Muideen T. Olaiya

Effectiveness of a shared team approach between nurses and doctors for improved risk factor management in survivors of stroke: a cluster randomized controlled trial.

Limited evidence exists on the benefits of organized care for improving risk factor control in patients with stroke or transient ischaemic attack. The effectiveness of an individualized management programme in reducing absolute cardiovascular disease risk in this high‐risk population was determined.

Community-Based Intervention to Improve Cardiometabolic Targets in Patients With Stroke: A Randomized Controlled Trial

Background and Purpose— Many guidelines for secondary prevention of stroke focus on controlling cardiometabolic risk factors. We investigated the effectiveness of a management program for attaining cardiometabolic targets in survivors of stroke/transient ischemic attack. Methods— Randomized controlled trial of survivors of stroke/transient ischemic attack aged ≥18 years. General practices were randomized to usual care (control) or an intervention comprising specialist review of care plans and nurse education in addition to usual care. The outcome is attainment of pre-defined cardiometabolic targets based on Australian guidelines. Multivariable regression was undertaken to determine efficacy and identify factors associated with attaining targets. Results— Overall, 283 subjects were randomized to the intervention and 280 to controls. Although we found no between-group difference in overall cardiometabolic targets achieved at 12 months, the intervention group more often achieved control of low-density lipoprotein cholesterol (odds ratio, 1.97; 95% confidence interval, 1.18–3.29) than controls. At 24 months, no between-group differences were observed. Medication adherence was ≥80% at follow-up, but uptake of lifestyle/behavioral habits was poor. Older age, being male, being married/living with partner, and having greater functional ability or a history of diabetes mellitus were associated with attaining targets. Conclusions— The intervention in this largely negative trial only had a detectable effect on attaining target for lipids but not for other factors at 12 months or any factor at 24 months. This limited effect may be attributable to inadequate uptake of behavioral/lifestyle interventions, highlighting the need for new or better approaches to achieve meaningful behavioral change. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: ACTRN12608000166370.

Long-term unmet needs and associated factors in stroke or TIA survivors: An observational study

Objective: To extensively investigate long-term unmet needs in survivors of stroke or TIA and to identify factors associated with these unmet needs. Methods: Community-dwelling adults were invited to participate in a survey ≥2 years after discharge for stroke/TIA. Unmet needs were assessed across 5 domains: activities and participation, environmental factors, body functions, post–acute care, and secondary prevention. Factors associated with unmet needs were determined with multivariable negative binomial regression. Results: Of 485 participants invited to complete the survey, 391 (81%) responded (median age 73 years, 67% male). Most responders (87%) reported unmet needs in ≥1 of the measured domains, particularly in secondary prevention (71%). Factors associated with fewer unmet needs included older age (incident rate ratio [IRR] 0.62, 95% confidence interval [CI] 0.50–0.77), greater functional ability (IRR 0.33, 95% CI 0.17–0.67), and reporting that the general practitioner was the most important in care (IRR 0.69, 95% CI 0.57–0.84). Being depressed (IRR 1.61, 95% CI 1.23–2.10) and receiving community services after stroke (IRR 1.45, 95% CI 1.16–1.82) were associated with more unmet needs. Conclusions: Survivors of stroke/TIA reported considerable unmet needs ≥2 years after discharge, particularly in secondary prevention. The factors associated with unmet needs could help guide policy decisions, particularly for tailoring care and support services provided after discharge.

Statistical analysis plan (SAP) for Shared Team Approach between Nurses and Doctors For Improved Risk Factor Management (STANDFIRM): a randomised controlled trial

