Preventing recurrence of thromboembolic events through coordinated treatment in the District of Columbia

Information provision for stroke survivors and their carers

BACKGROUND

A stroke is a sudden loss of brain function caused by lack of blood supply. Stroke can lead to death or physical and cognitive impairment and can have long lasting psychological and social implications. Research shows that stroke survivors and their families are dissatisfied with the information provided and have a poor understanding of stroke and associated issues.

OBJECTIVES

The primary objective is to assess the effects of active or passive information provision for stroke survivors (people with a clinical diagnosis of stroke or transient ischaemic attack (TIA)) or their identified carers. The primary outcomes are knowledge about stroke and stroke services, and anxiety.

SEARCH METHODS

We updated our searches of the Cochrane Stroke Group Specialised Register on 28 September 2020 and for the following databases to May/June 2019: the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 5) and the Cochrane Database of Systematic Reviews (CDSR; 2019, Issue 5) in the Cochrane Library (searched 31 May 2019), MEDLINE Ovid (searched 2005 to May week 4, 2019), Embase Ovid (searched 2005 to 29 May 2019), CINAHL EBSCO (searched 2005 to 6 June 2019), and five others. We searched seven study registers and checked reference lists of reviews.

SELECTION CRITERIA

Randomised trials involving stroke survivors, their identified carers or both, where an information intervention was compared with standard care, or where information and another therapy were compared with the other therapy alone, or where the comparison was between active and passive information provision without other differences in treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We categorised interventions as either active information provision or passive information provision: active information provision included active participation with subsequent opportunities for clarification and reinforcement; passive information provision provided no systematic follow-up or reinforcement procedure. We stratified analyses by this categorisation. We used GRADE methods to assess the overall certainty of the evidence.

MAIN RESULTS

We have added 12 new studies in this update. This review now includes 33 studies involving 5255 stroke-survivor and 3134 carer participants. Twenty-two trials evaluated active information provision interventions and 11 trials evaluated passive information provision interventions. Most trials were at high risk of bias due to lack of blinding of participants, personnel, and outcome assessors where outcomes were self-reported. Fewer than half of studies were at low risk of bias regarding random sequence generation, concealment of allocation, incomplete outcome data or selective reporting. The following estimates have low certainty, based on the quality of evidence, unless stated otherwise. Accounting for certainty and size of effect, analyses suggested that for stroke survivors, active information provision may improve stroke-related knowledge (standardised mean difference (SMD) 0.41, 95% confidence interval (CI) 0.17 to 0.65; 3 studies, 275 participants), may reduce cases of anxiety and depression slightly (anxiety risk ratio (RR) 0.85, 95% CI 0.68 to 1.06; 5 studies, 1132 participants; depression RR 0.83, 95% CI 0.68 to 1.01; 6 studies, 1315 participants), may reduce Hospital Anxiety and Depression Scale (HADS) anxiety score slightly, (mean difference (MD) -0.73, 95% CI -1.10 to -0.36; 6 studies, 1171 participants), probably reduces HADS depression score slightly (MD (rescaled from SMD) -0.8, 95% CI -1.27 to -0.34; 8 studies, 1405 participants; moderate-certainty evidence), and may improve each domain of the World Health Organization Quality of Life assessment short-form (WHOQOL-BREF) (physical, MD 11.5, 95% CI 7.81 to 15.27; psychological, MD 11.8, 95% CI 7.29 to 16.29; social, MD 5.8, 95% CI 0.84 to 10.84; environment, MD 7.0, 95% CI 3.00 to 10.94; 1 study, 60 participants). No studies evaluated positive mental well-being. For carers, active information provision may reduce HADS anxiety and depression scores slightly (MD for anxiety -0.40, 95% CI -1.51 to 0.70; 3 studies, 921 participants; MD for depression -0.30, 95% CI -1.53 to 0.92; 3 studies, 924 participants), may result in little to no difference in positive mental well-being assessed with Bradley's well-being questionnaire (MD -0.18, 95% CI -1.34 to 0.98; 1 study, 91 participants) and may result in little to no difference in quality of life assessed with a 0 to 100 visual analogue scale (MD 1.22, 95% CI -7.65 to 10.09; 1 study, 91 participants). The evidence is very uncertain (very low certainty) for the effects of active information provision on carers' stroke-related knowledge, and cases of anxiety and depression. For stroke survivors, passive information provision may slightly increase HADS anxiety and depression scores (MD for anxiety 0.67, 95% CI -0.37 to 1.71; MD for depression 0.39, 95% CI -0.61 to 1.38; 3 studies, 227 participants) and the evidence is very uncertain for the effects on stroke-related knowledge, quality of life, and cases of anxiety and depression. For carers, the evidence is very uncertain for the effects of passive information provision on stroke-related knowledge, and HADS anxiety and depression scores. No studies of passive information provision measured carer quality of life, or stroke-survivor or carer positive mental well-being.

