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No instruments are currently available to help health systems identify target areas for reducing door-to-needle times for the administration of intravenous tissue plasminogen activator to eligible patients with ischemic stroke. A 67-item Likert-scale survey was administered by telephone to stroke personnel at 252 U.S. hospitals participating in the “Get With The Guidelines-Stroke” quality improvement program. Factor analysis was used to refine the instrument to a four-factor 29-item instrument that can be used by hospitals to assess their readiness to administer intravenous tissue plasminogen activator within 60 minutes of patient hospital arrival.

While predictive tools are being developed to identify those at highest risk for developing diabetes, little is known whether these assays affect clinical care.Thirty sites who used the PreDx(®) (Tethys BioScience, Emeryville, CA) abstracted clinical information from baseline clinic visits prior to a PreDx test and from the most recent visit at time of abstraction. All visits occurred between May 2008-April 2011 (median follow-up 198 days, IQR 124-334). The primary analysis was the influence of the PreDx test (5-year diabetes prediction) on subsequent care; descriptive statistics were used to summarize baseline and follow-up variables. Overall 913 patients with 2 abstracted visits were included. Relative to baseline, median SBP decreased 1.5 mmHg (p = 0.039), DBP decreased 2 mmHg (p 0.001), LDL-C decreased 4 mg/dL (p = 0.009), and HDL-C increased 2 mg/dL (p 0.001) at follow-up. Behavioral or lifestyle counseling was not significantly different from baseline to follow-up (71.2% vs. 68.1% (p = 0.077), but BMI was lower by 0.2 kg/m(2) at follow up (p = 0.013). At follow-up, more patients were prescribed metformin (13.7% vs. 9.7%, p 0.001). A higher PreDx score was significantly associated with metformin prescription (p = 0.0003), lifestyle counseling (p = 0.0099), and a lower BMI at follow-up (p = 0.007).The use of a prognostic test in patients perceived to be high risk for diabetes was associated with a modest but significant increase in the prescription of metformin and lifestyle interventions and a reduction in BMI.

We aimed to compare quality of life (QOL) in women and men after ischemic stroke or TIA, and to determine the incremental impact of demographic, socioeconomic, clinical, and stroke-specific effects on longitudinal QOL.We assessed QOL in patients with ischemic stroke or TIA at 3 and 12 months postdischarge in the Adherence eValuation After Ischemic stroke-Longitudinal Registry using the European Quality of Life-5 Dimensions (EQ-5D) instrument. We generated multivariable linear regression models to evaluate the association between sex and EQ-5D while sequentially adjusting for sociodemographic, clinical, and stroke-related variables. We also used a proportional odds model to assess sex differences in the change in EQ-5D scores from 3 to 12 months.A total of 1,370 patients were included, 53.7% male, median age 65 years (interquartile range 56-77 years). Women had significantly lower QOL at 3 months (unadjusted EQ-5D 0.81 in women vs 0.84 in men; p0.001) and 12 months (0.83 vs men 0.84; p0.001) poststroke. After multivariable adjustment for sociodemographic, clinical, and stroke-related factors, women continued to have lower QOL at 3 months (mean difference -0.036; p = 0.003) and at 12 months (mean difference -0.022; p = 0.046). Women fared worse in the dimensions of mobility, pain/discomfort, and anxiety/depression at 3 and 12 months. There were no sex differences in change in EQ-5D score from 3 to 12 months.Women have worse QOL than men up to 12 months after stroke, even after adjusting for important sociodemographic variables, stroke severity, and disability.