With reducing case fatality following stroke (1), many more people in the community are living with stroke and are at risk of further vascular events. There are many proven treatments that prevent further vascular events in survivors of stroke. These include blood pressure (BP) lowering (2), antiplatelet therapy (3), anticoagulant therapy in people with nonrheumatic atrial fibrillation (4,5), and use of HMG CoA reductase inhibitors (6,7). Behavioral changes are also effective for improving risk factor profiles, with most evidence coming from cohort studies of primary prevention. Effective strategies include dietary counselling and review by trained specialists to lower cholesterol levels (8,9); diabetes management using exercise regimes, and pharmacotherapy for BP, cholesterol, and glycemic control; simplified drug regimens and education to improve medication compliance (10–13); smoking cessation (14,15); reducing dietary salt (16–18); consuming a diet high in vegetables and fruit (19), particularly among those with dyslipidemia (20,21) and obesity (22); increasing physical activity (23); and reducing alcohol consumption (24). Behavior change has been more effective by tailoring lifestyle interventions to an individual (25), and providing educational and motivational counseling (8,9), e.g., ‘Lifescripts’ was a national initiative in Australia, which provided tools for general practitioners (GPs) to encourage risk factor management in partnership with patients to promote self-efficacy (26). There is strong evidence that secondary prevention strategies for people with stroke are currently underutilized (27,28), e.g., about 30% of stroke survivors have BP levels ≥ 140/90 mmHg (29). In addition, only about 16% of patients hospitalized with atrial fibrillation and eligible for warfarin therapy were discharged on warfarin at the time the study commenced (30), although this has improved somewhat in recent years (31). Patients who do not receive these agents may be more susceptible to recurrent strokes and other poor outcomes. The potential gains of secondary prevention are considerable. Using mathematical modeling, we assessed the cost per quality adjusted life year (QALY) gained of different BP lowering strategies to reduce the burden of stroke in Australia. We tested the impact of increasing the proportion of patients being treated for hypertension to 60% (from current estimates of 50%). Using a combined angiotensin converting enzyme inhibitor/diuretic therapy, we estimated that 2859 strokes would be prevented each year (32), with a minimal cost per QALY saved of

Effectiveness of an Intervention to Improve Risk Factor Knowledge in Patients With Stroke: A Randomized Controlled Trial.

2120 (32). In other estimates, about 1700 recurrent strokes could be avoided in Australia each year (with a mean cost per case avoided) using any one of: voluntary smoking cessation (no cost), long-term aspirin use in those with ischemic stroke (

Housing quality and risk of acute respiratory infections among hospitalized children under five in Ibadan, Nigeria

2000), or use of cholesterollowering drugs (

Nurse-led intervention to improve knowledge of medications in survivors of stroke or transient ischemic attack: a cluster randomized controlled trial

41 000) (33). Thus, considerable health gains could be made over and above that obtained with current practice at minimal extra cost. Moreover, a combined approach may achieve even better results. In Australia, nurse-assisted interventions for coronary heart disease (and heart failure) have been proven effective in reducing rehospitalizations (34). Interventions include education of patients and caregivers on factors such as adherence to treatment, introduction of a simple exercise regimen, referral to other clinicians when required, and regular telephone follow-up. No such studies of stroke in Australia have been published. Only one longterm study has been completed in patients with stroke elsewhere (35). This Canadian study, focusing on quality of life, had a small sample size (96 patients/group). No hard end-points, such as recurrent events or management, were included. Fewer specialist visits occurred in the intervention group, this being the only difference observed. In another very short-term study (threemonths), only 47 patients were recruited per group (36). Despite their positive outcome, it is important to assess whether management can be sustained in the longer term, particularly as management is often not finalized this early. General practices are ideally placed to coordinate the long-term preventive care needs of people with stroke. In Australia, a Correspondence: Amanda G. Thrift*, Epidemiology & Prevention Division, Stroke and Ageing Research (STARC), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Vic. 3800, Australia. E-mail: amanda.thrift@monash.edu Epidemiology & Prevention Division, Stroke and Ageing Research (STARC), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Vic., Australia The Florey Institute of Neuroscience and Mental Health, Melbourne University, Heidelberg, Vic., Australia Menzies Research Institute Tasmania, Hobart, Tas., Australia School of Medicine, University of Tasmania, Hobart, Tas., Australia

Community-Based Intervention to Improve Cardiometabolic Targets in Patients With Stroke

Background and Purpose— Despite the benefit of risk awareness in secondary prevention, survivors of stroke are often unaware of their risk factors. We determined whether a nurse-led intervention improved knowledge of risk factors in people with stroke or transient ischemic attack. Methods— Prospective study nested within a randomized controlled trial of risk factor management in survivors of stroke or transient ischemic attack. Intervention: 3 nurse education visits and specialist review of care plans. Outcome: unprompted knowledge of risk factors of stroke or transient ischemic attack at 24 months. Effect of intervention on knowledge and factors associated with knowledge were determined using multivariable regression models. Results— Knowledge was assessed in 268 consecutive participants from the main trial, 128 in usual care and 140 in the intervention. Overall, 34% of participants were unable to name any risk factor. In adjusted analyses, the intervention group had better overall knowledge than controls (incidence risk ratio, 1.26; 95% confidence interval, 1.00–1.58). Greater functional ability and polypharmacy were associated with better knowledge and older age and having more comorbidities associated with poorer knowledge. Conclusions— Overall knowledge of risk factors of stroke or transient ischemic attack was better in the intervention group than controls. However, knowledge was generally poor. New and more effective strategies are required, especially in subgroups identified as having poor knowledge. Clinical Trial Registration— URL: http://www.anzctr.org.au. Unique identifier: ACTRN12608000166370.

