Health Services Research & Development

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Spotlight on Stroke

May 2019

Every year, approximately 800,000 people in the United States have a stroke. More than 600,000 of these are new strokes, with nearly 1 of 4 occurring in people who have had a stroke previously. Almost 90% are ischemic strokes, in which a narrowing or blockage of blood vessels restricts blood flow to the brain1. The remainder are hemorrhagic strokes, wherein a blood vessel in the brain ruptures or leaks.2 Approximately 15 to 30 percent of stroke survivors are left with severe disability while 40 percent experience moderate functional impairments. Transient ischemic attack (TIA), also called mini-stroke, is when blood flow is disrupted temporarily and is a warning sign for future stroke3.

Approximately 6,000 Veterans per year are admitted to VA facilities with a stroke, and Veterans receive approximately 60,000 stroke related outpatient visits annually4. VA spends more than $250 million every year to care for Veterans with acute strokes3.

Following are examples of research and treatment HSR&D is implementing to improve the lives of Veterans with stroke, and help them control risk factors that can lead to subsequent strokes.

Spanish Online and Telephone Intervention for Caregivers of Veterans with Stroke

Spanish Online & Telephone Intervention for Caregivers of Veterans with Stroke

© iStock/oonal

Stroke is major cause of disability and a leading cause of outpatient medical utilization within VA. Family members are often the major sources of support for stroke survivors. Unlike other chronic diseases, strokes occur suddenly, and family members have little time to prepare and adjust to their new caregiving roles. Previous research has found that family members, particularly Hispanics, have high rates of depression and burden when their stroke survivors return home. Problem-solving telephone support and web-based learning have been shown to be effective stroke caregiver support tools.

This study builds on a decade-long stroke caregiving program of research that started with a project funded through VA HSR&D’s Quality Enhancement Research Initiative (QUERI) service directed project (SDP). The purpose of the initial study, was to develop, implement, and evaluate web-based informational materials linked with My HealtheVet for both formal and informal stroke caregivers. This study resulted in the Resources & Education for Stroke Caregivers’ Understanding and Empowerment (RESCUE) website.

The Spanish Online & Telephone Intervention for Caregivers of Veterans with Stroke study seeks to test the impact of a culturally adapted Spanish telephone and online intervention using materials developed in the RESCUE site to reduce caregiver burden and depression and improve quality of life through enhanced caregiver problem solving and self-efficacy. Additional goals are to improve Veteran stroke survivors’ functional abilities and determine healthcare utilization and cost, as well as caregiver perceptions of the intervention. A sample of 290 Hispanic stroke caregivers will be randomly assigned to either an intervention or a standard care group. The intervention group will receive eight telephone/online informational tool and problem-solving sessions using the Spanish version of the VA RESCUE stroke caregiver website.

Findings:

Data is currently being collected and analyzed.

Impact:  This study is the first known randomized control trial to test a Spanish-language telephone and online intervention for caregivers in VA and addresses the need for culturally appropriate health information for an understudied population. These findings can serve as a model for caregivers of Veterans with other conditions by providing education and support and helping reduce caregiver depression and burden.

Principal Investigator: Ivette Magaly Freytes PhD, MEd is a Research Health Scientist at the Center of Innovation on Disability & Rehab Research-GNV at the North Florida/South Georgia Veterans Health System in Gainesville, FL.

This study resulted in the following publications:

None at this time.


Evaluating National Program to Improve Access to Acute Stroke Services for Rural Veterans

Evaluating National Program to Improve Access to Acute Stroke Services for Rural Veterans

VA Emergency Department staff and simulation trainers participate in the Telestroke Program go-live training at the Las Vegas VA Medical Center on January 18, 2018.

Stroke is the fourth leading cause of death in the United States. Nearly 90% are ischemic strokes, in which blood flow to the brain is blocked. Ischemic stroke is common among Veterans, accounting for more than 6,000 admissions to VA facilities and approximately 60,000 outpatient visits for stroke-related care annually. Long-term effects can include impaired vision or speech, severe weakness or paralysis, difficulties swallowing, memory loss, depression, and mood swings. Prompt access to high-quality care is crucial to limiting the damage caused by stroke.

