Systematic Use of STroke AvertingINterventions (SUSTAIN) Trial‘Stay With the Guidelines’LA County DHSAmytis Towfighi, MD (...
Project Description: Background and Research QuestionsResearch Question #1:Does a Chronic Care model-based intervention me...
1st NP/PA call/clinic visit• Assess medication sideeffects, adherence• Adjust meds per protocol• Personalized action plan•...
Accomplishments/OutcomesCurrent Status:SUSTAIN trial enrollment was completed in summer 2012; trial isongoing through foll...
Scale and Spread1. Protocols for NP/PA stroke prevention caremanagement is gearing up for broad implementationinto the Str...
What is NextApplication submitted to NIH in April 2012 was successful; programincludes funding of a trial building on prel...
Lessons for Others1. Protocols for effective in-hospital recruitment in the LADHS medical centers2. Multiple strategies yi...
Added Value from CTSI FundingWithout the CTSI funding, we would not havebeen able to recruit the full study sample sizeand...
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Systematic Use of STroke Averting INterventions (SUSTAIN) Trial

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This study, which is also funded by the American Heart Association, will assess whether lifestyle group clinics, care managers and support from community health workers may reduce the risk of a second stroke in socioeconomically disadvantaged minority patients.

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Systematic Use of STroke Averting INterventions (SUSTAIN) Trial

  1. 1. Systematic Use of STroke AvertingINterventions (SUSTAIN) Trial‘Stay With the Guidelines’LA County DHSAmytis Towfighi, MD (Rancho LA-NRC)Lillie Hudson, PA, MPH (USC/RLANRC)Nerses Sanossian, MD (USC)Tom Anderson, MD (Harbor-UCLA)Robert Bryg, MD (Olive View-UCLA)Jeff Guterman, MD (Amb Care Network)Sandra Gross-Schulman, MD, MPH, RNUCLA: SOM, Dentistry, Public HealthBarbara Vickrey, MD, MPH, PI (Presenter)Eric Cheng, MD, MS, Co-PIWilliam Cunningham, MD, MPH, Co-ISusan Ettner, PhD, Health EconomicsHonghu Liu, PhD, BiostatisticsBrian Mittman, PhD, ImplementationCommunityLocal AHA - Sylvia BeanesHealthy African AmericanFamilies II/Drew University –Andrea JonesPartners In Care FoundationWatts Labor Community ActionCommittee – Phyllis WillisAlso funded by American Heart Association
  2. 2. Project Description: Background and Research QuestionsResearch Question #1:Does a Chronic Care model-based intervention meaningfully reduce risk ofstroke through improved control of multiple stroke risk factors, compared tousual care, among socio-economically disadvantaged patients dischargedfollowing ischemic stroke or transient ischemic attack, at 4 Los AngelesCounty safety net hospitals?Research Question #2:Is such an intervention feasible to implement and sustainable – particularlywith respect to cost - in a safety net healthcare system?Stroke is the leading cause of disability & 3rd leading cause of death in USYet, control of risk factors ((BP, cholesterol, physical activity, diet, aspirin,smoking cessation) enormously reduces recurrent stroke riskHowever, risk factor control to prevent another stroke is poor and worse forsocioeconomically disadvantaged minorities due to multiple barriers:• 1 in 8 Latino elders in LA public healthcare system have no education• Substantial transportation barriers in city with no good masstransit options• Lack of access to outpatient primary care after discharge• Wait times for outpatient neurology clinic were ~ 6 months• Lifestyle changes (activity, diet, smoking) are better addressedthrough approaches not offered in traditional physician visits
  3. 3. 1st NP/PA call/clinic visit• Assess medication sideeffects, adherence• Adjust meds per protocol• Personalized action plan• Home blood pressuremonitorSUSTAIN Intervention+ Usual Care (N = 205)NP/PA Phone Call(at 1 week) & ClinicVisit (at 1 month)1stGroup Clinic(at 2 months)2ndGroup Clinic(at 5 months)NP Clinic Visit(at 7 months)3rdGroup Clinic(at 10 months)One timedelivery ofeducationmaterials +Usual Care(N = 205)TelephoneCoordinationofCare/TrackingregistryRandomize Patients in 1:1 ratio (N = 410)Usual Inpatient Care1st Group clinic• NP/PA or dietician/OT ledstroke interactive seminar• Medication adherence**• Neuroimaging tool; reportcards• Q&A period, peerinteraction• Action plan refined bypatient and NP/PA duringbrief one-on-one sessionMethods: SUSTAIN Randomized Controlled TrialStudyoutcomes(both arms)measuredat 3-, 8-,and 12-months
  4. 4. Accomplishments/OutcomesCurrent Status:SUSTAIN trial enrollment was completed in summer 2012; trial isongoing through follow-up of final study participant in mid-2013What We Have Learned So Far:1. It is possible to achieve high rates of recruitment and high levels of12-month follow-up interviews (~75-80% of eligibles to date)through in-hospital recruitment and multiple approaches toidentifying ways to contact participants.2. Care managers (nurse practitioners,physician assistants) working within/at themedical centers and using stroke prevention-specific decision support can effectivelyfocus on medication management, butpatient load needs to be higher to besustainable.3. Patients who attend the group clinicsendorse their value for lifestyle changes indiet and physical activity, but participation is< 50% due mainly to transportation barriers.
  5. 5. Scale and Spread1. Protocols for NP/PA stroke prevention caremanagement is gearing up for broad implementationinto the Stroke Medical Home at Rancho Los AmigosNational Rehabilitation Center2. Repatriation of patients hospitalized for acute stroke atother hospitals into DHS system for outpatient follow-up is occurring due to protocols established underSUSTAIN3. The NP/PA care management component within thehealthcare delivery system of medical centers will be acomponent of the subsequent SUCCEED trial (teamingwith community health workers)
  6. 6. What is NextApplication submitted to NIH in April 2012 was successful; programincludes funding of a trial building on preliminary SUSTAIN findings:• “SUCCEED” – Secondary stroke prevention by UnitingCommunity and Chronic care model teams Early to EndDisparities• SUCCEED began September 30, 2012 and is funded throughAugust 31, 2017.• Builds on SUSTAIN implementation findings on transportationand other barriers for lifestyle group clinics and pragmatic needfor higher caseloads for care managers, by incorporatingcommunity health workers (CHW) for: Chronic disease self-managementprograms delivered in thecommunity Home visits Mobile health technologySUCCEED will have much greater involvement of current communitypartners (WLCAC, AHA) plus new partners (Worker EducationResource Center, Esperanza CHC, Chinatown Service Center, others)CHW
  7. 7. Lessons for Others1. Protocols for effective in-hospital recruitment in the LADHS medical centers2. Multiple strategies yielding effective retention of studyparticipants3. Strategy for teaching about cardiovascular diet in smallgroup setting and in both English and Spanish• Reading nutrition labels; use of “props”• Involvement of family• Culturally sensitive education4. Practical algorithms for care managers in strokeprevention; logic algorithms for programming intodecision support tools5. Recommendations and standardized training procedurefor blood pressure and lipid measurement for healthservices research intervention studies, and for homeblood pressure monitors for stroke patients
  8. 8. Added Value from CTSI FundingWithout the CTSI funding, we would not havebeen able to recruit the full study sample sizeand would have had insufficient power for ourstudy aims.

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