AUTHORS' CONCLUSIONS

Active information provision may improve stroke-survivor knowledge and quality of life, and may reduce anxiety and depression. However, the reductions in anxiety and depression scores were small and may not be important. In contrast, providing information passively may slightly worsen stroke-survivor anxiety and depression scores, although again the importance of this is unclear. Evidence relating to carers and to other outcomes of passive information provision is generally very uncertain. Although the best way to provide information is still unclear, the evidence is better for strategies that actively involve stroke survivors and carers and include planned follow-up for clarification and reinforcement.

Effect of Nurse Practitioner Interventions on Hospitalizations in the Community Transitions Intervention Trial

BACKGROUND

Despite improvements in hypertension treatment in the United States, Black and Hispanic individuals experience poor blood pressure control and have worse hypertension-related outcomes compared to Whites.

OBJECTIVE

The aim of the study was to determine the effect on hospitalization of supplementing usual home care (UHC) with two hypertension-focused transitional care interventions-one deploying nurse practitioners (NPs) and the other NPs plus health coaches.

METHODS

We examined post hoc the effect of two hypertension-focused NP interventions on hospitalizations in the Community Transitions Intervention trial-a three-arm, randomized controlled trial comparing the effectiveness of (a) UHC with (b) UHC plus a 30-day NP transitional care intervention or (c) UHC plus NP plus 60-day health coach intervention.

RESULTS

The study comprised 495 participants: mean age = 66 years; 57% female; 70% Black, non-Hispanic; 30% Hispanic. At the 3- and 12-month follow-up, all three groups showed a significant decrease in the average number of hospitalizations compared to baseline. The interventions were not significantly different from UHC.

CONCLUSION

The results of this post hoc analysis show that, during the study period, decreases in hospitalizations in the intervention groups were comparable to those in UHC, and deploying NPs provided no detectable value added. Future research should focus on testing ways to optimize UHC services.

Evaluation of Vascular Event Risk while on Long-term Anti-retroviral Suppressive Therapy [EVERLAST]: Protocol for a prospective observational study

Background & objective

Cardiovascular disease (CVD) risk among the HIV population is high due to a combination of accelerated atherosclerosis from the pro-inflammatory milieu created by chronic HIV infection and the potentially adverse metabolic side effects from cART (combination antiretroviral therapy) medications. Although sub-Saharan Africa (SSA) bears 70% of the global burden of HIV disease, there is a relative paucity of studies comprehensively assessing CVD risk among people living with HIV on the continent. The overarching objective of the Evaluation of Vascular Event Risk while on Long-term Anti-retroviral Suppressive Therapy (EVERLAST) Study is to characterize the burden of CVD among HIV patients on ART in Ghana, and explore factors influencing it.