Effectiveness of an Intervention to Improve Risk Factor Knowledge in Patients With Stroke

Acute respiratory infection is the fourth major cause of morbidity and mortality among children under five globally. However, information on housing characteristics that could predispose children under five to these infections is scanty in Nigeria. Therefore, this study assessed the quality of housing and its contribution to the acquisition of acute respiratory infections among children under five in Ibadan. A prospective case–control design was employed for this study. Two hundred and twenty children under five each with acute respiratory infection (cases) and without acute respiratory infection (controls) were selected from children visiting Oni-memorial Children Hospital and University College Hospital, Ibadan. A survey of 66 consented cases and controls each was carried out using a checklist to assess indoor housing indicators. Data were analysed using descriptive statistics, Chi-square and logistic regression at p < 0.05. More cases (43, 65.2%) than controls (28, 42.4%) reside in houses with poor housing quality (OR 2.5; 95% CI = 1.3–5.1). Presence of damp roof (OR 2.9; 95% CI = 1.1–8.1), mould growth on walls (OR 6.3; 95% CI = 2.0–19.6) and high indoor air relative humidity (OR 10.2; 95% CI = 3.0–35.2) were significant risk factors for acute respiratory infections in children under five. Inadequate housing conditions play an important role in the acquisition of acute respiratory infections. Therefore, considerable effort should be made to educate mothers of children under five on improved housing and hygiene conditions in order to reduce childhood morbidity and mortality risks associated with acute respiratory infections.

Knowledge of risk factors in patients with Stroke or TIA: Shared team approach between nurses and doctors for improved risk factor managment (STANDFIRM)

Introduction Limited evidence exists on effective interventions to improve knowledge of preventive medications in patients with chronic diseases, such as stroke. We investigated the effectiveness of a nurse-led intervention, where a component was to improve knowledge of prevention medications, in patients with stroke or transient ischemic attack (TIA). Methods Prospective sub-study of the Shared Team Approach between Nurses and Doctors for Improved Risk Factor Management, a randomized controlled trial of risk factor management. We recruited patients aged ≥18 years and hospitalized for stroke/TIA. The intervention comprised an individualized management program, involving nurse-led education, and management plan with medical specialist oversight. The outcome, participants’ knowledge of secondary prevention medications at 12 months, was assessed using questionnaires. A score of ≥5 was considered as good knowledge. Effectiveness of the intervention on knowledge of medications was determined using logistic regression. Results Between May 2014 and January 2015, 142 consecutive participants from the main trial were included in this sub-study, 64 to usual care and 78 to the intervention (median age 68.9 years, 68% males, and 79% ischemic stroke). In multivariable analyses, we found no significant difference between intervention groups in knowledge of medications. Factors independently associated with good knowledge (score ≥5) at 12 months included higher socioeconomic position (OR 4.79, 95% CI 1.76, 13.07), greater functional ability (OR 1.69, 95% CI 1.17, 2.45), being married/living with a partner (OR 3.12, 95% CI 1.10, 8.87), and using instructions on pill bottle/package as an administration aid (OR 4.82, 95% CI 1.76, 13.22). Being aged ≥65 years was associated with poorer knowledge of medications (OR 0.24, 95% CI 0.08, 0.71), while knowledge was worse among those taking three medications (OR 0.15, 95% CI 0.03, 0.66) or ≥4 medications (OR 0.09, 95% CI 0.02, 0.44), when compared to participants taking fewer (≤2) prevention medications. Conclusion There was no evidence that the nurse-led intervention was effective for improving knowledge of secondary prevention medications in patients with stroke/TIA at 12 months. However, older patients and those taking more medications should be particularly targeted for more intensive education. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12688000166370).