Management Of Secondary Prevention Research Articles

Early dynamic ultrasound for neonatal hip instability: implications for rural Australia

BackgroundNeonatal instability of the hip (NIH), where the femoral head can move away from the acetabulum, in the first weeks of life, is an important risk factor for developmental dysplasia of the hip (DDH). In rural areas in Australia, there is a recent trend to increased late diagnosis of DDH. Clinical screening of infant hips, a common practice in Australia, is experience dependent. Best practice early screening techniques are still debated with different techniques and timing used internationally. This systematic review examines early dynamic ultrasound (eDUS) screening for hip instability in the first 6 weeks after birth, and the early interventions informed by these findings and considers the findings for the context of rural Australia.MethodsThe Cochrane Library, Medline, CINAHL and PEDro were searched for original research or systematic reviews, and clinical studies 1998 to 2015 involving dynamic ultrasound. Critical Appraisal Skills Programme tools were used to appraise the studies.ResultNineteen studies were included. Early Dynamic Ultrasound (DUS) is consistently described as a reliable assessment of NIH. Early DUS is recommended for risk factors including geographical areas of high prevalence. Approaches to early intervention of hips with excessive movement are somewhat discipline-related and include: primary prevention (advice), secondary prevention (abduction supports), and conservative management (removable splints).ConclusionsIn the context of increased prevalence of DDH in rural Australia, contemporary evidence suggests that introduction of early DUS could provide rural infants with more effective screening than clinical examination alone. Targeted early advice about posturing and simple removable supports to abduct infant hips could prevent some cases of DDH in rural Australia.

Abstract TP415: A Pilot Study on the Effect of Neck Irradiation Treatment for Nasopharyngeal Carcinoma on Carotid Artery Stenosis

Introduction: Extracranial carotid stenosis, a risk factor for ischemic stroke, is thought to be accelerated by irradiation to the neck region. Nasopharyngeal carcinoma (NPC) has a predilection for East Asian with an incidence of 200-300 annually in Singapore. We studied the prevalence and severity of extracranial carotid disease in patients with prior neck irradiation for NPC, who were at different timepoints from the time of irradiation. Hypothesis: The prevalence of extracranial carotid disease is high among patients with prior neck irradiation, and this may justify a screening programme for early detection and primary stroke prevention. Methods: We conducted a pilot study to examine 50 patients (median age 55.2 years) with prior radiation for NPC with intensity-modulated radiation therapy (IMRT): 26 with <5 years after treatment and 24 with >=5 years after treatment. All patients received radiation therapy to the neck. Carotid disease was assessed by duplex sonography for severity of stenosis. The European Carotid Surgery Trial (ECST) criteria was employed for assessment for degree of stenosis. Results: Among patients with IMRT >=5 years ago, 25% (6/24) had carotid stenosis of >=50% compared to only 8% (2/26) of patients with IMRT within 5 years. Of these 8 patients with carotid stenosis >=50%, 5 (63%) had plaques with irregular or ulcerated surfaces, which is known to be associated with stroke risk. Based on these preliminary data, the study would require a larger sample size of 100 in each group to be powered at 90% with an alpha of 0.05. All 8 patients with carotid stenosis >=50% from the screening were referred for further evaluation for symptoms and risk factors, and management for secondary stroke prevention. Conclusions: Based on our findings, there is a rationale for screening for carotid disease among patients with prior neck irradiation and the timing of screening is more optimal after 5 years from IMRT. Patients found to have carotid disease should be counselled about risk factor control, antiplatelet medication and possibly carotid intervention for primary stroke prevention.