Methods

The EVERLAST study incorporates prospective CVD risk assessments and a convergent mixed methods approach. This prospective study will evaluate CVD risk by measuring Carotid Intimal Media Thickness (CIMT) and presence of traditional medical and lifestyle vascular risk among 240 Ghanaian HIV patients on antiretroviral therapy compared with age- and sex-matched HIV uninfected (n = 240) and HIV positive ART naïve controls (n = 240). A contextual qualitative analysis will also be conducted to determine attitudes/perceptions of various key local stakeholders about CVD risk among HIV patients. The primary outcome measure will be CIMT measured cross-sectionally and prospectively among the three groups. A host of secondary outcome variables including CVD risk factors, CVD risk equations, HIV associated neurocognitive dysfunction and psychological well-being will also be assessed.

Conclusion

EVERLAST will provide crucial insights into the unique contributions of ART exposure and environmental factors such as lifestyle, traditional beliefs, and socio-economic indicators to CVD risk among HIV patients in a resource-limited setting. Ultimately, findings from our study will be utilized to develop interventions that will be tested in a randomized controlled trial to provide evidence to guide CVD risk management in SSA.

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EVERLAST seeks to assess the burden and determinants of cardiovascular risk among Ghanaian HIV patients

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A mixed methods study with prospective analyses of CVD risk factors among HIV patients and HIV-negative controls over 12 months

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Primary outcome measure is sub-clinical carotid atherosclerosis measured using B-mode ultrasound.

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Secondary outcome measures include neurocognitive dysfunction, and CVD events.

Interventions for improving modifiable risk factor control in the secondary prevention of stroke

BACKGROUND

People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Stroke services need to be configured to maximise the adoption of evidence-based strategies for secondary stroke prevention. Smoking-related interventions were examined in a separate review so were not considered in this review. This is an update of our 2014 review.

OBJECTIVES

To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2017), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2017), CENTRAL (the Cochrane Library 2017, issue 3), MEDLINE (1950 to April 2017), Embase (1981 to April 2017) and 10 additional databases including clinical trials registers. We located further studies by searching reference lists of articles and contacting authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention.

DATA COLLECTION AND ANALYSIS

Four review authors selected studies for inclusion and independently extracted data. The quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach (GRADEpro GDT).Three review authors assessed the risk of bias for the included studies. We sought missing data from trialists.The results are presented in 'Summary of findings' tables.

MAIN RESULTS

The updated review included 16 new studies involving 25,819 participants, resulting in a total of 42 studies including 33,840 participants. We used the Cochrane risk of bias tool and assessed three studies at high risk of bias; the remainder were considered to have a low risk of bias. We included 26 studies that predominantly evaluated organisational interventions and 16 that evaluated educational and behavioural interventions for participants. We pooled results where appropriate, although some clinical and methodological heterogeneity was present.Educational and behavioural interventions showed no clear differences on any of the review outcomes, which include mean systolic and diastolic blood pressure, mean body mass index, achievement of HbA1c target, lipid profile, mean HbA1c level, medication adherence, or recurrent cardiovascular events. There was moderate-quality evidence that organisational interventions resulted in improved blood pressure control, in particular an improvement in achieving target blood pressure (odds ratio (OR) 1.44, 95% confidence interval (CI) 1.09 to1.90; 13 studies; 23,631 participants). However, there were no significant changes in mean systolic blood pressure (mean difference (MD), -1.58 mmHg 95% CI -4.66 to 1.51; 16 studies; 17,490 participants) and mean diastolic blood pressure (MD -0.91 mmHg 95% CI -2.75 to 0.93; 14 studies; 17,178 participants). There were no significant changes in the remaining review outcomes.

AUTHORS' CONCLUSIONS

We found that organisational interventions may be associated with an improvement in achieving blood pressure target but we did not find any clear evidence that these interventions improve other modifiable risk factors (lipid profile, HbA1c, medication adherence) or reduce the incidence of recurrent cardiovascular events. Interventions, including patient education alone, did not lead to improvements in modifiable risk factor control or the prevention of recurrent cardiovascular events.

