From guidelines to clinical practice in care for ischaemic stroke patients: A systematic review and expert opinion

Abstract

Background and purpose: Guidelines help physicians to provide optimal care for stroke patients, but implementation is challenging due to the quantity of recommendations. Therefore a practical overview related to applicability of recommendations can be of assistance.

Methods: A systematic review was performed on ischaemic stroke guidelines published in scientific journals, covering the whole acute care process for patients with ischaemic stroke. After data extraction, experts rated the recommendations on dimensions of applicability, that is, actionability, feasibility and validity, on a 9-point Likert scale. Agreement was defined as a score of ≥8 by ≥80% of the experts.

Results: Eighteen articles were identified and 48 recommendations were ultimately extracted. Papers were included only if they described the whole acute care process for patients with ischaemic stroke. Data extraction and analysis revealed variation in terms of both content and comprehensiveness of this description. Experts reached agreement on 34 of 48 (70.8%) recommendations in the dimension actionability, for 16 (33.3%) in feasibility and for 15 (31.3%) in validity. Agreement on all three dimensions was reached for seven (14.6%) recommendations: use of a stroke unit, exclusion of intracerebral haemorrhage as differential diagnosis, administration of intravenous thrombolysis, performance of electrocardiography/cardiac evaluation, non-invasive vascular examination, deep venous thrombosis prophylaxis and administration of statins if needed.

Discussion and conclusion: Substantial variation in agreement was revealed on the three dimensions of the applicability of recommendations. This overview can guide stroke physicians in improving the care process and removing barriers where implementation may be hampered by validity and feasibility.

Keywords: expert testimony; guidelines; ischaemic stroke; quality improvement; systematic review.

FIGURE 1

Study selection flowchart according to the Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA). Flowchart designed based on Page et al. [19].

FIGURE 2

Research overview. This figure provides an overview of the systematic review and expert opinion. The recommendations are listed in the first column. In the second column, the frequency with which each recommendation was mentioned in the included papers is displayed. The following columns indicate whether there was expert consensus (green) or not (blank) for the three domains of applicability. Within each clinical topic category, the recommendations are ranked based on the following priority criteria, from highest to lowest: the recommendations with consensus in the three domains of applicability; the recommendations with consensus for actionability and feasibility; the recommendations with consensus for actionability and validity; the recommendations with consensus for actionability alone, with the highest consensus percentage first; the recommendations with consensus for feasibility alone and the recommendations with consensus for validity alone; recommendations for which no consensus was reached. If the criteria described above were the same for multiple recommendations, their ranking was further refined by the frequency of their mention in the papers included in the systematic review.