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Implementation of a structured guideline-based program for the secondary prevention of ischemic stroke in China
Bin Peng1, Jun Ni, Craig S Anderson
1From the Department of Neurology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, China (B.P., J.N., Y.Z., J. Wang, L.Z., M.Y., S.G., W.X., L.C.); The George Institute for Global Health, Royal Prince Alfred Hospital and University of Sydney, Sydney, Australia (C.S.A.); Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.W.); Department of Neurology, People's Liberation Army General Hospital, Beijing, China (C.P.); Department of Neurology, Jilin University, Changchun, China (J. Wu); Department of Health Statistics, Second Military Medical University (J.H.); Department of Epidemiology, Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences; and School of Basic Medicine, Peking Union Medical College, Beijing, China (G.S.).
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.
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