Stroke Epidemiology and Risk Factor Management

Death from stroke has decreased over the past decade, with stroke now the fifth leading cause of death in the United States. In addition, the incidence of new and recurrent stroke is declining, likely because of the increased use of specific prevention medications, such as statins and antihypertensives. Despite these positive trends in incidence and mortality, many strokes remain preventable. The major modifiable risk factors are hypertension, diabetes mellitus, tobacco smoking, and hyperlipidemia, as well as lifestyle factors, such as obesity, poor diet/nutrition, and physical inactivity. This article reviews the current recommendations for the management of each of these modifiable risk factors. It has been documented that some blood pressure medications may increase variability of blood pressure and ultimately increase the risk for stroke. Stroke prevention typically includes antiplatelet therapy (unless an indication for anticoagulation exists), so the most recent evidence supporting use of these drugs is reviewed. In addition, emerging risk factors, such as obstructive sleep apnea, electronic cigarettes, and elevated lipoprotein (a), are discussed. Overall, secondary stroke prevention includes a multifactorial approach. This article incorporates evidence from guidelines and published studies and uses an illustrative case study throughout the article to provide examples of secondary prevention management of stroke risk factors.

Evidence of Secondary Preventive Management for Cardiovascular Disease

Evidence of Secondary Preventive Management for Cardiovascular Disease

Primary and secondary prevention of varicose disease in medical practice

Varicose veins are a common pathology in medical practice, easily diagnosed, with risk factors that can be universally recognized for starting preventive therapeutic measures. Early detection of this pathology in the family doctor's office involving secondary preventive measures and proper management, sometimes in collaboration with a specialist Phlebology, prevents the progression of complications. This study of adults(over 30 years), analyzes 104 people with a prevalence of 17.39% of varicose veins, with different prevalences in sexes, age groups and depending on the risk factors often meet with primary and secondary preventive indications.

Oral Anticoagulant Use in Atrial Fibrillation-Associated Ischemic Stroke: A Retrospective, Multicenter Survey in Northwestern China

Anticoagulation therapy has been recommended by major guidelines to reduce the risk of recurrent stroke in patients with atrial fibrillation-associated ischemic stroke (AFAIS). However, in real-world clinical practice, oral anticoagulants with either vitamin K antagonists or nonvitamin K antagonists are often underused for these patients. Here, we sought to investigate the current status of oral anticoagulant use in patients with AFAIS in northwestern China. We reviewed medical records of consecutive patients with AFAIS discharged from 14 hospitals in northwestern China between January 2012 and May 2015. A total of 1014 cases were included in this study. The mean age of the patients was 70.3 ± 10.8 years. Fifty-four percent were female. Among all participants, only 20.0% received anticoagulants (19.4% warfarin and .6% nonvitamin K antagonist oral anticoagulants), whereas 57.5% took antiplatelet drugs and 22.5% received neither anticoagulant nor antiplatelet treatment. Anticoagulant use decreased with increasing age and CHA2DS2-VASc scores. The proportions of anticoagulant use at discharge in patients younger than 65 years, 65-74 years, and 75 years or older were 28.5%, 20.7%, and 13.9%, respectively. Nonvalvular atrial fibrillation patients with CHA2DS2-VASc scores of 2, 3, 4, 5, 6, and 7 had anticoagulant use rates at discharge of 19.2%, 24.8%, 20.3%, 13.7%, 8.1%, and 8.0%, respectively. In northwestern China, oral anticoagulants are substantially underutilized in patients with AFAIS, especially in patients at higher risk of stroke, suggesting a large treatment gap in the secondary prevention management in patients with AFAIS.

Prevalence of Diabetes according to Occupation among Workers in the Ulsan Area

The prevalence of diabetes was higher in non-manual workers (OR 1.305, 95% CI 1.130–1.508) than in manual workers. Conclusion: Differences in risk for diabetes were observed in groups of individuals with different types of occupations. Therefore, we need to monitor workers at a higher risk of developing diabetes and provide suitable education, screening, and management for primary and secondary prevention of diabetes.

The value of transesophageal echocardiography for embolic strokes of undetermined source.

