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Improving post-stroke care in general practice: an investigation of outcomes after stroke and an analysis of a new intervention for managing patients who have had a stroke
thesisposted on 22.02.2017, 01:03 by Kim, Joosup
Introduction: Improving the understanding of factors contributing to poor outcomes, and identifying beneficial elements of interventions, can assist better management of patients who have had a stroke. Part 1 Aim: To investigate associations between risk factors and long-term outcomes after stroke. Methods: Using data obtained for a community-based study of stroke, we undertook Cox proportional hazards regression analyses to identify factors associated with the risk of stroke, acute myocardial infarction or death. Results: For the first time, we found evidence that smoking at the time of stroke (hazard ratio [HR]: 1.30, 95% confidence interval [CI]: 1.06 – 1.60, p=0.012) and a systolic blood pressure <121 mmHg at 5 years post-stroke (HR: 1.54, 95% CI: 1.04 – 2.31, p=0.033) were associated with the risk of poor long-term outcomes when compared to the absence of these factors. Part 2 Aim: To better understand each component of a secondary stroke prevention intervention provided in the Shared Team Approach between Nurses and Doctors For Improved Risk factor Management randomised controlled trial (STAND FIRM RCT). Methods: Firstly, to further advocate the use of new interventions for post-stroke care we analysed qualitative data obtained from GPs participating in our stroke education activity. Following a seminar on secondary stroke prevention, GPs audited patients with stroke managed in their clinic and reported on how the secondary prevention management of their patients could be improved. Secondly, we monitored the utilisation of individualised management plans (IMPs) developed for patients in the intervention arm of the STAND FIRM RCT. Multivariable logistic regression analysis was conducted to investigate whether utilisation of the IMPs was associated with improvements in secondary prevention management. Education visits were provided to patients in the intervention arm of the STAND FIRM RCT. Nurses documented issues related to post-stroke care and secondary prevention reported by the patients and the information they provided to the patients to resolve these issues. We conducted qualitative analysis of these notes. Results: GPs indicated that improvements could be made to the pharmacological and non-pharmacological management, and the documentation of risk factors in the patients they audited. There was evidence that IMPs had been utilised for 60% of patients in the STAND FIRM RCT. Compared to patients whose GPs did not utilise IMPs, patients for whom GPs utilised IMPs did not have a detectable difference in prescription of new secondary prevention medications (odds ratio [OR]: 0.18, 95% CI: 0.03 – 1.09, p=0.061), but were more often provided lifestyle education (OR: 2.0, 95% CI: 1.06 – 3.82, p=0.032). At the education visits conducted for patients in the STAND FIRM RCT, nurses provided information to resolve several issues related to the use of secondary prevention medications. Overall conclusions: The findings on risk factors should provide further impetus for physicians to provide smoking cessation interventions and optimise blood pressure control in survivors of stroke. Implementing the findings of these studies and other aspects of stroke management into clinical practice may be assisted by providing patients with IMPs and by educating patients.