VA’s Office of Neurology, in collaboration with VA’s Office of Rural Health, launched a National TeleStroke Program (NTSP) to improve access to acute stroke services for Veterans residing in rural communities. The NTSP uses mobile and telehealth technologies to bring acute stroke expertise to the bedside – anywhere in the country. In this way specialty care is provided by a virtual team of stroke neurologists directly to a Veteran presenting to the emergency department of a rural VA medical center or other VA facility without access to specialty stroke neurologists. One of HSR&D’s Quality Enhancement Research Initiative (QUERI) national programs, the Precision Monitoring to Transform Care (PRIS-M), is assessing the impact of the NTSP program on patient access and quality of care – and is also collecting feedback from facilities and Veterans about their level of satisfaction with this innovative service.

Findings:

  • In the first six months of operation, 94 acute Telestroke consultations were completed. Of these, 46% were diagnosed with stroke and 11% with transient ischemic attack (TIA). More than half of the Veterans receiving a Telestroke consultation were living in rural or highly rural areas.
  • The program is using iPads with FaceTime as the primary technology, and both patients and providers using the system are reporting excellent ability to see and hear each other.
  • Of those who could be reached by phone and could recall and report on the experience, the average satisfaction score on a scale of 1 to 7 (7 being the best) was 6.5.

Impact: VA facilities that partner with the NTSP have access to some of the country’s best academic stroke neurologists, enabling emergency room consultations during the critical first 60 minutes of acute stroke onset. The program is expanding across VA, with more than 25 sites currently participating. Veterans are highly satisfied with their Telestroke experience. One Veteran stated that “It felt like a personal interaction…like we were important,” and that “The Telestroke doctor seemed very knowledgeable…truly interested.” Other Veteran patients and their families were impressed with the use of technology, with one Veteran describing the virtual services as “…It was like [the Telestroke doctor] was there with me, just without being able to touch me so he used the nurses to do that.” 

Principal Investigator: Linda Williams, MD is with PRIS-M QUERI, and a Staff Neurologist and Joint Commission Primary Stroke Center Director at the Richard L. Roudebush VA Medical Center.

This study resulted in the following publications:

Damush T, Miller K, Plue L, Schmid A, Myers L, Graham G, and Williams L. National implementation of acute stroke care centers in the Veterans Health Administration: Formative evaluation of the field response. Journal of General Internal Medicine. December 2014;29(Suppl 4):845-852.


Stroke Self-Management: Effect on Function and Stroke Quality of Life

Stroke Self-Management: Effect on Function and Stroke Quality of Life

© istock/FredFroese

Approximately 60,000 Veterans had a primary outpatient encounter for stroke during FY2010. Data from VA’s Office of Quality and Performance (OQP) Stroke Study demonstrate that more than 5,000 Veterans were admitted to a VA facility for acute ischemic stroke and another 5,000 were seen at a VA urgent care or emergency department for transient ischemic attack (TIA) or mini-stroke in FY07. The total VA cost of stroke treatment was almost $315 million in FY05, with a cost per patient of over $18,000. Stroke/TIA survivors are at elevated risk for future vascular events, yet there are no systematic post-stroke programs offered widely in VA that are designed to reduce this risk and increase stroke-specific quality of life.

This study sought to test the effectiveness of a VA developed, stroke self-management program based on the Stanford Chronic Disease program. Researchers conducted a randomized trial comparing 258 stroke survivors randomly assigned to receive the stroke self-management program or usual care. A nurse facilitator delivered the intervention by telephone and included 6 bi-weekly sessions over 12 weeks followed by monthly booster sessions during weeks 13-24. Primary outcomes were patient functioning and self-efficacy, and stroke-specific quality of life. Additionally, researchers conducted an evaluation among VA clinicians, Veterans with stroke, and their caregivers to understand program implementation barriers and facilitators.

 Findings:

  • After six months, the adjusted, total stroke-specific quality of life (SSQoL) improved significantly in the intervention group compared to the control group.
  • Those with any impairment at baseline had significantly higher improvement on SSQoL physical functioning domains at six months compared to those with no impairment at the stroke event.
  • The positive mean change in patient self-efficacy to manage health and symptoms from baseline to six months had a significant positive effect on total SSQoL at six months.
  • Among Veterans using antidepressants (78% of cohort) at baseline, a significantly smaller proportion reported moderate to severe depressive symptoms compared to stroke survivors who did not use antidepressants (25% vs. 54%).
  • The intervention group showed improved knowledge of and response to stroke warning signs at three, six and 12 months.
  • Veterans reported preferences to receive telephone calls for program delivery; however, among Veterans who regularly traveled to the VA medical facility, they would visit the nurse at the VA facility for a session.