A Targeted Self-Management Approach for Reducing Stroke Risk Factors in African American Men Who Have Had a Stroke or Transient Ischemic Attack

PURPOSE

This study compared a novel self-management (TargetEd MAnageMent Intervention [TEAM]) versus treatment as usual (TAU) to reduce stroke risk in African American (AA) men.

DESIGN

Six-month prospective randomized controlled trial with outcomes evaluated at baseline, 3 months, and 6 months.

SETTING

Academic health center.

PARTICIPANTS

Thirty-eight (age < 65) AA men who had a stroke or transient ischemic attack and a Barthel index score of >60 were randomly assigned to TEAM (n = 19) or TAU (n = 19).

INTERVENTION

Self-management training, delivered in 1 individual and 4 group sessions (over 3 months).

MEASURES

Blood pressure, glycosylated hemoglobin (HbA1c), lipids, medication adherence, weight, and standardized measures of health behaviors (diet, exercise, smoking, substances), depression, and quality of life. Qualitative assessments evaluated the perspectives of TEAM participants.

ANALYSIS

T tests for paired differences and nonparametric tests. Thematic content qualitative analysis.

RESULTS

Mean age was 52.1 (standard deviation [SD] = 7.4) and mean body mass index was 31.4 (SD = 7.4). Compared to TAU, TEAM participants had significantly lower mean systolic blood pressure by 24 weeks, and there was also improvement in HbA1c and high-density lipoprotein cholesterol ( P = .03). Other biomarker and health behaviors were similar between groups. Qualitative results suggested improved awareness of risk factors as well as positive effects of group support.

A Pilot Trial of a Lifestyle Intervention for Stroke Survivors: Design of Healthy Eating and Lifestyle after Stroke (HEALS)

BACKGROUND

Stroke survivors have high rates of subsequent cardiovascular and recurrent cerebrovascular events, and mortality. While healthy lifestyle practices - including a diet rich in fruits and vegetables, limited alcohol intake, and regular physical activity - can mitigate these outcomes, few stroke survivors adhere to them. Minorities from socioeconomically disadvantaged communities who obtain care in safety-net health systems experience the most barriers to implementing healthy lifestyle changes after stroke.

PURPOSE

To report the design of Healthy Eating and Lifestyle After Stroke (HEALS), a randomized controlled trial (RCT) was designed to test the feasibility of using a manualized, lifestyle management intervention in a safety-net setting to improve lifestyle practices among ethnically diverse individuals with stroke or transient ischemic attack (TIA).

METHODS

Design: Pilot RCT.

PARTICIPANTS

Inclusion criteria: 1) Adults (≥40 years) with ischemic stroke or TIA (≥ 90 days prior); 2) English- or Spanish-speaking.

SETTING

Outpatient clinic, safety-net setting.

INTERVENTION

Weekly two-hour small group sessions led by an occupational therapist for six weeks. The sessions focused on implementing nutrition, physical activity, and self-management strategies tailored to each participant's goals.

MAIN OUTCOME MEASURES

Body mass index, diet, and physical activity.

CONCLUSIONS

Recruitment for this study is complete. If the HEALS intervention study is feasible and effective, it will serve as a platform for a large-scale RCT that will investigate the efficacy and cost-effectiveness of life management interventions for racially and ethnically diverse, low-income individuals with a history of stroke or TIA who seek healthcare in the safety-net system.