Our aim was to evaluate the diagnostic yield of transesophageal echocardiography (TEE) in consecutive patients with ischemic stroke (IS) fulfilling the diagnostic criteria of embolic strokes of undetermined source (ESUS). We prospectively evaluated consecutive patients with acute IS satisfying ESUS criteria who underwent in-hospital TEE examination in 3 tertiary care stroke centers during a 12-month period. We also performed a systematic review and meta-analysis estimating the cumulative effect of TEE findings on therapeutic management for secondary stroke prevention among different IS subgroups. We identified 61 patients with ESUS who underwent investigation with TEE (mean age 44 ± 12 years, 49% men, median NIH Stroke Scale score = 5 points [interquartile range: 3-8]). TEE revealed additional findings in 52% (95% confidence interval [CI]: 40%-65%) of the study population. TEE findings changed management (initiation of anticoagulation therapy, administration of IV antibiotic therapy, and patent foramen ovale closure) in 10 (16% [95% CI: 9%-28%]) patients. The pooled rate of reported anticoagulation therapy attributed to abnormal TEE findings among 3,562 acute IS patients included in the meta-analysis (12 studies) was 8.7% (95% CI: 7.3%-10.4%). In subgroup analysis, the rates of initiation of anticoagulation therapy on the basis of TEE investigation did not differ (p = 0.315) among patients with cryptogenic stroke (6.9% [95% CI: 4.9%-9.6%]), ESUS (8.1% [95% CI: 3.4%-18.1%]), and IS (9.4% [95% CI: 7.5%-11.8%]). Abnormal TEE findings may decisively affect the selection of appropriate therapeutic strategy in approximately 1 of 7 patients with ESUS.

Factors Influencing Non-Persistence with Antiplatelet Medications in Elderly Patients After Ischaemic Stroke.

This study investigated the extent of, and patient-related characteristics for, non-persistence with antiplatelet therapy during follow-up in elderly patients after their first ischaemic non-cardioembolic stroke. A database of the largest health insurance provider in the Slovak Republic was used to assemble the study cohort of 4319 patients (56.8% were women) aged ≥65 years in whom antiplatelet therapy was initiated following a hospital-based diagnosis of stroke during the period 1 January 2010 to 31 December 2010. Patients were followed for 3 years from the date on which the first prescription of antiplatelet medication was recorded. Patients with a 6-month treatment gap without antiplatelet medication prescription were designated as non-persistent, and the Cox proportional hazards model was used to identify predictors of non-persistence. At the end of the 3-year follow-up period, 1184 (27.4%) patients were considered non-persistent with antiplatelet medication. In 1244 (28.8%) patients, a switch in the use of a particular antiplatelet drug was registered during this follow-up period. Female sex (hazard ratio [HR] 1.25) was associated with increased risk of non-persistence. In contrast, factors associated with lower probability of non-persistence were age ≥75 years (HR 0.72), switch in antiplatelet medication use (HR 0.76), diabetes mellitus (HR 0.81), dementia (HR 0.69) and epilepsy (HR 0.69). Our results suggest that women, patients aged <75 years, and patients without certain comorbid conditions may need improved assistance in secondary prevention management after an ischaemic stroke.

Diabetes Mellitus, Hypertension and Hypercholesterolemia in Relation to the 10-Year ACS Prognosis; the GREECS Study.

Although hypertension, hypercholesterolemia and diabetes mellitus (DM) are recognized as major cardio-metabolic risk factors in primary Acute Coronary Syndrome (ACS) prevention, studies focusing on secondary ACS incidence are scarce. In the present study, the association between the aforementioned factors and 10-year ACS prognosis was evaluated. From October 2003 to September 2004 2,172 consecutive patients with ACS diagnosis, from 6 Greek hospitals, were enrolled. During 2013-14, the 10-year follow-up was performed in 1,918 participants. Baseline clinical factors were assessed through physical examination, medical records and pharmacological management. All-cause mortality and the development of fatal or non-fatal ACS events were recorded through medical records or hospital registries. Logistic regression models were applied to evaluate the impact of baseline clinical status on the ACS prognosis. The 10-year all cause and ACS mortality rate was 32.6 and 17.8%, respectively. Multi-adjusted analysis highlighted that, after taking into account various potential confounders, DM was the sole clinical factor associated with adverse effect on the 10-year ACS fatal incidence [Odds Ratio (OR)=1.35, 95% Confidence Interval (95% CI) 1.01, 1.80, p=0.04]. DM was the only clinical factor that aggravated ACS prognosis, whereas abnormal lipids profile and blood pressure did not seem to determine prognosis. Thus, glycaemic control may play a critical role in the secondary CVD prevention management of ACS patients.

