The Self-management TO Prevent - (STOP) Stroke program delivered onsite at the Michael E. DeBakey VA Medical Center is overwhelming endorsed by participants. While satisfactions scores are high, attendance rates are low at 45%. Travel distance to the main VA facility has been identified as the primary barrier to participation. Moreover, 32% of participants report receiving primary care services at a satellite Community Based Outpatient Clinic (CBOC). Thus, telehealth solutions may improve access to the STOP Stroke Program to reach rural veterans that receive primary care services at a CBOC. Video Teleconference (VT) delivery is one form of telehealth whereby a synchronous, two-way audio and visual connection is made between two or more sites.
The overall objective of this pilot study was to explore the feasibility of using a VT delivery model to improve access to the STOP Stroke Program. Hence, the VT program is called V-STOP. We sought to: (1) determine barriers and facilitators to the implementation of V-STOP (2) describe the effects of V-STOP on access, attendance, acceptability, patients' knowledge about stroke risk, self-management behaviors, self-efficacy, and quality of life (QOL), and (3) determine effect sizes and measurement strategies for a subsequent randomized controlled trial.
Focus group, survey, and pre/post test methods were utilized to identify factors associated with feasibility and effectiveness of implementation. A sample of (N=37) veterans with a history of stroke, transient ischemic attack, or with multiple stroke risk factors were recruited from two CBOCs in a two-phase study. During phase-one, veterans (n=13) were recruited equally from both CBOC sites to participate in V-STOP as initially designed. After completion of the intervention, focus groups were conducted with participants, and clinicians completed semi-structured interviews. Direct content analysis was applied to identify system, patient, and provider barriers and facilitators to implementation. The V-STOP program was refined based on phase-one findings.
During phase-two, (n = 24) veterans were recruited from both sites to participate in the refined V-STOP program. Implementation of the intervention was evaluated in terms of program attendance, access and acceptability. Pre/post test measures as well as change scores were calculated to obtain estimates of the effectiveness of V-STOP on patients' self-management skills, stroke risk knowledge, self-efficacy, QOL, and stroke risk factor biomarkers. For continuous variables, we calculated descriptive statistics, and paired t-tests and repeated measures analyses were completed as appropriate. For categorical variables, we calculated the proportions of patients in the categories at baseline and at follow-up.
Phase-one and phase-two samples were similar in terms of demographics. Of the 13 participants enrolled in phase-one, none were lost to follow-up. Sixty-two percent were white and 38% were African American with a mean age of 60. All were male and 42 % had a high school education or higher. All had multiple chronic diseases with the top five conditions being hypertension (92%), chronic pulmonary disease (69%), arthritis (46%), diabetes (38%), and heart disease (31%). Of the 24 participants enrolled in phase-two, 5 were lost to follow up at 12-weeks, 3 were lost to follow up at 18-weeks and 1 died before the 6-week assessment. The sample was predominantly male (96%) with a mean age of 62. Seventy-one percent were white and 29% were African. Most (70%) had some college or higher and lived with at least one other person (79%). All had multiple chronic conditions with the most common being hypertension (87%), diabetes (70%), depression (58%), heart disease (54%), and arthritis (50%).
Focus group themes around implementation barriers to the V-STOP program were related to information, time, and delivery methods. Participants reported there was 'too much information' covered in the 2 VT classes and that 2.5 hours was 'too long' for a single class session. 'More specific information on diet' was consistently identified as an area of needed focus. Focus group themes around implementation facilitators of the V-STOP program were related to support, course content, and convenience. Participants reported the program provided them a 'support system', 'peer encouragement' and 'positive behavior change'. Course content was viewed as 'personalized' and 'easy to understand'. Offering the program at the CBOC sites using VT delivery was viewed as 'very convenient', 'easy to attend', 'much better than driving' to the main VA facility.
Clinicians reported two specific implementation barriers: 1) no time to assist with technology malfunctions and 2) limited clinic space to hold the VT sessions. Implementation facilitators identified by clinicians were: 1) the program made staff more aware of patients at risk for stroke, 2) provided a mechanism to help high risk patients, and 3) opened communication between patient and staff. All clinicians endorsed continuation of the V-STOP program. Identified barriers were addressed and implemented with the participants in phase-two.
