Strategies to Improve Preventive Vascular Health Services Evidence-based guidelines are useful only if the recommen- dations translate into clinical practice. Primary vascular pre- vention approaches are underused in general practice.1,927 For example, in the United States, 6% of adults have undiag- nosed hypertension, and although the number of patients with BP treated to recommended targets has improved from 27% stantial gaps in quality remain.224,928 Opportunities to improve preventive services exist across the range of vascular risk fac- In the United States, vascular health varies substantially across the 50 states, but overall, only 3% of the adult popula- tion has ideal vascular health defined across 7 domains: hyper- tension, hyperlipidemia, smoking, BMI, diabetes mellitus, physical activity, and consumption of fruits and vegetables.929 Although preventive vascular services are a core activity of primary care physicians, specialists also have the opportunity and responsibility to identify stroke risk factors, to ensure that patients receive recommended treatments, and to encourage adherence to therapeutic interventions.930 Strategies to help cli- nicians implement guideline recommendations are often aimed at changing physician behavior related to risk factor preven- A combination of techniques is usually necessary to improve stroke preventive care, including physician education, audit and feedback of quality data, and use of checklists.931 939 Some strategies to improve stroke prevention care, although relatively costly, are more consistently effective, including electronic medical records; computer-based clinical reminder systems; and tailored, multifaceted programs.940 944 Other strate- gies focus on changing the organization or context in which the care is delivered, including delegation of preventive services to nonphysician staff (eg, nurses or pharmacists), the use of group visits, or the implementation of clinics devoted to screening and Quality improvement efforts that include activities that focus on the system, the provider, and the patient, as well as the coordination of services across these domains, are often the most effective.949 Studies examining the effectiveness of stroke education programs have generally iden- tified a modest effect on patient knowledge, risk perception, or However, studies have demonstrated the effectiveness of tailored patient self-management programs to improve vascular risk factor control.950,951 Integrated healthcare systems that have focused on improving the quality of vascu- lar prevention have demonstrated improvements in a variety of stroke risk factors at the facility or system level.952,953 Achieving sustained improvements in the quality of vascular prevention care at the system level may require multidimensional interven- tions, including implementation of electronic medical record systems, ongoing performance measurement, change in the cul- ture, and alignment of economic incentives.953,954 Stroke preven- tion services are most cost-effective for populations at increased risk (eg, patients >50 years of age).955 Preventive Health Services: Summary and Gaps Although stroke risk factor quality of care is improving, sub- stantial gaps in primary stroke prevention care exist. 