Prevention, management, and rehabilitation of stroke in low- and middle-income countries.

Although stroke incidence in high-income countries (HICs) decreased over the past four decades, it increased dramatically in low- and middle-income countries (LMICs). In this review, we describe the current status of primary prevention, treatment, and management of acute stroke and secondary prevention of and rehabilitation after stroke in LMICs. Although surveillance, screening, and accurate diagnosis are important for stroke prevention, LMICs face challenges in these areas due to lack of resources, awareness, and technical capacity. Maintaining a healthy lifestyle, such as no tobacco use, healthful diet, and physical activity are important strategies for both primary and secondary prevention of stroke. Controlling high blood pressure is also critically important in the general population and in the acute stage of hemorrhagic stroke. Additional primary prevention strategies include community-based education programs, polypill, prevention and management of atrial fibrillation, and digital health technology. For treatment of stroke during the acute stage, specific surgical procedures and medications are recommended, and inpatient stroke care units have been proven to provide high quality care. Patients with a chronic condition like stroke may require lifelong pharmaceutical treatment, lifestyle maintenance and self-management skills, and caregiver and family support, in order to achieve optimal health outcomes. Rehabilitation improves physical, speech, and cognitive functioning of disabled stroke patients. It is expected that home- or community-based services and tele-rehabilitation may hold special promise for stroke patients in LMICs.

Efficacy and safety of carotid artery stenting for stroke prevention

BackgroundExtracranial carotid artery stenosis is a leading cause of ischemic stroke. Carotid endarterectomy (CEA) is the gold-standard management for secondary stroke prevention yet carotid artery stenting (CAS) has emerged in the last decade as an alternative for high surgical risk patients. PurposeTo assess the effectiveness, safety and outcomes of CAS in extra-cranial carotid artery stenosis patients in terms of stroke prevention. MethodologyTwenty patients with symptomatic and asymptomatic carotid artery stenosis were enrolled between 2012 and 2014. Symptomatic patients were eligible for CAS if the internal carotid artery stenosis was ⩾50%, while 80% was the threshold in asymptomatic patients. ResultsSymptomatic patients enrolled were fifteen (75%) and asymptomatic patients were five (25%). Two patients (10%) were excluded owing to target vessel occlusion. One patient (5%) underwent bilateral CAS. The procedure was successful in eighteen patients (90%) one of them complicated by distal embolization (5%). One patient died secondary to associated chronic liver disease (5%), otherwise no stroke or death was recorded along the follow-up period. ConclusionCareful patient selection and technique optimization are crucial to improve clinical outcome which make it a safe alternative for surgical revascularization in stroke prevention.

Update on Diverticular Disease and Implications for Primary Care

Recent data would seem to suggest a change in primary care management of diverticulosis. Studies now question the etiology, management, and recommendations for primary and secondary prevention of diverticular disease in the primary care setting. Although diverticulosis is commonly found on colonoscopy, few patients will go on to develop diverticular disease, which is characterized by abdominal symptoms and the presence of chronic inflammation in some cases. Data suggest more active management and specialty referral for patients with diverticular disease to prevent complications of bleeding, diverticulitis, colitis, abscess formation, fistula, stricture, and perforation and, possibly, neoplasia.

Inadequate management for secondary fracture prevention in patients with distal radius fracture by trauma surgeons.