The purpose of this study is to explore factors associated with recall of medication education and satisfaction with healthcare provider communication in patients with acute stroke or transient ischemic attack. This is an analysis of data from the AVAIL (Adherence Evaluation of Acute Ischemic Stroke Longitudinal) study. At 3 months after discharge, 2,219 stroke patients from 99 sites were interviewed and asked about their perceptions of education and communication with their healthcare providers as well as their current medication use and knowledge. Results show that less than 2% of the respondents reported not understanding how to take their medications, 4% did not know how to refill their medications, and 5% did not know the reason they were taking them. A vast majority (92%) of participants reported high levels of satisfaction in their communications with healthcare providers after discharge. Although overall understanding and satisfaction was high, older subjects were less likely to recall receiving medication information at discharge or to understand their medications. Similarly, African Americans and patients discharged from an academic hospital were less likely to report receiving a written medication list. This report highlights the success of education efforts and potential areas for additional improvement.

Early treatment with intravenous (IV) recombinant tissue plasminogen activator/alteplase (tPA) is associated with improved outcomes for patients with an acute ischemic stroke. Thus, rapid triage and treatment of stroke patients are essential, with a goal of door-to-needle time of no more than 60 minutes. We sought to identify best practices associated with faster treatment among hospitals participating in Get With the Guidelines--Stroke. Qualitative telephone interviews were conducted to elicit strategies being used by these centers to assess, treat, and monitor stroke patients treated with IV tPA. We sequentially carried out these interviews until we no longer identified novel factors. Interviews were conducted with 13 personnel at 7 top-performing U.S. hospitals. With the use of a hermeneutic-phenomenological framework, 5 distinct domains associated with rapid IV tPA delivery were identified. These included (a) communication and teamwork, (b) process, (c) organizational culture, (d) performance monitoring and feedback, and (e) overcoming barriers.

Background— Several studies that used claims and registry data have reported that 40% to 80% of patients eligible for an implantable cardioverter defibrillator (ICD) fail to receive one in clinical practice, and the rates are especially high among women and blacks. The extent and documented reasons for nonuse of ICDs among patients with left ventricular systolic dysfunction are unknown. Methods and Results— Using hospital claims and clinical data, we identified patients hospitalized with a heart failure diagnosis and left ventricular ejection fraction ≤30% between January 1, 2007, and August 30, 2007, at a tertiary-care center. Using claims data, we determined placement of an ICD or cardiac resynchronization therapy with defibrillation device at any time up to 1 year after hospitalization. Medical records for patients without an ICD were abstracted to determine reasons for nonuse. Patients with an ICD were compared with patients without an ICD and also with patients without an ICD who did not have any contraindication for an ICD as identified through chart abstraction. Of the 542 potentially eligible patients identified, 224 (41%) did not have an ICD. In the initial adjusted analysis, female sex (odds ratio=1.90; 95% CI, 1.28 to 2.81) and increasing age (odds ratio=1.07; 95% CI, 1.04 to 1.11) were associated with a higher likelihood of not having an ICD. After detailed chart review, of the 224 patients without an ICD, 117 (52%) were ineligible for the device and 38 (17%) patients refused the device, resulting in only 69 (13%) patients eligible for an ICD who failed to receive one. In this subsequent adjusted analysis, remaining factors associated with a higher likelihood of not having an ICD were absence of ventricular arrhythmias (odds ratio=4.93; 95% CI, 2.56 to 9.50), noncardiology hospital service (odds ratio=3.73; 95% CI, 1.98 to 7.04), and lack of health insurance (odds ratio=3.10; 95% CI, 1.48 to 6.46). Conclusions— On the basis of a detailed chart review, the true rate of ICD underuse may be substantially lower than previous estimates. In addition, after accounting for ICD eligibility criteria, patient sex and age disparities in ICD therapy were no longer present.

Purpose: Rural residents are less likely to obtain optimal care for many serious conditions and have poorer health outcomes than those residing in more urban areas. We determined whether rural vs urban residence affected postdischarge medication persistence and 1 year outcomes after stroke. Methods: The Adherence eValuation After Ischemic Stroke-Longitudinal (AVAIL) study is a multicenter registry of stroke patients enrolled in 101 hospitals nationwide. Medications were recorded at hospital discharge and again after 3 and 12 months. Persistence was defined as continuation of prescribed discharge medications. Participants were categorized as living in rural or urban settings by cross-referencing home ZIP code with metropolitan statistical area (MSA) designation. Findings: Rural patients were younger, more likely to be white, married, smokers, and less likely to be college graduates. There was no difference in stroke type or working status compared to urban patients, and there were minor differences in comorbid conditions. There were no differences based on rural vs urban residence in medication persistence at 3 or 12 months postdischarge and no differences in outcomes of recurrent stroke or rehospitalization at 12 months. Conclusion: Despite differences in patient characteristics, there was no difference in medication persistence or outcomes between rural and urban dwellers after hospitalization for ischemic stroke or transient ischemic attack (TIA).

Background: Implantable cardioverter defibrillator (ICD) therapy improves survival of patients with systolic heart failure. We assessed whether physicians’ recommendation for ICD therapy varies as a function of patient age, gender, race, and physician's specialty. Methods: We surveyed a random sample (n = 9969) of U.S. physicians who are active members of the American College of Cardiology (ACC). We asked participants about their likelihood to recommend ICD therapy in 4 clinical scenarios that randomly varied patient age, gender, race, and ICD indication (guideline Class I, Class IIa, Class III, and Class I in a noncompliant patient). Results: Responses were received from 1210 physicians (response rate 12%), of whom 1127 met the study inclusion criteria. Responders and nonresponders had similar demographics. In responding to hypothetical clinical scenarios, physicians were less likely to recommend an ICD to older patients (≥80 vs 50 years) (P < 0.01) but were unaffected by gender or race for all class indications. Compared with nonelectrophysiologists (EPs), EPs were significantly more likely to recommend an ICD for a Class I indication (92.4% vs 81.4%; P < 0.01), but they were not more likely to offer an ICD for a Class III indication (0.4% vs 0.6%; P = 0.95). Conclusions: Based on survey responses, physicians were equally willing to offer an ICD to men and women and to whites and blacks, but were less likely to offer an ICD to an older patient even when indicated by practice guidelines. Electrophysiologists (EPs) more often adhered to practice guideline recommendations on ICD therapy compared with non-EPs. Ann Noninvasive Electrocardiol 2011;16(1):77–84

Background Stroke is the leading cause of disability among adults in the United States. The association of patients’ pre-event socioeconomic status (SES) with post-stroke disability is not well understood. We examined the association of three indicators of SES—educational attainment, working status, and perceived adequacy of household income—with disability 3-months following an acute ischemic stroke. Methods We conducted retrospective analyses of a prospective cohort of 1965 ischemic stroke patients who survived to 3 months in the Adherence eValuation After Ischemic stroke – Longitudinal (AVAIL) study. Multivariable logistic regression was used to examine the relationship of level of education, pre-stroke work status, and perceived adequacy of household income with disability (defined as a modified Rankin Scale of 3–5 indicating activities of daily living limitations or constant care required). Results Overall, 58% of AVAIL stroke patients had a high school or less education, 61% were not working, and 27% perceived their household income as inadequate prior to their stroke. Thirty five percent of patients were disabled at 3-months. After adjusting for demographic and clinical factors, stroke survivors who were unemployed or homemakers, disabled and not-working, retired, less educated, or reported to have inadequate income prior to their stroke had a significantly higher odds of post-stroke disability. Conclusions In this cohort of stroke survivors, socioeconomic status was associated with disability following acute ischemic stroke. The results may have implications for public health and health service interventions targeting stroke survivors at risk of poor outcomes.

Participants in a variety of health plans, clinics and employer groups were invited to participate in the Asthma Self-Management Program (ASMP), an education program designed to improve self-management skills and daily functioning in individuals with asthma. The ASMP is an 8-week classroom program that provides information on the respiratory system, trigger avoidance, use of monitoring techniques and asthma medications. After program completion, graduates were contacted at scheduled intervals to reinforce performance of behaviors that are important to asthma self-management and to collect outcomes data. This paper reports the results of 2 years of follow-up with these individuals.

The Individualized Asthma Care Training (IACT®) program is a 12-month, one-on-one in-home training and education program for adults with severe or uncontrolled asthma. Patients at a university hospital's outpatient clinic and members of a health plan who had had a minimum of one hospitalization or two or more emergency department visits in the previous year were invited to participate. Trained healthcare professionals worked with these individuals to help them learn about asthma, improve their disease monitoring and management skills, and encourage them to become partners with their physician in their own healthcare. In addition, trainers conducted an environmental assessment of participants' homes with the participants' help. Trainers used a computer software application, which contained asthma educational materials including prompts for the trainer and video clips. Additionally, the software was used to recruit and track patients and to collect outcomes data. Forty individuals completed the program and ...

Background Black individuals eligible for an implantable cardioverter/defibrillator (ICD) are considerably less likely than white individuals to receive one. This disparity may, in part, be explained by racial differences in patient preferences. We hypothesized that a targeted patient-centered educational video could improve knowledge of sudden cardiac arrest (SCA) and ICDs and reduce racial differences in ICD preferences. We conducted a pilot study to assess the feasibility of testing this hypothesis in a randomized trial. Methods We created a video that included animation, physician commentary, and patient testimonials on SCA and ICDs. The primary outcome was the decision to have an ICD implanted as a function of race and intervention. Between January 1, 2011, and December 31, 2011, 59 patients (37 white and 22 black) were randomized to the video or health care provider counseling/usual care. Results Relative to white patients, black patients were younger (median age, 55 vs 68 years) and more likely to have attended college or technical school. Baseline SCA and ICD knowledge was similar and improved significantly in both racial groups after the intervention. Black patients viewing the video were as likely as white patients to want an ICD (60.0% vs 79.2%, P = .20); and among those in the usual care arm, black patients were less likely than white patients to want an ICD (42.9% vs 84.6% P = .05). Conclusion Among individuals eligible for an ICD, a video decision aid increased patient knowledge and reduced racial differences in patient preference for an ICD.

Reporting on the results of the CATCH study, Coutts et al1 were surprised that 15% of subjects with transient ischemic attack (TIA) or minor stroke were disabled (modified Rankin Score >2) at 90 days and indicate that their study “is novel in that it emphasizes the need to examine disability even in minor stroke.” Although differing in purpose and design, their data are consistent with our study, in which we found 37% of patients with TIA had a modified Rankin Score >2, 3 months …

Background Patients who are hospitalized with a first or recurrent stroke often are discharged with new medications or adjustment to the doses of pre-admission medications, which can be confusing and pose safety issues if misunderstood. The purpose of this pilot study was to assess the feasibility of medication coaching via telephone after discharge in patients with stroke. Methods Two-arm pilot study of a medication coaching program with 30 patients (20 intervention, 10 control). Consecutive patients admitted with stroke or TIA with at least 2 medications changed between admission and discharge were included. The medication coach contacted intervention arm patients post-discharge via phone call to discuss risk factors, review medications and triage patients’ questions to a stroke nurse and/or pharmacist. Intervention and control participants were contacted at 3 months for outcomes. The main outcomes were feasibility (appropriateness of script, ability to reach participants, and provide requested information) and participant evaluation of medication coaching. Results The median lengths of the coaching and follow-up calls with requested answers to these questions were 27 minutes and 12 minutes, respectively, and participant evaluations of the coaching were positive. The intervention participants were more likely to have seen their primary care provider than were control participants by 3 months post discharge. Conclusions This medication coaching study executed early after discharge demonstrated feasibility of coaching and educating stroke patients with a trained coach. Results from our small pilot showed a possible trend towards improved appointment-keeping with primary care providers in those who received coaching.

