Core Elements of Delivery of Secondary Stroke Prevention Services

Recommendations

A critical component of secondary stroke prevention is access to specialized stroke prevention services (SPS), ideally provided by dedicated stroke prevention clinics.  Stroke prevention clinics (or similar vascular prevention clinics, services or models of care) provide a comprehensive interdisciplinary approach to prevention of first or recurrent stroke, conduct detailed assessments by a range of healthcare disciplines, facilitate timely access to appropriate diagnostic testing and interventions, and provide education to patients and families.  They also promote continuity of care between acute care facilities, rehabilitation services, the patient, their family and caregivers, primary care providers, and other community care service providers.

In 2016, the Heart and Stroke Foundation conducted a Stroke Prevention Services Resource Inventory (SPSRI) through which 123 stroke prevention services were identified across Canada.  Services were available in every province; however, there were considerable differences between prevention services with respect to structural elements such as models of care, hours of operation, SPS team members, and availability of diagnostic services; process elements such as wait times for appointments and wait times to access services such as imaging and Holter monitoring; and outcome elements such as monitoring quality of care and stroke recurrence rates.

The SPSRI inventory was created using a modified Delphi methodology.  The foundation of the SPSRI is the Canadian Stroke Best Practice Recommendations, and in particular this module on the Secondary Prevention of Stroke.  A review of the literature was performed to identify different models of prevention services, and core elements of such services.  Consultations were then held with stroke prevention service providers, funders, and policy makers.  An extensive list of elements of prevention services was then developed that aligned with the evidence-based best practice recommendations.  The draft SPSRI underwent three rounds of voting by a wide range of stroke care clinicians, managers, patients, and funders to identify the final set of elements for the inventory. SPSRI was sent to a specific contact person at each of the 123 identified SPS.  A total of 119 services completed the inventory (97% response rate).  Analysis of the responses informed further refinement of the inventory and final inclusion list of core elements of stroke prevention services.

A framework of key components of delivering prevention services (Figure Two), and a comprehensive list of the core elements of stroke prevention services (Table Two).  The purpose of this framework and list of elements is multifaceted, and are to:

• enable stroke prevention service providers, regardless of size or location, to assess the types and level of services provided.
• identify gaps in the core elements of prevention services to inform planning, development, and quality improvement initiatives.
• identify issues of access to stroke prevention services, based on location of services as well as hours of operation (e.g., once a week versus daily), and availability of healthcare professionals and diagnostic services (e.g., CAT scanner) onsite.
• to identify the list of elements present and not yet available that serve as enablers to implementation of the stroke best practice recommendations included in this update of the Secondary Prevention of Stroke Best Practices update 2020.
• to strengthen service provision and increase accountability.

Figure Two: CSBPR Core Elements of Stroke Prevention Services Underlying Framework

Table Two: H&S Core Elements of Stroke Prevention Services (Update 2020)