Introduction Primary care interventions are often multicomponent, with several targets (eg, patients and healthcare professionals). Improving Primary Care After Stroke (IPCAS) is a novel primary care-based model of long-term stroke care involving a review of stroke-related needs, a self-management programme, a direct point of contact in general practice, enhanced communication between care services, and a directory of national and local community services, currently being evaluated in a cluster randomised controlled trial (RCT). Informed by Medical Research Council guidance for complex interventions and the Behaviour Change Consortium fidelity framework, this protocol outlines the process evaluation of IPCAS within this RCT. The process evaluation aimed to explore how the intervention was delivered in context and how participants engaged with the intervention.
Methods and analysis Mixed methods will be used: (1) design: intervention content will be compared with ‘usual care’; (2) training: intervention training sessions will be audio/video-recorded where feasible; (3) delivery: healthcare professional self-reports, audio recordings of intervention delivery and observations of My Life After Stroke course (10% of reviews and sessions) will be coded separately; semistructured interviews will be conducted with a purposive sample of healthcare professionals; (4) receipt and (5) enactment: where available, structured stroke review records will be analysed quantitatively; semistructured interviews will be conducted with a purposive sample of study participants. Self-reports, observations and audio/video recordings will be coded and scored using specifically developed checklists. Semistructured interviews will be analysed thematically. Data will be analysed iteratively, independent of primary endpoint analysis.
Aquino MRJR, Mullis R, Kreit E, Johnson V, Grant J, Lim L, Sutton S, Mant J (2020) Improving Primary Care After Stroke (IPCAS) randomised controlled trial: protocol for a multidimensional process evaluation. BMJ Open. 10:e036879
Reference: McManus RJ, Mant J, Franssen M, Nickless A, Schwartz C, Hodgkinson J, Bradburn P, Farmer A, Grant S, Greenfield SM, Heneghan C, Jowett S, Martin U, Milner S, Monahan M, Mort S, Ogburn E, Perera-Salazar R, Shah SA, Yu LM, Tarassenko L, Hobbs FDR; TASMINH4 investigators. Efficacy of self-monitored blood pressure, with or without telemonitoring, for titration of antihypertensive medication (TASMINH4): an unmasked randomised controlled trial. Lancet. 2018 Feb 27. pii: S0140-6736(18)30309-X
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34% of participants who attended a stroke review as part of our intervention attended at least one session of an MLAS course
28% of attendees brough a carer or significant other with them to at least one of the six sessions
73% of MLAS attendees completed an MLAS course based on the completion criteria
The majority of participants who completed an MLAS course had theistroke 10+ years ago
Recruitment for the IPCAS study finished in August 2019 with a total of 1042 participants.
We have reached the end of randomisation for our 46 sites with an equal split of 23 – 23 Intervention and control.
Participant recruitment is also in the final stages.
Professor Jonathan Mant summarises top tips for patients and practitioners on stroke risk assessment and reduction
There are over 100,000 strokes in the UK per year. It is the fourth commonest cause of death, and is a leading cause of disability in the UK, with over 1.2 million survivors, costing the NHS and social care around £1.7 billion a year. Much can be done to reduce this burden of disease through prevention—the large INTERSTROKE case control study suggests that modifiable risk factors potentially account for 90% of all stroke cases.
- Eating a healthy diet
Diet has a big impact on stroke risk. Changing diet can help a patient to reduce their risk of stroke in several different ways: reducing dietary sodium intake and increasing fruit and vegetable consumption will lower blood pressure, an important risk factor for stroke (see below) and a diet rich in fruit, vegetables, nuts, fish, and olive oil—the so-called ‘Mediterranean diet’—will reduce risk of stroke and myocardial infarction. Likewise, weight loss will reduce body mass index (BMI), which is in turn a risk factor for stroke (at least down to a BMI of 22.5)
- Adopt a healthy lifestyle
As well as diet, changing other lifestyle habits can help to reduce stroke risk. Any physical activity compared to inactivity is associated with reduced risk of stroke. Smoking is associated with a 2–3-fold increase in risk of death from stroke. Stopping smoking, even at older ages, will have an effect on future stroke risk. Alcohol consumption is associated with increased stroke risk, with each 100g (i.e approximately 12 units) associated with a 14% increase in risk.
