2007

Secondary Stroke Prevention Clinic: A New Model for Closing the Evidence-Practice Gap

Points to Remember

• Although stroke is a leading cause of disability and death, prevention strategies are often underutilized.
• This gap between existing evidence and clinical practice is especially concerning for patients who have had a stroke because of the risk of recurrent stroke and other disorders.
• Mayo Clinic is investigating a new model to close the evidence-practice gap in management of cerebrovascular disease: a physician-led, nurse-staffed outpatient Secondary Stroke Prevention Clinic.

The Challenge

Stroke is the leading cause of disability in the United States and the third leading cause of death. It is therefore an important factor in both health care budgets and the "emotional economy" of families. Although much is known about modifying risk factors to prevent first stroke (primary prevention) or recurrent stroke (secondary prevention), too often a consistent, systematic assessment and management of stroke risk factors is lacking in clinical practice. Underutilization of stroke risk assessment strategies creates a gap between existing evidence and actual practice. This gap is especially concerning for patients after they have already had a stroke, because an estimated 30% of survivors of an initial ischemic stroke will have a subsequent stroke within 5 years, 18% of which will be fatal.

A New Approach

Secondary stroke prevention is well suited to a new model of care aimed at preventing long-term morbidity and mortality for 2 main reasons:

1. risk modification strategies can lessen the likelihood of recurrent stroke or other adverse outcomes.
2. patients with initial stroke can be readily identified.

One promising new model is the stroke prevention clinic modeled after cardiac rehabilitation clinics.

Enlarge

To help close the evidence-practice gap in stroke prevention and to prepare for the changing demographics of stroke as the population ages and more people are at risk of stroke, Mayo Clinic Rochester has begun to evaluate a physician-led, nurse-assisted stroke management program. It is currently being assessed for its long-term effectiveness in managing cerebrovascular disease. The program aims to achieve with stroke the success that cardiac rehabilitation clinics have obtained with secondary prevention of coronary heart disease. Through this approach, neurologists play a leading role in meeting the emerging demand for preventive stroke services by obtaining training in management of atherosclerotic risk factors; by making stroke risk factor modification a part of the neurologic evaluation; and by providing long-term follow-up and appropriate care in the setting of a physician-led, nurse-assisted stroke prevention clinic. The neurologic team can closely collaborate with the patient's primary care provider to optimize management.

Data for similar nurse-assisted, physician-led clinics — such as the Stanford Coronary Risk Intervention Project — have shown that this approach can improve patient outcomes while reducing use of medical resources. In the Mayo Clinic secondary stroke prevention initiative, nurses guided by physicians provide intensive multiple risk factor reduction counseling and support in the outpatient setting. This outpatient clinic is the next step in the continuum of care of the stroke patient, after acute treatment and evaluation have been provided in the Saint Marys Hospital inpatient stroke center and, if needed, a stay in the stroke rehabilitation unit. The goals of this ongoing outpatient care are to support lifestyle changes known to reduce the risk factors of stroke, to utilize appropriate medications to assist in reducing these risk factors, and to enhance use of appropriate antithrombotic agents (Table). The initiative has been carefully evaluated by a research study over the past 2 years and may transition into standard practice when data analysis is completed later in 2007.