Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED)

Abstract

BackgroundRecurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population.Methods/designIn this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care.DiscussionIf this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings.Trial registrationClinicalTrials.gov Identifier NCT01763203.

Antihypertensive drug use and blood pressure control among stroke survivors in the United States: NHANES 2003‐2014

“…While the linear trends were significant for older adults and White stroke survivors, results were not significant younger patients and subgroups of Black or other race. To address these unmet needs of the stroke survivors not at goal, interventions such as health care professional led case management, self‐monitoring, and integrated care approach might serve as effective strategies.…”

A trial-based economic evaluation of the Restore4Stroke self-management intervention compared to an education-based intervention for stroke patients and their partners

“…To our knowledge, this the first full economic evaluations of self-management intervention for post stroke patients. Although the importance was recognised [9,35] and ongoing studies are identified [36][37][38][39], no economic evaluation relating to this topic was published yet. The USER-Participation scores were significant different between the two groups, this does not account for UPCC, Utilities and QALYs.…”

Cardiovascular Risk Factor Burden in Veterans and Non-Veterans with Parkinson Disease

“…To the degree that each of these goals reflect ongoing priorities among the broader PD research community, developing and trialing interventions to improve the burden of cardiovascular comorbidities among PD patients within the VA Health System may be a large scale goal worth considering. Although multidisciplinary care for PD is universally lauded [35–37], the coordination for such care for patients with chronic health conditions in the United States is generally limited [38]. The VA health system differs from this fractured model in its use of a centralized health care administration, a single electronic medical record, and strong emphasis on delivery of primary and preventative care [39].…”