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CDA 11-262 – HSR&D Study

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CDA 11-262
Improving Cerebrovascular Risk Factor Management in Post-Stroke Veterans
Jason Sico MD MHS
VA Connecticut Healthcare System West Haven Campus, West Haven, CT
West Haven, CT
Funding Period: August 2014 - July 2018

BACKGROUND/RATIONALE:
Background: Over 6,000 Veterans are admitted with an acute ischemic stroke annually within the VA Healthcare System, whereas nearly 25% of all strokes are recurrent events. Most Veterans receive their post-stroke risk factor management within VA Primary Care and Patient Aligned Care Teams (PACTs). Recurrent strokes are a leading cause of disability and death within our Veteran population. Effective, guideline concordant management of such important cerebrovascular risk factors as hypertension, diabetes, hyperlipidemia, atrial fibrillation, and carotid artery disease, is the cornerstone of secondary stroke prevention.

Recent VA/DoD and American Heart Association/American Stroke Association (AHA/ASA) guidelines recommend addressing cerebrovascular risk factors among all eligible stroke patients. The most prevalent and robust, modifiable risk factor is hypertension. Optimizing vascular risk factor control, especially hypertension control, has been shown to decrease morbidity and mortality, especially during the six-month post-stroke period, when most stroke and non-stroke related hospitalizations and deaths occur. Therefore, focusing on prevention of future strokes by designing and implementing strategies to effectively treat hypertension among Veterans with stroke is necessary to improve outcomes in this population.

OBJECTIVE(S):
Objectives: To develop a theory-based cerebrovascular risk factor improvement pilot intervention within the post-stroke Veteran population, we wish to identify patient-, provider-, and facility-level predictors of guideline adherent management of important cerebrovascular risk factors (i.e., hypertension, diabetes, hyperlipidemia, atrial fibrillation, carotid artery disease), and use a consolidated measure of cerebrovascular risk factor management, based on a review of medical records six-months post-stroke, to rank sites as "best" to "worse" facilities in terms of quality of care. After this ranking is obtained, we will identify potential barriers and facilitators to "best" vascular risk factor management by conducting semi-structured interviews among patients, providers, and administrators at "best" and "worse" VAMCs. Themes identified through these formative evaluations will be used to develop a theory-based "cerebrovascular risk factor improvement" pilot intervention. This intervention will then be piloted at a single, worse performing VAMC in regards to vascular risk factor control, and its feasibility and acceptability will be assessed.

METHODS:
Methods: Predictors of "best" cerebrovascular risk factor management were identified using the VHA Administrative data. A consolidated measure was developed using hierarchical modeling to rank VAMCs as "best" to "worst" regarding management of cerebrovascular risk factors. Facility-level pass rates were examined for each individual risk factor (e.g., hypertension) as well. Semi-structured interviews of providers, and administrators were conducted at better and worse performing sites to understand barriers and facilitators to optimal risk factor control. Transcribed data were placed into an NVivo 10 file, and the constant comparison technique utilized to identify themes, which informed the development of a post-stroke hypertension improvement intervention. The Consolidated Framework for implementation research will be used in the development, implementation, and the evaluation of the intervention.

FINDINGS/RESULTS:
Not yet available.

IMPACT:
Impact: Interventions that improve management of common and important cerebrovascular stroke risk factors are necessary to prevent recurrent strokes. Identifying predictors of "best" cerebrovascular risk factor management and understanding potential barriers and facilitators can help to inform the development of an intervention, whereas implementation science strategies can assess its uptake and sustainability. Potential benefits of this body of work to the Veteran population with stroke involve the improvement of risk factor care and the associated reduction in vascular events, and their associated morbidity and mortality.

A more proximal benefit that may be achieved as a result of the planned work is an understanding of key aspects of the culture of collaboration between specialists and generalists, including care coordination and communication. This understanding may be generalizable beyond the stoke population. For example, if our results indicate a need to better integrate neurology care within existing PACT structures, these findings would be relevant not only for stroke patients but also potentially to patients with other chronic neurological conditions (e.g., traumatic brain injury [TBI]) which require effective collaboration, coordination, and communication between specialists and generalists.