We evaluated the secondary fracture prevention in 1445 patients with distal radius fracture by trauma surgeons. The rate of patients with distal radius fracture who underwent bone mineral density (BMD) examination was low, suggesting that appropriate treatment for osteoporosis by trauma surgeons is not performed at present. To clarify the status of osteoporosis interventions after distal radial fractures by trauma surgeons who play the main role in treatment for these fractures, we performed a survey involving multiple institutions in Japan. We asked 155 board members of the Japanese Society for Fracture Repair for their cooperation and performed a survey in 48 institutions with which members who gave cooperation were affiliated. The subjects consisted of consecutive patients with distal radial fractures occurring between January and December 2012. The presence or absence of a diagnosis of osteoporosis and bone mineral density examination after fracture was investigated. A total of 1445 patients with distal radial fractures were evaluated in this study. BMD examination for diagnosis and treatment for osteoporosis after fracture was performed respectively in 126 (8.7%) and 193 (13.4%) of 1445 patients. Treatment for osteoporosis was performed in 93 (73.8%) of 126 patients who underwent BMD examination after fracture and 100 (8.2%) of 1219 who did not undergo BMD examination. Of the 126 patients who underwent BMD examination after fracture, 89 showed a BMD <80% of the young adult mean as a criterion for the initiation of drug treatment for osteoporosis in Japan and 77 (86.5%) of the 89 patients were treated with drugs. The rate of patients with distal radial fractures who underwent BMD examination was low, suggesting that appropriate treatment for osteoporosis by trauma surgeons is not performed at present.

The Association Between Central Fat Distribution and Recurrent Cardiovascular Disease Events in Female Survivors of Nonfatal Myocardial Infarction

Visceral fat has been shown to be an important predictor of metabolic alterations that lead to increased cardiovascular disease (CVD) risk factors, morbidity, and mortality. The aim of this study was to investigate the association between central fat distribution and the risk of recurrent coronary events among a cohort of female myocardial infarction (MI) survivors. Participants included 356 women (mean ± SD age, 55 ± 8.71 years) discharged alive after an incident MI from hospitals in Erie and Niagara (New York) counties between 1996 and 2004. A recurrent cardiovascular event was any nonfatal or fatal International Classification of Diseases, Ninth Revision-coded diagnosis between 390 and 450. The mean ± SD follow-up time was 4.01 ± 2.6 years. Interviews and self-administered follow-up surveys were used to collect pertinent information, and a search of the National Death Index Plus database was completed. Eighty-five women experienced a recurrent cardiovascular event. Using Cox proportional hazards analyses, the crude model for body mass index suggested that after incident MI, women had a 39% risk of a recurrent CVD event (hazard ratio [HR], 1.39; confidence interval [CI], 0.76-2.54; P = .293), whereas crude models for waist circumference and sagittal abdominal distention showed the risk to be more than twice as high (HR, 2.12; CI, 1.08-4.16; P = .010; and HR, 2.16; CI, 1.09-4.28; P = .037, respectively). Both measures of central fat distribution appeared to be better predictors of recurrent cardiovascular events when compared with body mass index, whereas sagittal abdominal distention was the better predictor compared with waist circumference, even after multivariate adjustment. After adjusting for secondary prevention interventions-statin, aspirin, β-blocker use, and physical activity-the risk of recurrent event was observed to decrease by about 1%. These results suggest that central fat distribution is positively associated with a recurrence of cardiovascular events after incident MI in women. The absence of decreased risk with secondary prevention interventions suggests that more investigation into the association of central abdominal fat and secondary prevention management is warranted.

HIV and adolescents: focus on young key populations

Adolescents and young adults are at increased risk for HIV due to the many developmental, psychological, social, and structural transitions that converge in this period of the lifespan. In addition, adolescent deaths resulting from HIV continue to rise despite declines in other age groups. There are also young key populations (YKPs) that bear disproportionate burdens of HIV and are the most vulnerable, including young men who have sex with men (MSM), transgender youth, young people who inject drugs, and adolescent and young adult sex workers. As a society, we must do more to stop new HIV infections and untimely HIV-related deaths through both primary and secondary prevention and better management approaches. Using an interwoven prevention and treatment cascade approach, the starting point for all interventions must be HIV counselling and testing. Subsequent interventions for both HIV-negative and HIV-positive youth must be “adolescent-centred,” occur within the socio-ecological context of young people and take advantage of the innovations and technologies that youth have easily incorporated into their daily lives. In order to achieve the global goals of zero infections, zero discrimination and zero deaths, a sustained focus on HIV research, policy and advocacy for YKPs must occur.

