Dorien Brouwer

96 Chapter 2.1 PART 2 1-h small group educational session followed by six 1-h sessions after discharge. [24] A second study, with 205 stroke and TIA patients, evaluated the effect of additional input from the stroke nurse vs. advice provided by medical staff. The stroke nurse reviewed patients at monthly intervals for approximately three-months. [30] Another randomized controlled trial assessed whether extra care of a stroke nurse specialist could be beneficial in terms of the cardiovascular risk profile. [31] In addition to a vascular screening and prevention programme, the stroke nurse specialist promoted the self- management of risk factors. Selfmanagement refers to the individual’s ability to manage both physical and psychosocial consequences including lifestyle changes inherent to living with a chronic condition. In self management, attention can be given to what is important and motivational to the individual patient. [32] Two hundred and thirty-six patients with manifestations of a vascular disease and with two or more modifiable vascular risk factors were pre-randomized according to the Zelen design to receive treatment by a nurse practitioner plus usual care or usual care alone. In the Zelen design participants are randomly allocated before seeking consent. [33] Participants allocated to the intervention group are then approached and offered the intervention, which they can decline or accept. Sixty-one patients (25%) refused to participate. This may have led to the selection of more motivated patients in the intervention group, and therefore, larger effects. After one-year, risk factors were assessed again. The primary endpoint was achievement of treatment goals for blood pressure, lipid, glucose and homocysteine levels, body mass index (BMI) and smoking. Treatment delivered by nurse practitioners resulted in a significantly better management of blood pressure, cholesterol and BMI than usual care alone after one-year. [31] The PROTECT cohort study systematically implemented, at the time of TIA or ischemic stroke, eight medication/behavioral secondary prevention measures known to improve outcome. [34] Medication goals were initiation of an antithrombotic, a statin, an angiotensin- converting enzyme inhibitor and a thiazide diuretic. The four behavioral interventions were smoking cessation counselling, exercise counseling, diet counselling and education about personal stroke risk factors and the need to call 911 if new stroke symptoms would occur. Endpoints were the proportion of individuals compliant with medical and lifestyle modification interventions after three-months and the frequency of recurrent vascular events. Adherence rates in patients were 100% for antithrombotics, 99% for statins, 92% for angiotensin-converting enzyme inhibitors and 80% for thiazide diuretics. Adherence to diet and exercise guidelines were 78% and 70%, respectively. Of the 24 smokers, 20 permanently stopped (83%). The authors from this uncontrolled study concluded that the increase in treatment adherence was associated with a favorable clinical event rate, with substantially fewer recurrent vascular events within the PROTECT cohort of individuals compared with results from other three-month hospitalization cohort studies. [35]