Utility of a post-hospitalization stroke prevention program managed by nurses.

GOAL

Evidence-based guidelines exist for the prevention and treatment of patients with cerebral ischemia. Despite these guidelines, there are gaps in clinical practice. Our study aimed to determine if a physician-directed, nurse-case-management program could reduce individual patient vascular risk factors.

METHODS

Patients hospitalized with atherosclerotic cerebral ischemia with ≥ 1 major uncontrolled risk factor for stroke (hypertension, tobacco use, dyslipidemia, diabetes) were eligible to enroll in our study. Patients were randomized to management by the nurse-prevention program or usual care. Patients in the usual-care group received their initial risk-factor assessment and a scheduled follow-up at 1 year. Patients in the usual-care group underwent further follow-up by primary care and/or neurology as recommended during their hospitalization or outpatient visit. Patients assigned to the prevention group received individualized education, motivational interviewing, and were aided in setting up their risk-factor modification goal plan. Additional education was tailored to each patient based on individualized risk factors. Prevention-group patients also underwent consultation with a registered dietitian and an exercise physiologist. The primary endpoint of the study was improvement of ≥ 1 major patient risk factor for occurrence of stroke to goal at 1 year.

RESULTS

At 1-year post-hospitalization, patients in the nurse-care-management group were 42% more likely to have met the primary endpoint (n = 18; 61% nurse-managed patients) compared with 33% (n = 18) of patients undergoing usual care (P = 0.09). There was no significant reduction in minor risk factors for either patient group. Patients in the prevention group had greater reductions in low-density lipoprotein cholesterol levels (-38 vs -4; P = 0.0083), changes in cardiovascular risk score (-5.2 vs 1.3; P = 0.0033), and had a greater reductions in systolic blood pressure (-12.2 vs -0.105; P = 0.07) than their usual-care counterparts (changes shown respectively). Patients in the prevention group were more likely to follow a prescribed diet than those in the usual-care group (50% vs 7%, respectively; P = 0.0070) and maintain an exercise program (83% vs 33%, respectively; P = 0.0018).

SUMMARY

A physician-directed, nurse case-management system for patients post-hospitalization for cerebral ischemia is feasible and may help improve long-term control of major patient risk factors for stroke. A larger trial is needed to verify trends noted in our study.