Background: Socioeconomic status (SES) is widely recognized as an area of inequity that affects health outcomes. However, social determinants of health are less frequently measured in longitudinal studies of acute stroke patients. The relationship of SES on disability 3-months post-stroke is unknown. Methods: We analyzed ischemic stroke patients in the AVAIL registry who were enrolled at 98 hospitals participating in Get With The Guidelines-Stroke. Patients who died (n=64) or did not complete a modified Rankin Scale (mRS) at 3-months (n=154) were excluded. Multivariable logistic regression was used to examine the relationship of SES (defined by level of education, work status, and perceived adequacy of household income to meet needs) and disability (mRS scores 3-5). Results: Among the 2092 stroke patients who met eligibility criteria, the mean age was 65.5 ± 13.7, 44.2% were female, and 82.7% were White. Fifty seven percent had a high school or less education, 11.4% were not working post-stroke and were home not by choice, and 25.7% were without an adequate household income. A third of the sample had some level of disability at 3-months (34.6% mRS 3-5). Those with disability were more likely to be older, non-White, female, single, less educated, have inadequate income, and were home not by choice. In the multivariable analysis, lower education, inadequate income, and being home but not by choice (compared with those who returned to work) were independently associated with disability (pTable ). Conclusion: In this national cohort of stroke survivors, socioeconomic status as measured by level of education, work status, and income were independently associated with post-stroke disability.

Background/rationale: Depression is common after stroke and is associated with poor functional outcome, but its relationship with the change in functional status after adjustment for other factors remains uncertain. We investigated the independent relationship between depression and post-stroke functional recovery. Methods: Data were obtained as part of the multicenter Adherence eValuation After Ischemic stroke-Longitudinal (AVAIL) registry in which depression assessed by a self-reported depressive symptoms scale (the Patient Health Questionnaire-8; PHQ-8≥10), and modified Rankin scale (mRS) were prospectively assessed 3 and 12 months following hospitalization for ischemic stroke. Univariate logistic analysis followed by multivariable logistic modeling adjusted for race, gender, age and post-hospital rehabilitation, was performed to evaluate the association between depression at each time-point and the change in mRS between 3 and 12 months. Results: Data was available for 1444 patients (55.7% men, 82.6% White) from 97 hospitals in the United States. Relative to 3 months, the 12 month mRS was stable or improved in 692 (75.8%) and worse in 349 (24.2%) patients. Overall, 134 patients were persistently depressed, 126 had resolving depression by 12 months and 104 patients had incident depression at 12 months. Older age, lack of rehabilitation, and 3 and 12 months depression status were associated with worse disability (increasing mRS) between 3 and 12 months. After covariate adjustment, both depression status at 3 and 12 months (p= 0.010) and older age (OR= 1.02, 95% CI 1.01-1.03 per 10-years, p Conclusion: The change in depressive status between 3 and 12 months following hospitalization for stroke was associated with incremental changes in functional outcome. Patients who had resolving post-stroke depression were less likely to have worsening disability. A reciprocal relationship and a confounding effect between depression and mRS cannot be excluded.