- Use a cardiovascular disease risk calculator to assess stroke risk
Risk factors for stroke and coronary heart disease overlap, so for practical purposes, a cardiovascular disease risk calculator (rather than a stroke-specific risk calculator) is appropriate to identify high-risk individuals and inform treatment options.
- Treat high blood pressure
Hypertension is a major risk factor for stroke so it is important to treat high blood pressure.
- Statin therapy
Statin therapy is effective at reducing risk of stroke, and should be offered to people depending upon their underlying cardiovascular risk. There is strong evidence from randomised controlled trials that use of statins lowers risk of stroke and other cardiovascular events and increases life expectancy.
- Take opportunities to case find atrial fibrillation
Opportunistic case finding is an effective way to identify atrial fibrillation (AF), an important risk factor for stroke. Atrial fibrillation is associated with a nearly five-fold increase in risk of stroke.
- Anticoagulation for people with AF
Anticoagulation is highly effective at reducing the risk of stroke in people with AF.
- Urgent specialist assessment after TIA
The early risk of completed stroke after a transient ischaemic attack (TIA) is high—about 5% within a week—so urgent specialist assessment and treatment of possible TIAs is required. This risk can be modified by prompt secondary prevention treatment, particularly with aspirin, and further investigation may reveal underlying causes such as carotid stenosis or atrial fibrillation. The National clinical guideline for stroke recommends: ‘patients with acute neurological symptoms that resolve completely within 24 hours (i.e. suspected TIA) should be given aspirin 300 mg immediately and assessed urgently within 24 hours by a specialist physician in a neurovascular clinic or an acute stroke unit.’
- Antithrombotic therapy
Existing cardiovascular disease is an important risk factor for further cardiovascular events and the risk can be reduced by antiplatelet therapy.
- Consider all secondary prevention options
People who have had a stroke are at high risk of a second stroke so all secondary prevention options should be considered.
To read the full article and reference list as published in the Guidelines in Practice journal please click here
*a full reference list can also be found here
We have currently recruited 960 patients (exceeding our original patient recruitment target of 20 per Practice = 920). Of the 46 recruited GP Practices 9 are still open to recruitment. Of the 37 sites that have finished recruiting 81% have reached the target of 16-24 stroke survivors and 40% have exceeded this target.
A paper focusing on using a checklist to facilitate management of long-term care needs after stroke has just been published in BMC Family Practice. This paper uses insights from focus groups and a feasibility study. It was concluded that the checklist is a potentially valuable tool to structure stroke reviews using a patient-centred approach.
A link to the full paper can be found here.
We are currently searching for people to join our team of MLAS Facilitators who could cover areas in Northamptonshire, Essex and Suffolk. If you have excellent organisation, time management and a passion for helping others this role may be for you.
MLAS (“My Life After Stroke”) is a self-management programme for stroke survivors and their carers. The course is one component of a new model of primary care services for stroke currently being tested in a clinical trial organised by researchers at the University of Cambridge.
The role of an MLAS Facilitator is to help deliver individual and group sessions for stroke survivors and their carers. As an MLAS facilitator you will be paid for your time and receive specialist training. You do not need to be clinically trained to become a facilitator. If you would like to become a facilitator you will be asked to attend 3 days of specialist training in January in Cambridge. You may also be asked to ensure that your core skills such as Manual Handling and Basic Life Support are up-to-date if you do not already have these.
If you would like to find out more about the MLAS programme or you are interested in becoming an MLAS facilitator please contact us at firstname.lastname@example.org or check out the links below to find out more details: