Implementation of telephone-based secondary preventive intervention after stroke and transient ischemic attack - participation rate, reasons for nonparticipation and one-year mortality.
OBJECTIVE
Patients who experience a stroke or transient ischemic attack (TIA) are known to be at high risk of subsequent vascular events, underscoring the need for secondary preventive intervention. However, previous studies have indicated insufficiency in the implementation of secondary prevention, emphasizing the need to develop effective methods of follow-up. In the present study, we examined the potential of implementing a telephone-based, nurse-led, secondary preventive follow-up in stroke and TIA patients on a population level by analyzing the participation rate, reasons for nonparticipation, and one-year mortality.


METHODS
Between January 1, 2010 and December 31, 2011, all patients admitted to Östersund hospital, Sweden, and diagnosed with either stroke or TIA were considered for inclusion into the secondary preventive follow-up. Baseline data were collected at the hospital, and reasons for nonparticipation were documented. Multivariate logistic regression was performed to identify predictors of the patient decision not to participate and to explore independent associations between baseline characteristics and exclusion. A one-year follow-up of mortality was also performed; the survival functions of the three groups (included, excluded, declining participation) was calculated using the Kaplan-Meier estimator.


RESULTS
From a total of 810 identified patients, 430 (53.1%) were included in the secondary preventive follow-up, 289 (35.7%) were excluded mainly due to physical or cognitive disability, and 91 (11.2%) declined participation. Age ≥85 years, ischemic and hemorrhagic stroke, modified Rankin scale score >3, body mass index ≥25, congestive heart failure, and lower education level were independently associated with exclusion, whereas lower education level was the only factor independently associated with the patient decision not to participate. Exclusion was associated with a more than 12 times higher risk of mortality within the first year after discharge.


CONCLUSIONS
Population-based implementation of secondary prevention in stroke and TIA patients is limited by the high prevalence of comorbidity and a considerable degree of disability. In our study, a large proportion of patients were unable to participate even in this simple form of secondary preventive follow-up. Exclusion was associated with substantially higher one-year mortality, and education level was independently associated with physical ability as well as the motivation to participate in the secondary preventive follow-up program.
Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
Anna-Lotta
AL
Irewall
Department of Public Health and Clinical Medicine at Östersund, Umeå University, Umeå, Sweden.
Lisa
L
Bergström
Department of Public Health and Clinical Medicine at Östersund, Umeå University, Umeå, Sweden.
Joachim
J
Ogren
Department of Pharmacology and Clinical Neuroscience at Östersund, Umeå University, Umeå, Sweden.
Katarina
K
Laurell
Department of Unit of Clinical Research Center, County Council of Jämtland, Östersund Hospital, Östersund, Sweden.
Lars
L
Söderström
Department of Public Health and Clinical Medicine at Östersund, Umeå University, Umeå, Sweden.
Thomas
T
Mooe
Implementation; Secondary prevention; Socioeconomic status; Stroke; Transient ischemic attack