Impact: This study has produced standardized manuals for case managers and stroke survivors that may be used in the field, in the patient medical care home, and via telehealth to improve patient self-management and the health-related quality of life of stroke survivors.

Principal Investigator: Teresa M. Damush PhD is a Core Investigator at HSR&D’s Center for Health Information and Communication (CHIC), and Co-Principal Investigator at the Precision Monitoring to Transform Care (PRISM) QUERI Center.

This study resulted in the following publications:

Chen CX, Kroenke K, Stump TE, Kean J, Carpenter JS, Krebs EE, Bair MJ, Damush TM, Monahan PO. Estimating minimally important differences for the PROMIS pain interference scales: results from 3 randomized clinical trials. Pain. 2018 Apr 1; 159(4):775-782.


Hypertension Improvement Pilot Intervention in Post-Stroke Veterans

Hypertension Improvement Pilot Intervention in Post-Stroke Veterans

© istock/GlobalStock

Annually, more than 6,000 Veterans are admitted to VA healthcare facilities with an ischemic stroke. Nearly 25% of all strokes are repeated events, and more than half of all strokes are attributable to uncontrolled high blood pressure, or hypertension. Three quarters of Veterans under VA care for stroke also have high blood pressure, which can lead to stroke. Most stroke-related hospitalizations and deaths occur during the six-months after a stroke has occurred. If blood pressure can be kept within guidelines set by VA and the American Heart Association/American Stroke Association (AHA/ASA), the risk of death and additional stroke-related illness is reduced significantly, yet many Veterans don’t have well-controlled blood pressure in the six months following a stroke.

This study sought to test the feasibility of a post-stroke blood pressure improvement intervention for Veterans at the North Texas VA Health Care System, during the high-risk six-month period following a stroke. The “CAre Transitions and Hypertension” management program (CATcH) for stroke patients identifies Veterans admitted with a stroke who have uncontrolled high blood pressure – and enhances care coordination and collaboration between all of their healthcare providers, with the goal of improving blood pressure control in the critical six-month post-discharge period. This includes physicians, nurses, and clinical pharmacists in inpatient, outpatient, primary and specialty care, as well as telehealth settings. The feasibility and acceptability of CATcH will be assessed via qualitative interviews with end users of the intervention. Blood pressure was measured at the beginning of the study and at three-month, and six-month intervals, while Veterans were given primary care, neurology, telehealth, and clinical pharmacy care designed to control blood pressure.

Findings:

Thus far, study findings show that:

  • More than 100 Veterans with ischemic stroke have been the recipient of the CATcH program. At the time of discharge, all patients receive a primary care and PACT-clinical pharmacy appointment
  • Nearly 20% of participating Veterans have been enrolled in home telehealth for blood pressure monitoring.
  • Healthcare personnel and Veterans have given the CATcH program high marks regarding feasibility and acceptability of the intervention.

Impact:  

The CATcH program incorporates the implementation science practice of using quality improvement methods from Lean Six Sigma - drawing on the strengths of infrastructure already available within VA to deliver high-quality blood pressure care for Veterans. This use of existing infrastructure indicates that the program could be sustained and spread to other VAMCs and to other diseases where blood pressure is problematic, such as congestive heart failure.

Principal Investigator: Jason Sico MD, MHS, is a Core Investigator with the PRIME Center and PRIS-M QUERI, and Director of Stroke Care at VA Connecticut Healthcare System, West Haven, CT

This study resulted in the following publications:

None at this time.

References

  • Stroke Facts [Internet]. Atlanta (GA): Centers for Disease Control and Prevention; 2017 [cited 2019 April 18]. Available from: https://www.cdc.govhttps://www.cdc.gov/stroke/facts.htm/stroke/
  • Stroke [Internet]. Rochester (MN): Mayo Clinic; 2019 [cited 2019 April 24]. Available from: https://www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/syc-20350113
  • Department of Veterans Affairs, Veterans Health Administration, Treatment of Acute ischemic Stroke, VHA Directive 1155(1), Washington, DC. June 2, 2018
  • Damush T, Miller K, Plue L. National implementation of acute stroke care centers in the Veterans Health Administration: Formative evaluation of the field response. Journal of General Internal Medicine. December 2014;29(Suppl 4):845-852.