Objective: Several studies using claims or registry data have reported high rates of under-utilization of ICDs in clinical practice. Women and elderly were reported to be particular subgroups at risk for non-use. We used detailed chart review to determine the true extent of ICD non-use in patients with left ventricular systolic dysfunction. Methods: Using hospital claims and clinical data, we identified patients hospitalized between 1/07 through 8/07 at a tertiary care center with a heart failure (HF) diagnosis and LVEF ≤ 30% who also had follow-up at the same institution. Placement of an ICD or CRT-D up to 1 year after hospitalization was determined. Medical records for patients without an ICD were abstracted to determine reasons for non-use. Results: Of the 542 patients identified as potentially eligible for an ICD, 224 (41%) did not have an ICD up to 1 year after hospitalization. Among these, women (adjusted OR 1.93; 95% CI 1.28-2.93) and those with advanced age (adjusted OR 1.08; 95%CI 1.04-1.12) were more likely to not have an ICD ( Table ). Detailed chart review found that 38 (7%) patients refused an ICD and 117 (22%) were ineligible for an ICD (53 had improvement in EF after index hospitalization, 54 had limited life expectancy, 1 had complicated anatomy precluding ICD implant, and 9 had Class IV HF). Therefore, with only 69 patients found to be eligible for an ICD after chart review, the true rate of ICD non-use was 13%. In this population, factors significantly associated with non-use of an ICD are shown in the Table. Of note, women and those of advanced age were not significantly more likely to be non-recipients of an ICD. Conclusion: Previously reported rates of ICD under-utilization using claims or registry data may be an overestimate. After detailed record review, only 13% of truly eligible hospitalized HF patients failed to receive an ICD. Gender and age differences in ICD use may also be accounted for by ICD eligibility differences. Adjusted Odds Ratios and 95% Confidence Intervals for Characteristics Associated with No ICD Characteristics All ICD Recipients versus All Non-Recipients All ICD Recipients versus Non-Recipients Without Refusal/Contraindication No Ventricular Arrhythmia 3.32 (2.21, 5.00) 5.62 (2.82, 11.11) Index Hospitalization on Non-Cardiology Service 3.36 (2.03, 5.56) 4.59 (2.33, 9.09) Age (per 1 year) 1.08 (1.04, 1.12) 1.02 (1.00, 1.04) Female 1.93 (1.28, 2.93) 1.00 (0.52, 1.92) Qualifying EF (per 1% increase) 1.03 (1.00, 1.07) 1.05 (1.00, 1.10) Days from Qualifying EF to Index Hospital discharge (per 10 days) 0-200 days 200+ days - - 0.92 (0.89, 0.95) 1.01 (1.00, 1.03) - - 0.91 (0.87, 0.97) 1.01 (0.99, 1.03) No Health Insurance 1.58 (0.89, 2.80) 2.96 (1.39, 6.29) African American race 1.38 (0.90, 2.11) 1.27 (0.66, 2.45) Ischemic Heart Disease 1.15 (0.75, 1.75) 1.03 (0.54, 1.94) Diabetes 0.87 (0.65, 1.44) 0.58 (0.32, 1.07)

Background: Post-stroke depression is common, yet little is known about factors associated with antidepressant use in this population Methods: Data from the multicenter, prospective Adherence eValuation After Ischemic stroke-Longitudinal (AVAIL) registry was used to identify patients with post-stroke depression and to describe factors associated with antidepressant use. The analysis was performed after 3 months in 1751 ischemic stroke patients who had been admitted to 97 hospitals nationwide; 12 month follow-up was available for 1637 patients. The Get with the Guidelines-Stroke database was used to collect baseline data. Patients were classified as depressed based on a self-report scale (the Patient Health Questionnaire-8; score range 0 to 24, score ≥10 indicating depression). Frequencies were compared with Pearson X 2 and unadjusted ORs were calculated. Results: The prevalence of post stroke depression was similar at 3 and 12 months (19% [331/1751] vs 17% [280/1637], respectively, p=0.17). Regardless of depression status, antidepressant use was higher at 12 months (16% [287/1751] vs 20% [334/1637], p=0.002). Antidepressant use was also higher at 12 months in depressed patients (25% [84/331] vs 35% [98/280], p=0.009). The odds of antidepressant use at 3 months was higher in women than men (OR 1.6, 95% CI 1.2-2.1), Whites vs. Blacks (OR 1.7, 95% CI 1.1-2.8), in patients with vs. without cognitive deficits (OR 1.6, 95% CI 1.2-2.1) and in those with more severe disabilities (mRS≥3 vs. mRS Conclusion: Three-quarters of depressed stroke patients at 3-months and nearly two-thirds at 12 months were not receiving antidepressants. Regardless of depression status, utilization of antidepressants after 3 and 12 months varied based on gender, race/ethnicity, cognitive status, disability level, and after 12-months, stroke recurrence. The reasons for the apparent underuse of antidepressants in patients with prevalent post-stroke depression require further study.

