Systematic Use of STroke Averting

INterventions (SUSTAIN) Trial

‘Stay With the Guidelines’

LA County DHS

Amytis 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, RN

UCLA: SOM, Dentistry, Public Health

Barbara Vickrey, MD, MPH, PI (Presenter)

Eric Cheng, MD, MS, Co-PI

William Cunningham, MD, MPH, Co-I

Susan Ettner, PhD, Health Economics

Honghu Liu, PhD, Biostatistics

Brian Mittman, PhD, Implementation

Community

Local AHA - Sylvia Beanes

Healthy African American

Families II/Drew University –

Andrea Jones

Partners In Care Foundation

Watts Labor Community Action

Committee – Phyllis Willis

Also funded by American Heart Association

Project Description: Background and Research Questions

Research Question #1:

Does a Chronic Care model-based intervention meaningfully reduce risk of

stroke through improved control of multiple stroke risk factors, compared to

usual care, among socio-economically disadvantaged patients discharged

following ischemic stroke or transient ischemic attack, at 4 Los Angeles

County safety net hospitals?

Research Question #2:

Is such an intervention feasible to implement and sustainable – particularly

with respect to cost - in a safety net healthcare system?

Stroke is the leading cause of disability & 3rd leading cause of death in US

Yet, control of risk factors ((BP, cholesterol, physical activity, diet, aspirin, smoking cessation) enormously reduces recurrent stroke risk

However, risk factor control to prevent another stroke is poor and worse for socioeconomically 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 mass

transit 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 addressed

through approaches not offered in traditional physician visits

1st NP/PA call/clinic visit

• Assess medication side

effects, adherence

• Adjust meds per protocol

• Personalized action plan

• Home blood pressure

monitor

SUSTAIN Intervention

+ Usual Care (N = 205)

NP/PA Phone Call

(at 1 week) & Clinic

Visit (at 1 month)

1st

Group Clinic

(at 2 months)

2nd

Group Clinic

(at 5 months)

NP Clinic Visit

(at 7 months)

3rd

Group Clinic

(at 10 months)

One time

delivery of

education

materials +

Usual Care

(N = 205)

Te

lep

ho

ne

Co

ord

ina

tio

n o

f

Ca

re/T

rac

kin

g r

eg

istr

y

Randomize Patients in 1:1 ratio (N = 410)

Usual Inpatient Care

1st Group clinic

• NP/PA or dietician/OT led

stroke interactive seminar

• Medication adherence**

• Neuroimaging tool; report

cards

• Q&A period, peer

interaction

• Action plan refined by

patient and NP/PA during

brief one-on-one session

Methods: SUSTAIN Randomized Controlled Trial

Study outcomes (both arms) measured at 3-, 8-, and 12-months

Accomplishments/Outcomes Current Status:

SUSTAIN trial enrollment was completed in summer 2012; trial is

ongoing through follow-up of final study participant in mid-2013

What We Have Learned So Far:

1. It is possible to achieve high rates of recruitment and high levels of

12-month follow-up interviews (~75-80% of eligibles to date)

through in-hospital recruitment and multiple approaches to

identifying ways to contact participants.

2. Care managers (nurse practitioners,

physician assistants) working within/at the

medical centers and using stroke prevention-

specific decision support can effectively

focus on medication management, but

patient load needs to be higher to be

sustainable.

3. Patients who attend the group clinics

endorse their value for lifestyle changes in

diet and physical activity, but participation is

< 50% due mainly to transportation barriers.

Scale and Spread

1. Protocols for NP/PA stroke prevention care

management is gearing up for broad implementation

into the Stroke Medical Home at Rancho Los Amigos

National Rehabilitation Center

2. Repatriation of patients hospitalized for acute stroke at

other hospitals into DHS system for outpatient follow-

up is occurring due to protocols established under

SUSTAIN

3. The NP/PA care management component within the

healthcare delivery system of medical centers will be a

component of the subsequent SUCCEED trial (teaming

with community health workers)

What is Next

Application submitted to NIH in April 2012 was successful; program

includes funding of a trial building on preliminary SUSTAIN findings:

• “SUCCEED” – Secondary stroke prevention by Uniting

Community and Chronic care model teams Early to End

Disparities

• SUCCEED began September 30, 2012 and is funded through

August 31, 2017.

• Builds on SUSTAIN implementation findings on transportation

and other barriers for lifestyle group clinics and pragmatic need

for higher caseloads for care managers, by incorporating

community health workers (CHW) for:

Chronic disease self-management

programs delivered in the

community

Home visits

Mobile health technology

SUCCEED will have much greater involvement of current community

partners (WLCAC, AHA) plus new partners (Worker Education

Resource Center, Esperanza CHC, Chinatown Service Center, others)

CHW

Lessons for Others 1. Protocols for effective in-hospital recruitment in the LA

DHS medical centers

2. Multiple strategies yielding effective retention of study

participants

3. Strategy for teaching about cardiovascular diet in small

group setting and in both English and Spanish

• Reading nutrition labels; use of “props”

• Involvement of family

• Culturally sensitive education

4. Practical algorithms for care managers in stroke

prevention; logic algorithms for programming into

decision support tools

5. Recommendations and standardized training procedure

for blood pressure and lipid measurement for health

services research intervention studies, and for home

blood pressure monitors for stroke patients

Added Value from CTSI Funding

Without the CTSI funding, we would not have

been able to recruit the full study sample size

and would have had insufficient power for our

study aims.