Novel Post-Stroke Intervention Suggests Tailored Approach Can Reduce Recurrence Risk

Bernadette Boden-Albala, DrPH, MPH, the senior associate dean of research and program development, and the interim chair and a professor in the Department of Epidemiology at the NYU College of Global Public Health

Bernadette Boden-Albala, DrPH, MPH

The results of secondary analyses have suggested that culturally-tailored, skills-based strategies may be an important substitute for knowledge-focused approaches in order to sustain vascular risk reduction and prevent recurrence in patients with stroke and transient ischemic attack (TIA).

A randomized clinical trial including more than 500 patients found that a culturally-tailored, skills-based discharge program with follow-up led to a nonsignificant systolic blood pressure (BP) reduction of 2.5 mm Hg after 1 year compared to usual care, with a significant systolic BP reduction among a subgroup of Hispanic individuals.¹

Led by Bernadette Boden-Albala, DrPH, MPH, the senior associate dean of research and program development, and the interim chair and a professor in the Department of Epidemiology at the NYU College of Global Public Health, the investigators developed an interactive behavioral intervention delivered by a community health coordinator at the time of discharge, with 3 reinforcement phone calls. The Discharge Strategies for Reduction of Vascular Events (DESERVE) intervention, was borne out of a mandate from resulting engagement from a previous trial in stroke preparedness, the SWIFT study.²

The team of investigators randomized 552 patients with mild/moderate stroke or TIA 1:1 to either the intervention arm (n = 274) or the usual care arm (n = 278), of which 478 were included in the intent-to-treat analysis. Patients in the intervention arm were slightly younger (63.3 years vs. 65.9 years; P = .02), though the groups were well balanced overall. Patients were assessed by reductions in systolic BP, as it has been shown to be a strong predictor of stroke.³

Ultimately, the mean (standard deviation [SD]) reduction in systolic BP at 12 months was 7.0 mm Hg (SD, 25.5) for the intervention arm compared to 4.3 mm Hg (SD, 23.4) in the usual care group for a difference of 2.5 mm Hg (95% CI, —1.9 to 6.9). Although, as Boden-Albala and colleagues noted, the intervention arm had an almost 10 mm Hg-greater mean reduction in systolic BP compared with usual care among Hispanic participants (difference, 9.9; 95% CI, 1.8 to 18.0; P = .05).

In an accompanying editorial,⁴ Joosup Kim, PhD, and Amanda G. Thrift, PhD, wrote that although “there have been numerous studies on managing risk factors after stroke, this is one of few targeted at disadvantaged populations. Patients in the intervention arm were reminded and followed up about physician visits, while the education component aimed to enhance patient-physician contact.”

Boden-Albala and colleagues also examined whether or not there was a dose-response relationship in the intervention arm between systolic BP reduction and participation in the 3 follow-up calls, of which 67.2% (n = 184) received all 3 calls. Additionally, 15% (n = 41) had 2 calls, 6.2% (n = 17) received 1 call, and 11.7% (n = ) received no calls. It appeared that each additional follow-up call was associated with a greater mean reduction in systolic BP, with those receiving all 3 calls having a mean reduction of 8.3 mm Hg, compared to 6.1 mm Hg and 0.4 mm Hg for those receiving 2 and 1 calls, respectively (F = .77; P = .51).

Overall, those who received the full intervention had a greater reduction compared with those who received the partial intervention of fewer than 3 calls (8.3 vs 3.5 mm Hg; t = −1.32; P = .19).

As the authors acknowledged, Hispanic individuals in the United States commonly have low stroke-specific health literacy, and thus are less likely to be aware of their status related to several stroke-related risk factors. As this assessed intervention appeared to have a significant impact on a subgroup of these patients, the authors noted it may be due to “specific components of the intervention design that address some of these gaps.”

“The intervention included English and Spanish materials and bilingual coordinators delivering the intervention who were ethnically concordant with participants whenever possible,” they wrote. “Among Hispanic individuals, our culturally tailored stroke survivorship narrative video developed in partnership with community members framed recovery in the context of faith and spirituality, in contrast to the video for African American individuals, which presented recovery after stroke as a matter of self-determination. Importantly, DESERVE educational materials also focused on building patient-physician communication skills, which are a documented barrier to care among Hispanic individuals.”

REFERENCES

1. Boden-Albala B, Goldmann E, Parikh NS, et al. Efficacy of a discharge educational strategy vs standard discharge care on reduction of vascular risk in patients with stroke and transient ischemic attack: the DESERVE randomized clinical trial. JAMA Neurol. Epub October 8, 2018. doi: 10.1001/jamaneurol.2018.2926.

2. Boden-Albala B, Stillman J, Roberts ET, et al. Comparison of acute stroke preparedness strategies to decrease emergency department arrival time in a multiethnic cohort: the Stroke Warning Information and Faster Treatment Study. Stroke. 2015;46(7):1806-1812. doi:10.1161 /STROKEAHA.114.008502.

3. Lindenstrøm E, Boysen G, Nyboe J. Influence of systolic and diastolic blood pressure on stroke risk: a prospective observational study. Am J Epidemiol. 1995;142(12):1279-90. doi: 10.1093/oxfordjournals.aje.a117595.

4. Kim J, Thrift AG. A promising skills-based intervention to reduce blood pressure in individuals with stroke and transient ischemic attack. JAMA Neurol. Epub October 8, 2018. doi: 10.1001/jamaneurol.2018.2935.