Addressing post-stroke care in rural areas with Peru as a case study. Placing emphasis on evidence-based pragmatism

Stroke is a major cause of death and disability, with most of its burden now affecting low- and middle-income countries (LMIC). People in rural areas of LMIC who have a stroke receive very little acute stroke care and local healthcare workers and family caregivers in these regions lack the necessary knowledge to assist them. Intriguingly, a recent rapid growth in cell-phone use and digital technology in rural areas has not yet been appropriately exploited for health care training and delivery purposes. What should be done in rural areas, at the community setting-level, where access to healthcare is limited remains a challenge. We review the evidence on improving post-stroke outcomes including lowering the risks of functional disability, stroke recurrence, and mortality, and propose some approaches, to target post-stroke care and rehabilitation, noting key challenges in designing suitable interventions and emphasizing the advantages mHealth and communication technologies can offer. In the article, we present the prevailing stroke care situation and technological opportunities in rural Peru as a case study. As such, by addressing major limitations in rural healthcare systems, we investigate the potential of task-shifting complemented with technology to utilize and strengthen both community-based informal caregivers and community healthcare workers.

Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED)

BACKGROUND

Recurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population.

METHODS/DESIGN

In this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care.

DISCUSSION

If this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT01763203 .

Interventions for improving modifiable risk factor control in the secondary prevention of stroke

BACKGROUND

People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Evidence-based strategies for secondary stroke prevention have been established. However, the implementation of prevention strategies could be improved.

OBJECTIVES

To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2013), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2013), CENTRAL (The Cochrane Library 2013, issue 3), MEDLINE (1950 to April 2013), EMBASE (1981 to April 2013) and 10 additional databases. We located further studies by searching reference lists of articles and contacting authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention.

DATA COLLECTION AND ANALYSIS

Two review authors selected studies for inclusion and independently extracted data. One review author assessed the risk of bias for the included studies. We sought missing data from trialists.

MAIN RESULTS

This review included 26 studies involving 8021 participants. Overall the studies were of reasonable quality, but one study was considered at high risk of bias. Fifteen studies evaluated predominantly organisational interventions and 11 studies evaluated educational and behavioural interventions for patients. Results were pooled where appropriate, although some clinical and methodological heterogeneity was present. The estimated effects of organisational interventions were compatible with improvements and no differences in the modifiable risk factors mean systolic blood pressure (mean difference (MD) -2.57 mmHg; 95% confidence interval (CI) -5.46 to 0.31), mean diastolic blood pressure (MD -0.90 mmHg; 95% CI -2.49 to 0.68), blood pressure target achievement (OR 1.24; 95% CI 0.94 to 1.64) and mean body mass index (MD -0.68 kg/m(2); 95% CI -1.46 to 0.11). There were no significant effects of organisational interventions on lipid profile, HbA1c, medication adherence or recurrent cardiovascular events. Educational and behavioural interventions were not generally associated with clear differences in any of the review outcomes, with only two exceptions.

AUTHORS' CONCLUSIONS

Pooled results indicated that educational interventions were not associated with clear differences in any of the review outcomes. The estimated effects of organisational interventions were compatible with improvements and no differences in several modifiable risk factors. We identified a large number of ongoing studies, suggesting that research in this area is increasing. The use of standardised outcome measures would facilitate the synthesis of future research findings.

Health promotion interventions for increasing stroke awareness in ethnic minorities: a systematic review of the literature

Background

Stroke places a significant burden to all affected individuals, but it is perhaps more significant amongst members of black, minority and ethnic communities, who may experience poorer awareness of stroke symptoms than the general population. Recently, several initiatives tried to improve public awareness that symptoms of stroke need to be treated as a medical emergency. However, ethnic communities present cultural barriers, requiring tailored health promotion interventions, whose effectiveness remains uncertain. Our systematic review aimed to identify relevant published evidence, synthesize the main study components and identify evidence of the effectiveness of the interventions.

Methods

MEDLINE, EMBASE, CINAHL, and PsycInfo were searched for journal articles on health promotion interventions for increasing stroke awareness in ethnic minorities, published in English between 1995 and 2012. Search results were collaboratively assessed by the authors; included studies were analysed to identify their main characteristics, and a thematic analysis of their content was conducted. No meta-analysis was performed, due to the heterogeneity of results.

