The guideline-focused education programme increased standard dual antiplatelet therapy use from 30.6% to 45.2%, a 13.6% adjusted absolute increase (p<0.001) in patients with minor non-cardioembolic stroke or high-risk TIA.
Observational (n=58,491)
Yes
Does a regional guideline-education initiative improve standard DAPT use and reduce in-hospital stroke recurrence in patients with minor non-cardioembolic stroke or high-risk TIA?
A regional guideline-education and audit-feedback initiative significantly increased adherence to standard DAPT and was associated with a modest reduction in in-hospital stroke recurrence.
Effect estimate: Adjusted absolute difference 13.6% (95% CI 12.8 to 14.4) (95% CI 12.8 to 14.4)
Absolute Event Rate: 45.2% vs 30.6%
p-value: p=<0.001
Background Dual antiplatelet therapy (DAPT) reduces recurrent stroke in patients with minor non-cardioembolic ischaemic stroke or high-risk transient ischaemic attack (TIA). However, real-world prescribing remains heterogeneous. The Shanghai Stroke Service System (4S) initiated a guideline-focused education and audit-feedback programme aimed at improving standard DAPT use for minor strokes since 2019. This study evaluates its impact on the adherence to DAPT and clinical outcomes before and after this initiative. Methods This retrospective study used data from the 4S registry. Consecutive adult patients with acute minor ischaemic stroke (National Institutes of Health Stroke Scale≤3) or high-risk TIA (ABCD 2 score ≥4) between 2015 and 2021 were enrolled. Patients with suspected cardioembolism or who received intravenous thrombolysis were excluded. Standard DAPT was defined as aspirin plus clopidogrel initiated within 24 hours. Education throughout the 4S on the use of DAPT was carried out during 2018–2019. Outcomes during postimplementation period (2019–2021) were compared with preimplementation period (2015–2018). The primary outcome was standard DAPT rate; secondary outcomes included in-hospital stroke recurrence and non-standard DAPT. Results Among 58 491 patients, standard DAPT increased by 13.6% (95% CI 12.8 to 14.4; p<0.001) following 4S initiative. In-hospital stroke recurrence rate decreased by about 1% (aOR=0.91, 95% CI 0.85 to 0.98; p=0.01), driven primarily by improvements in tertiary hospitals. Paradoxically, non-standard DAPT also increased by 10.0% (95% CI 9.3 to 10.7; p<0.001). Interpretation Following implementation of a regional guideline-education initiative within 4S, standard DAPT use increased and overall in-hospital stroke recurrence declined. However, the parallel rise in non-standard DAPT use observed in secondary hospitals highlights persistent practice variability and the need for targeted quality-improvement strategies. Trial registration number NCT02735226 .
Sha et al. (Thu,) conducted a observational in Adults with minor non-cardioembolic ischaemic stroke (NIHSS ≤3) or high-risk TIA (ABCD2 score ≥4) admitted to hospitals in Shanghai, China (n=58,491). Guideline-focused education and audit-feedback programme to improve dual antiplatelet therapy (aspirin plus clopidogrel) use vs. Usual care before implementation of 4S education programme was evaluated on Proportion of standard dual antiplatelet therapy (DAPT) use (aspirin plus clopidogrel initiated within 24 hours) in eligible minor non-cardioembolic stroke or high-risk TIA patients (Adjusted absolute difference 13.6% (95% CI 12.8 to 14.4), 95% CI 12.8 to 14.4, p=<0.001). The guideline-focused education programme increased standard dual antiplatelet therapy use from 30.6% to 45.2%, a 13.6% adjusted absolute increase (p<0.001) in patients with minor non-cardioembolic stroke or high-risk TIA.