CarePoint Integrated Care Program

Expenditure on healthcare in Australia is increasing at an unprecedented rate as the population ages, chronic disease becomes more prevalent, and technological development accelerates. A small proportion of patients with complex, chronic health conditions utilize a hugely disproportionate burden. The current Australian healthcare system, with its fragmented structure and fee for service model, is reactive not proactive and rewards quantity not quality. It does not incentivise cost and utilisation management, nor does it focus on the consumer experience and engagement. It is failing in secondary prevention and cost effective management of chronic disease. CarePoint is a program designed test the effectiveness and efficacy of a care planning and facilitation model in primary care for patients with chronic disease resulting in poor health, frequent hospitalisations and high healthcare costs. Multiple interventions will be used at the General Practice level for patients with complex, chronic health conditions, including enhanced care planning use of a specialized IT platform, case managers, home assessments, improved communication between care providers, and increased education and engagement of General Practitioners. It is postulated that these interventions would result in a reduction in hospital admissions and readmissions by 25%, reduced length of stay, and a reduction in emergency department attendances. Better care coordination of care will improve patient experience, improve health outcomes and significantly reduce cost to the health system. CarePoint is a longitudinal case-control cohort study including both public and privately insured patients. 2000 patients in Southern and Eastern Melbourne, who have had frequent recent hospitalizations as a result of chronic disease, will be recruited from General Practice. The Program is a jointly funded initiative between the Victorian Department of Health and Medibank Private. There has been active engagement with local hospital networks, local service providers and GP practices. World Congress on Integrated Care 2014, Sydney, November 23-26, 2014. International Journal of Integrated Care – Volume 14, 8 December – URN:NBN:NL:UI:10-1-116673– http://www.ijic.org/ Patients will be recruited over a 6 month timeframe with the intervention being applied for a period of 2 years for every patient. The program commenced recruitment in July 2014. Data evaluation will be performed by an independent body at baseline and program end. CarePoint has been designed around successful integrated care programs in place for many years internationally. A model of integrative care directed at the general practice level is innovative and breaking new ground in Australian healthcare. It has the potential to reduce hospital and other healthcare costs dramatically, remove inefficiencies and duplication of service, along with improving population heath, and the experience and satisfaction of patients and healthcare providers alike. The program is sustainable, the cost being minimal compared with the savings gained from reduced preventable hospitalizations and other healthcare costs. It is easily transferable to all of Australia, given General Practice is structured and funded consistently across all states and territories. The program is a simple structure utilizing existing services and aligning with but enhancing current models of care. This program is in the initial stages of recruitment. Conclusions including key findings are not available at this point.

S107 Explaining The Mortality Gap In Copd Patients After Myocardial Infarction: Data From The Uk Myocardial Ischaemia National Audit Project (minap)