Participants in phase-two saved, on average, 103 miles by traveling to a CBOC as compared to traveling to the main VA facility. The overall attendance rate for all V-STOP encounters (2 VT clinics, 3 VT classes and 1 telephone follow-up) was 87%. When compared to the STOP Stroke program delivered at the main VA facility, VT delivery showed a 42% higher attendance rate. Acceptability of the VT delivery model was scored high in terms of quality of care, similarity to in-person care, and VT interaction. Overall satisfaction with the V-STOP program was very high at 4.7 out of 5.
There were significant improvements from baseline to 18 weeks in participant's stroke risk knowledge (p = 0.0003), stroke risk scores (p= 0.0385), cognitive symptoms management (p=0.0063) and communication with healthcare providers (p=0.001). Action plan attainment was significantly improved from week-3 to week-4 (p = 0.043) and from week-3 to week-5 (p=0.022). While no significant change in exercise behavior was observed, both aerobic and stretching activities increased. There were overall decreases in calorie and sodium intake but these changes were not significant. The sample demonstrated high baseline scores for functional status, social activity and QQL and no significant changes were observed in these measures. This was also the case for self-efficacy scores and no significant change in participants' self-efficacy was observed.
No significant changes were observed in stroke risk factor biomarkers from baseline to 12 and 18 weeks. All participants with hypertension and diabetes were on appropriate medications and mean baseline blood pressure (120/71) and hemoglobin A1C (6.9) values showed that the sample was well controlled in terms of hypertension and diabetes management. Of the 12% of participants with atrial fibrillation, all were appropriately managed on anticoagulation medication. The sample was obese with a mean Body Mass Index of 33.8. Twelve-percent of the sample smoked and none reported heavy alcohol consumption.
This pilot project supports the feasibility of using a VT delivery model for patient self-management education and preventative care services to reduce stroke risk factors among veterans receiving primary care services at a CBOC. We are encouraged by the significant findings of this pilot project indicating that V-STOP is not only feasible, but is also effective for improving stroke risk knowledge, self-management of symptoms associated with chronic conditions, and communication with healthcare providers. While no significant findings were observed in stroke risk factor biomarkers, we gained valuable insight on how to collect these data for our future comparative effectiveness study. We will apply these finding to determine an appropriate sample size and to design a data collection protocol that will effectively capture stroke risk factor biomarkers.
- Anderson JA, Willson P, Godwin KM, Peterson NJ, Kent T. Use of a Clinical Video Teleconference (CVT) Technology Model to Implement Patient Self-Management to Prevent Stroke. The Internet Journal of Advanced Nursing Practice. 2014 Sep 1; 13(1):ispub.com/IJANP/13/1/15930.
- Anderson J, Godwin KM, Petersen NJ, Willson P, Kent TA. A pilot test of videoconferencing to improve access to a stroke risk-reduction programme for Veterans. Journal of telemedicine and telecare. 2013 Apr 1; 19(3):153-159.
- Satterfield G, Anderson J, Moore C. Evidence supporting the incorporation of the dietary approaches to stop hypertension (DASH) eating pattern into stroke self-management programs: a review. The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses. 2012 Oct 1; 44(5):244-50; quiz 251-2.
- Anderson JA, Saleem J, Russell S, Nedo A, Kimmel B, Robinson J, Merchant M. Usability testing the self-management TO prevent stroke tool. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2011 Mar 1; 42(3):e237.
- Anderson JA. Video Teleconference Technology to Implement Patient Self-management TO Prevent Stroke. Paper presented at: American Heart Association / American Stroke Association International Stroke Conference; 2012 Feb 1; New Orleans, LA.
- Anderson JA, Petersen N, Willson P. Feasibility of Implementing Videoteleconference Self-management TO Prevent Stroke. Presented at: Sigma Theta Tau International Honor Society of Nursing Biennial Convention; 2011 Oct 28; Grapevine, TX.
- Anderson JA, Saleem J, Russell S, Nedo A, Kimmel B, Robinson J, Merchant M. Usability Testing the Self-management TO Prevent Stroke Tool. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2011 Feb 8; Los Angeles, CA.
- Anderson J, Rittman M, Willson P, Vogel B, Heesaker M, Vega-Trujillo M. Using telehealth modalities to implement a Transition Assistance Program (TAP) for ethnically diverse stroke caregivers. Presented at: VA Telehealth 2010 and Beyond Conference on Expanding Patient-Centric Care; 2010 May 12; St. Louis, MO.