited from the UK Clinical Practice Research Datalink and allocated to intervention and control trial arms by minimization. Remotely installed, electronic decision support tools promoted intensified secondary prevention for 12 months with last measure of systolic blood pressure as the primary outcome. Outcome data from electronic health records were analyzed using marginal models.

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Section: Comparison With Other Studiessupporting

confidence: 86%

Point-of-Care Cluster Randomized Trial in Stroke Secondary Prevention Using Electronic Health Records

Dregan

Staa

McDermott

et al. 2014

Stroke

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“…Patients were identified in parallel with the Quality Improvement in Stroke Prevention (QUISP) study, a clusterrandomized trial of standardized discharge order sets. 18 Full details of QUISP have been published elsewhere, 18 but in brief, 12 of 16 KPMCP hospitals were randomized through a matched-pair design to continue best medical care or to implement standardized discharge orders for patients with ischemic stroke. Patients were included if they had brain imaging performed during the hospitalization to confirm ischemic stroke, were Ն40 years, had full KPMCP pharmacy benefits, and had been discharged to home or to a facility other than a hospice.…”

Section: Design and Study Populationmentioning

confidence: 99%

Validation of the Stroke Prognostic Instrument-II in a Large, Modern, Community-Based Cohort of Ischemic Stroke Survivors

Navi

Kamel

Sidney

et al. 2011

Stroke

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Background and Purpose-The risk of recurrent stroke in the modern era of secondary stroke prevention is not well defined. Several prediction models, including the Stroke Prognostic Instrument-II (SPI-II), have been created to identify patients at highest risk, but their performance in modern populations has been infrequently tested. We aimed to assess the 1-year risk of recurrence after hospital discharge in a recent, large, community-based cohort of patients with ischemic stroke and to validate the SPI-II prediction model in this cohort. Methods-From 2004 through 2006, 5575 patients with acute ischemic stroke were prospectively identified and followed for recurrent events. Kaplan-Meier statistics were used to analyze the cumulative incidence of recurrent ischemic stroke. Harrell c-statistic was calculated to determine the performance of SPI-II in predicting stroke or death at 1 year, and the log-rank test was used to compare the differences among low-, middle-, and high-risk groups. Results-Among 5575 patients with ischemic stroke, recurrence was observed in 221 during the subsequent year.Kaplan-Meier estimates of cumulative rates of recurrent stroke were 2.5%, 3.6%, and 4.8% at 3, 6, and 12 months, respectively. Rates of stroke or death for SPI-II in the low-, middle-, and high-risk groups were 8.2%, 24.5%, and 35.6%, respectively (trend, Pϭ0.001). The c-statistic for SPI-II was 0.62 (95% CI, 0.61-0.64). Conclusions-The modern 1-year rate of recurrent stroke after hospital discharge is low but still substantial at 4.8%.SPI-II is a modestly effective tool in identifying patients with ischemic stroke at highest risk of developing recurrence or death. (Stroke. 2011;42:3392-3396.)

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“…The RCT found that hospital-level assistance in the development and implementation of standardised stroke discharge orders was not associated with improved adherence over 12 months at the hospital level (57.3% vs 62.9%; OR 1.26, 95% CI 0.70 to 2.30; p=0.36), although there was improvement in adherence to statins at the individual level (OR 1.29, 1.04 to 1.60; p=0.02). 19 One retrospective cohort study in acute MI patients in Canada 31 showed that predischarge medication counselling (76.0% vs 64.8%; OR 1.61, 1.26 to 2.04; p=0.0001) and having a cardiologist (vs general practitioner) responsible for patient care were associated with adherence at 120 days postdischarge (34.5% vs 25.4%; OR 1.80, 1.34 to 2.43; p=0.0001), with no association with treatment at a teaching hospital (14.8% vs 11.8%; OR 1.35, 0.93 to 1.97; p=0.11). In a retrospective cohort study of stroke/TIA patients in the USA, 30 12-month persistence with secondary prevention medications was associated with fewer medications (OR=1.04, 1.02 to 1.06, p<0.001 per one medication decrease); in-patient rehabilitation (13.4% vs 21.6%; OR=0.57, 0.43 to 0.76, p<0.001); primary care follow-up (92.1% vs 88.4%; OR=1.47, 1.05 to 2.07, p=.0.027) and neurology follow-up (43.3% vs 35.0%; OR=1.20, 1.03 to 1.41, p=0.023).…”

Section: Hospital-level Quality Improvementmentioning

confidence: 99%

Health system barriers and facilitators to medication adherence for the secondary prevention of cardiovascular disease: A systematic review

Werba

Khandelwal

Nambiar

et al. 2017

Nutrition, Metabolism and Cardiovascular Diseases

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Background: Secondary prevention is cost-effective for cardiovascular disease (CVD), but uptake is suboptimal. Understanding barriers and facilitators to adherence to secondary prevention for CVD at multiple health system levels may inform policy.Objectives: To conduct a systematic review of barriers and facilitators to adherence/persistence to secondary CVD prevention medications at health system level.Methods: Included studies reported effects of health system level factors on adherence/persistence to secondary prevention medications for CVD (coronary artery or cerebrovascular disease). Studies considered at least one of β blockers, statins, angiotensin-renin system blockers and aspirin. Relevant databases were searched from 1 January 1966 until 1 October 2015. Full texts were screened for inclusion by 2 independent reviewers.

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Standardized discharge orders after stroke: Results of the quality improvement in stroke prevention (QUISP) cluster randomized trial

Abstract: Implementation of standardized discharge orders after stroke was associated with increased rates of optimal secondary prevention; this improvement was not significant in the primary analysis at the hospital level.

Cited by 30 publications

References 47 publications

Point-of-Care Cluster Randomized Trial in Stroke Secondary Prevention Using Electronic Health Records

Point-of-Care Cluster Randomized Trial in Stroke Secondary Prevention Using Electronic Health Records

Validation of the Stroke Prognostic Instrument-II in a Large, Modern, Community-Based Cohort of Ischemic Stroke Survivors

Health system barriers and facilitators to medication adherence for the secondary prevention of cardiovascular disease: A systematic review

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