Results

Eighteen studies were included, reporting 15 interventions conducted in the US, for African-Americans or Hispanics; populations sizes differed between interventions. Interventions were mostly carried out in community settings with different educational techniques, focussing on experiential methods. Health professionals usually organized the programs, delivered by nurses, other health professionals or volunteers.

The few theory-based interventions focussed on individual-level behavioural change. Practical cultural adaptation strategies were not linked to specific theoretical frameworks. Interventions widely differed as for target populations, settings, delivery methods, contents and professional roles involved. All study designs were quantitative, and the emerging evidence of effectiveness was inconclusive.

Such interventions operate in very complex scenarios, and several variables may influence their effectiveness. Therefore, qualitative or mixed-methods study designs may shed light on barriers and facilitators, experiential education strategies and community involvement.

Network- and community-level theories may help improving design and evaluation of interventions.

Conclusions

Eleven case reports and four RCTs provide evidence about stroke awareness interventions organized in the US. The studies provide only partial and inconclusive evidence about the effectiveness of the interventions. Hence, further research is needed on different countries and ethnic minorities.

Trials to improve blood pressure through adherence to antihypertensives in stroke/TIA: systematic review and meta-analysis

Background

The purpose of this study was to determine whether interventions including components to improve adherence to antihypertensive medications in patients after stroke/transient ischemic attack (TIA) improve adherence and blood pressure control.

Methods and Results

We searched MEDLINE, EMBASE, CINAHL, BNI, PsycINFO, and article reference lists to October 2012. Search terms included stroke/TIA, adherence/prevention, hypertension, and randomized controlled trial (RCT). Inclusion criteria were participants with stroke/TIA; interventions including a component to improve adherence to antihypertensive medications; and outcomes including blood pressure, antihypertensive adherence, or both. Two reviewers independently assessed studies to determine eligibility, validity, and quality. Seven RCTs were eligible (n=1591). Methodological quality varied. All trials tested multifactorial interventions. None targeted medication adherence alone. Six trials measured blood pressure and 3 adherence. Meta‐analysis of 6 trials showed that multifactorial programs were associated with improved blood pressure control. The difference between intervention versus control in mean improvement in systolic blood pressure was −5.3 mm Hg (95% CI, −10.2 to −0.4 mm Hg, P=0.035; I²=67% [21% to 86%]) and in diastolic blood pressure was −2.5 mm Hg (−5.0 to −0.1 mm Hg, P=0.046; I²=47% [0% to 79%]). There was no effect on medication adherence where measured.

Conclusions

Multifactorial interventions including a component to improve medication adherence can lower blood pressure after stroke/TIA. However, it is not possible to say whether or not this is achieved through better medication adherence. Trials are needed of well‐characterized interventions to improve medication adherence and clinical outcomes with measurement along the hypothesized causal pathway.

Comparative effectiveness and implementation research: directions for neurology

There is an enormous unmet need for knowledge about how new insights from discovery and translational research can yield measurable, population-level improvements in health and reduction in mortality among those having or at risk for neurological disease. Once several, well-conducted randomized controlled trials establish the efficacy of a given therapy, implementation research can generate new knowledge about barriers to uptake of the therapy into widespread clinical care, and what strategies are effective in overcoming those barriers and in addressing health disparities. Comparative effectiveness research aims to elucidate the relative value (including clinical benefit, clinical harms, and/or costs) of alternative efficacious management approaches to a neurological disorder, generally through direct comparisons, and may include comparisons of methodologies for implementation. Congress has recently appropriated resources and established an institute to prioritize funding for such research. Neurologists and neuroscientists should understand the scope and objectives of comparative effectiveness and implementation research, their range of methodological approaches (formal literature syntheses, randomized trials, observational studies, modeling), and existing research resources (centers for literature synthesis, registries, practice networks) relevant to research for neurological conditions, to close the well-documented evidence-to-practice gap. Future directions include building this research resource capacity, producing scientists trained to conduct rigorous comparative effectiveness and implementation research, and embracing innovative strategies to set research priorities in these areas.