Introduction COPD patients are at increased risk of myocardial infarction (MI) and have increased mortality after an MI. Although some of this increased risk may be due to COPD itself, differences in management after an MI may play a role.1 We therefore investigated whether the increased in-hospital and 180 day mortality for COPD patients could be explained by differences in in-hospital and discharge treatment. Methods Patients with a first MI between 2003–2013 were identified from the UK MINAP database. COPD patients had a record of obstructive airway disease, smoking history and were aged >35 years. Logistic regression was used to compare mortality in-hospital and at 180 days post-discharge between COPD and non-COPD patients. All models were adjusted for age, sex, smoking, previous cardiovascular disease, renal failure, diabetes and cardiovascular drugs used on admission. Variables relating to in-hospital management (delay in diagnosis, use of reperfusion and time to reperfusion/use of angiography in-hospital) and use of secondary prevention on discharge were then sequentially added to models to assess the extent to which they explained the mortality difference. Results 300,146 patients with a first MI were identified. 34,027 (11.3%) had COPD. In-hospital mortality was greater for COPD patients after a STEMI (see [Table 1][1]), this difference was reduced after adjusting for in-hospital factors. Mortality was also greater for COPD patients at 180 days; this was not reduced after adjustment for in-hospital factors, but was reduced after adjusting for use of secondary prevention. In-hospital mortality was also greater for COPD patients after a non-STEMI, this was reduced after adjusting for in-hospital factors. Mortality at 180-days after a non-STEMI was greater for COPD patients, this was reduced after adjusting for in-hospital factors, but not after adjusting for use of secondary prevention. Conclusions Improved recognition and timely use of reperfusion treatments after a STEMI may significantly reduce the in-hospital mortality for COPD patients. Longer term mortality in COPD patients after a STEMI may be improved by increased use of secondary prevention drugs. Increased use of timely angiography may improve mortality for COPD patients after a non-STEMI. Reference 1. Quint, JK et al . BMJ . 2013;347:f6650 View this table: Abstract S107 Table 1 Differences in mortality after an MI between COPD and non-COPD patients. All odds ratios compare COPD to non-COPD patients [1]: #T1

Physical activity and exercise recommendations for stroke survivors: a statement for healthcare professionals from the American Heart Association/American Stroke Association.

This scientific statement provides an overview of the evidence on physical activity and exercise recommendations for stroke survivors. Evidence suggests that stroke survivors experience physical deconditioning and lead sedentary lifestyles. Therefore, this updated scientific statement serves as an overall guide for practitioners to gain a better understanding of the benefits of physical activity and recommendations for prescribing exercise for stroke survivors across all stages of recovery. Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association's Manuscript Oversight Committee. The writers used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and indicate gaps in current knowledge. Physical inactivity after stroke is highly prevalent. The assessed body of evidence clearly supports the use of exercise training (both aerobic and strength training) for stroke survivors. Exercise training improves functional capacity, the ability to perform activities of daily living, and quality of life, and it reduces the risk for subsequent cardiovascular events. Physical activity goals and exercise prescription for stroke survivors need to be customized for the individual to maximize long-term adherence. The recommendation from this writing group is that physical activity and exercise prescription should be incorporated into the management of stroke survivors. The promotion of physical activity in stroke survivors should emphasize low- to moderate-intensity aerobic activity, muscle-strengthening activity, reduction of sedentary behavior, and risk management for secondary prevention of stroke.

Evolution of "the guideline advantage": lessons learned from the front lines of outpatient performance measurement.

Heart disease, cancer, stroke, and diabetes mellitus collectively account for >1.37 million U.S. deaths each year (1). Compounding the tragedy is the knowledge that many of those deaths could be avoided through better application of clinical guidelines related to primary and secondary prevention or disease management. The combined control of blood pressure, lipids, and glucose has been shown to substantially reduce mortality and cardiovascular events (2,3). Screening for colon, cervical, breast, and lung cancer has been proven to reduce age-adjusted mortality from these diseases (4). In recognition of the common risk factors across these disease areas, the chief executive officers of the American Cancer Society, American Diabetes Association, and American Heart Association formed the Preventive Health Partnership in 2004. The 3 organizations have been working closely ever since to increase public awareness about healthy lifestyles, support policies that increase funding for and access to prevention programs and research, and increase the focus on prevention among healthcare providers. The American Cancer Society, American Diabetes Association, and American Heart Association have long developed scientific statements and evidence-based guidelines that promote public health services and clinical interventions of known efficacy for improving patient outcomes. Thus, maximizing adherence to quality-of-care guidelines is a high priority for each organization, because this will save lives and improve quality of life. This common purpose has served as a focal point for much of the collaborative work undertaken by the 3 organizations, including The Guideline Advantage (TGA). Launched in 2011, TGA is a jointly operated program designed to promote consistent use of evidence-based practice guidelines through existing healthcare technology in the outpatient setting. The ultimate goal of this undertaking is to improve patient care through quality improvement programs that provide feedback to clinicians and their practices on performance across various quality measures. The data gathered through …