Rural residents are less likely to obtain optimal care for many serious conditions and have poorer health outcomes than those residing in more urban areas. We determined whether rural vs urban residence affected postdischarge medication persistence and 1 year outcomes after stroke.The Adherence eValuation After Ischemic Stroke-Longitudinal (AVAIL) study is a multicenter registry of stroke patients enrolled in 101 hospitals nationwide. Medications were recorded at hospital discharge and again after 3 and 12 months. Persistence was defined as continuation of prescribed discharge medications. Participants were categorized as living in rural or urban settings by cross-referencing home ZIP code with metropolitan statistical area (MSA) designation.Rural patients were younger, more likely to be white, married, smokers, and less likely to be college graduates. There was no difference in stroke type or working status compared to urban patients, and there were minor differences in comorbid conditions. There were no differences based on rural vs urban residence in medication persistence at 3 or 12 months postdischarge and no differences in outcomes of recurrent stroke or rehospitalization at 12 months.Despite differences in patient characteristics, there was no difference in medication persistence or outcomes between rural and urban dwellers after hospitalization for ischemic stroke or transient ischemic attack (TIA).

Background Several studies based on claims data have reported underutilization of evidence-based heart failure (HF) therapies. The degree to which these estimates fail to account for therapeutic contraindications is unclear. Methods We identified patients with HF and left ventricular ejection fraction ≤45% seen between January 1, 2010, and July 1, 2010, at a tertiary care Veterans Affairs Medical Center. Medical records were abstracted to evaluate utilization of and contraindications to β -blocker, angiotensin-converting enzyme inhibitor, aldosterone antagonist, anticoagulation for atrial fibrillation, implantable cardioverter-defibrillator, and cardiac resynchronization therapies. Results Of the 178 patients with HF and an ejection fraction ≤45%, 78 (44%) received every guideline-recommended therapy. After accounting for medical contraindications, 77 (72%) of 107 patients received every guideline-recommended therapy. Adherence to recommendations for β-blocker (98%), angiotensin-converting enzyme inhibitor/angiotensin blocker (95%), and anticoagulation (97%) were better than adherence to implantable cardioverter-defibrillator (82%), cardiac resynchronization therapy (59%), or aldosterone antagonist (51%) recommendations. In adjusted analysis, lower New York Heart Association functional class and care by a cardiologist were associated with improved guideline adherence ( P Conclusions Many patients with HF have therapeutic contraindications, and a failure to account for these may lead to a large underestimation of the true guideline adherence rates.

Objective To measure longitudinal use of stroke prevention medications following stroke hospital discharge. We hypothesized that a combination of patient-, provider-, and system-level factors influence medication-taking behavior. Design Observational cohort design. Setting One hundred six US hospitals participating in the American Heart Association Get With The Guidelines-Stroke program. Patients Two thousand eight hundred eighty-eight patients 18 years or older admitted with ischemic stroke or transient ischemic attack. Main outcome measure Regimen persistence, including use of antiplatelet therapies, warfarin, antihypertensive therapies, lipid-lowering therapies, or diabetes medications, from discharge to 3 months. Reasons for nonpersistence were also ascertained. Results Two thousand five hundred ninety-eight patients (90.0%) were eligible for analysis. At 3 months, 75.5% of subjects continued taking all secondary prevention medications prescribed at discharge. Persistence at 3 months was associated with decreasing number of medication classes prescribed, increasing age, medical history, less severe stroke disability, having insurance, working status, understanding why medications are prescribed and how to refill them, increased quality of life, financial hardship, geographic region, and hospital size. Conclusions One-quarter of stroke patients reported discontinuing 1 or more of their prescribed regimen of secondary prevention medications within 3 months of hospitalization for an acute stroke. Several modifiable factors associated with regimen persistence were identified and could be targets for improving long-term secondary stroke prevention.