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Multifaceted implementation of stroke prevention guidelines in primary care: cluster-randomised evaluation of clinical and cost effectiveness
  1. John Wright1,
  2. John Bibby2,
  3. Joe Eastham3,
  4. Stephen Harrison4,
  5. Maureen McGeorge1,
  6. Chris Patterson1,
  7. Nick Price1,
  8. Daphne Russell5,
  9. Ian Russell5,
  10. Neil Small6,
  11. Matt Walsh7,
  12. John Young1
  1. 1Bradford Teaching Hospitals NHS Trust, Bradford Royal Infirmary, Bradford, UK
  2. 2North Bradford PCT, Saltaire, Shipley, UK
  3. 3Teamwork Management Services Ltd, Bolton, UK
  4. 4University of Manchester, National Primary Care Research and Development Centre, Manchester, UK
  5. 5Institute of Medical and Social Care Research, University of Wales Bangor, Bangor, Gwynedd, UK
  6. 6School of Health Studies, The University of Bradford, Bradford, UK
  7. 7Bradford South & West PCT, Bryan Sutherland House, Bradford, UK
  1. Correspondence to:
 Professor J Wright
 Director of Clinical Quality & Research, Bradford Teaching Hospitals NHS Trust, Bradford Royal Infirmary, Duckworth Lane, Bradford, BD9 6RJ, UK; john.wright{at}


Objective: To evaluate clinical and cost effectiveness of implementing evidence-based guidelines for the prevention of stroke.

Design: Cluster-randomised trial

Setting: Three primary care organisations in the North of England covering a population of 400 000.

Participants: Seventy six primary care teams in four clusters: North, South & West, City I and City II.

Intervention: Guidelines for the management of patients with atrial fibrillation and transient ischaemic attack (TIA) were developed and implemented using a multifaceted approach including evidence-based recommendations, audit and feedback, interactive educational sessions, patient prompts and outreach visits.

Outcomes: Identification and appropriate treatment of patients with atrial fibrillation or TIA, and cost effectiveness.

Results: Implementation led to 36% increase (95% CI 4% to 78%) in diagnosis of atrial fibrillation, and improved treatment of TIA (odds ratio of complying with guidelines 1.8; 95% CI 1.1 to 2.8). Combined analysis of atrial fibrillation and TIA estimates that compliance was significantly greater (OR 1.46 95% CI 1.10 to 1.94) in the condition for which practices had received the implementation programme. The development and implementation of guidelines cost less than £1500 per practice. The estimated costs per quality-adjusted life year gained by patients with atrial fibrillation or TIA were both less than £2000, very much less than the usual criterion for cost effectiveness.

Conclusions: Implementation of evidence-based guidelines improved the quality of primary care for atrial fibrillation and TIA. The intervention was feasible and very cost effective. Key components of the model include contextual analysis, strong professional support, clear recommendations based on robust evidence, simplicity of adoption, good communication and use of established networks and opinion leaders.

  • PCT, primary care trust
  • QALY, quality-adjusted life year
  • TIA, transient ischaemic attack

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  • Funding: Department of Health—Northern and Yorkshire Research & Development Directorate.

  • Competing interests: None declared.

  • Ethics approval: The Bradford Local Research Ethics Committee reviewed and approved the study.

    Contributors: JW and JY had the original idea for the project. JW, SH, CP, IR, NS and JY designed the project and obtained funding. All authors had an active role in the development of the guidelines and their subsequent implementation. MM coordinated the project. DR and JE undertook the analysis. JW and IR wrote the paper in collaboration with the other authors and JW is the guarantor.