Abstract 251: The Association Between Receipt of Healthcare Services and Post-stroke Hypertension Control

Abstract

Hypertension is a known risk factor for primary as well as recurrent stroke. Improving blood pressure (BP) control has been associated with decreased risk of recurrent stroke. Several factors have been associated with poor BP control among stroke patients such as non-compliance and clinical inertia. We examined the receipt of health care services by patients in the one-year period following discharge for ischemic stroke. This was a retrospective cohort study of patients who were admitted for acute ischemic stroke at a Veterans Affairs hospital during year 2011 and who were discharged with a BP >140/90 mmHg. The following were reviewed: primary care visits; sub-specialty clinic visits; emergency department (ED) visits; hospitalizations; utilization of ancillary care (i.e., telehealth, pharmacy, nutrition services); medications upon discharge; adherence to medications and occurrence of recurrent stroke during the one-year post-discharge period. The cohort included 124 patients with an average age of 66.4 years (± standard deviation of10.3); 123 were male; 62.9% were white; diabetes mellitus was present in 32.5%; and 13.0% had history of coronary artery disease. The average BP at the time of discharge from the index stroke hospitalization was 149.5/82.6 (±11.3/9.8) mmHg. Only 38.7% of patients had an average BP over the one year period of <140/90 mmHg. The average number of primary care visits during this period was 2.8 (±1.6). The overwhelming majority of patients had at least one primary care visit (N=119, 95.9%) however the median time from discharge to the first primary clinic visit was 32 days (IQR 59). Forty four percent of patients were seen as outpatient by neurology, 19.4% by cardiology, 9.7% by nephrology, 5.7% by nutrition, 23.4% by clinical pharmacy, and 9.7% by the telehealth service. BP monitors were issued to or being used by 39.5% patients. Non-adherence was documented in the medical record as an interfering issue in 25.8% of patients. More than two antihypertensive agents were prescribed at discharge in 50.8% patients. During the one-year post-discharge period 29.0% of patients were hospitalized at least once and 24.2% had at least one ED visit. Recurrent stroke occurred in 3.2% of patients. The stroke rate was 4.23% among patients with uncontrolled BP compared with 2.08% among patients with well-controlled BP (p=0.40). This indicates that patients with elevated BP at the time of discharge from an ischemic stroke hospitalization remain with poorly controlled BP in the year post-discharge. Although patients appear to be receiving primary care services, these visits are not successfully achieving BP control. Relative underuse of certain resources for hypertension management such as ancillary services and home BP monitoring is observed.Future intervention studies seeking to improve the hypertension management of post-stroke patients should address these observed gaps in care.