Another benefit of the planned work involves gaining insight into how existing Primary Care and PACT approaches to risk factor management may be maximized for the specific post-stroke population. Such insight may also inform interventions that improve vascular risk factors in other patient populations (e.g., Veterans with ischemic heart disease). Work accomplished through this HSR&D Implementation Science CDA may also be generalizable to other populations within VA Primary Care/PACT.

This body of work also has potential benefits for the field of Implementation Science. We plan to conduct a rigorous, theory-based evaluation of the implementation of a cerebrovascular risk factor management intervention. By identifying theoretical framework domains that promote the effective and sustainable implementation of the intervention, and incorporating the use of systems redesign concepts to identify areas of non-value within post-stroke risk factor care, the findings of the single site pilot study can inform a larger implementation project. Through the course of developing the intervention, information that can be generalizable across disease states may be obtained; as we are investigating a disease process (acute ischemic stroke) where multiple care givers are involved, the lessons we learn about the culture of collaboration, coordination, and communication between specialists and generalists may translate to other chronic conditions that utilize a multidisciplinary approach. In examining the Consolidated Framework for Implementation Research (CFIR) conceptual framework, we may understand which intervention characteristics are most important in implementing a feasible and acceptable intervention.

PUBLICATIONS:

Journal Articles

  1. Sico JJ, Baye F, Myers LJ, Concato J, Ferguson J, Cheng EM, Jadbabaie F, Yu Z, Arling G, Zillich AJ, Reeves MJ, Williams LS, Bravata DM. Receipt of cardiac screening does not influence 1-year post-cerebrovascular event mortality. Neurology. Clinical practice. 2018 Jun 1; 8(3):192-200.
  2. Sico JJ, Myers LJ, Fenton BJ, Concato J, Williams LS, Bravata DM. Association between admission haematocrit and mortality among men with acute ischaemic stroke. Stroke and vascular neurology. 2018 Sep 1; 3(3):160-168.
  3. Sico JJ, Yaggi HK, Ofner S, Concato J, Austin C, Ferguson J, Qin L, Tobias L, Taylor S, Vaz Fragoso CA, McLain V, Williams LS, Bravata DM. Development, Validation, and Assessment of an Ischemic Stroke or Transient Ischemic Attack-Specific Prediction Tool for Obstructive Sleep Apnea. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2017 Aug 1; 26(8):1745-1754.
  4. Bravata DM, McClain V, Austin C, Ferguson J, Burrus N, Miech EJ, Matthias MS, Chumbler N, Ofner S, Foresman B, Sico J, Vaz Fragoso CA, Williams LS, Agarwal R, Concato J, Klar Yaggi H. Diagnosing and managing sleep apnea in patients with chronic cerebrovascular disease: a randomized trial of a home-based strategy. Sleep & Breathing = Schlaf & Atmung. 2017 Sep 1; 21(3):713-725.
  5. Chaturvedi S, Ofner S, Baye F, Myers LJ, Phipps M, Sico JJ, Damush T, Miech E, Reeves M, Johanning J, Williams LS, Arling G, Cheng E, Yu Z, Bravata D. Have clinicians adopted the use of brain MRI for patients with TIA and minor stroke? Neurology. 2017 Jan 17; 88(3):237-244.
  6. Rattray NA, Sico JJ, Cox LM, Russ AL, Matthias MS, Frankel RM. Crossing the Communication Chasm: Challenges and Opportunities in Transitions of Care from the Hospital to the Primary Care Clinic. Joint Commission Journal on Quality and Patient Safety. 2017 Mar 1; 43(3):127-137.
  7. Sico JJ, Phipps MS, Concato J, Brandt C, Wells CK, Lo AC, Nadeau SE, Williams LS, Gorman M, Boice JL, Bravata DM. Using Radiological Data to Estimate Ischemic Stroke Severity. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2016 Apr 1; 25(4):792-8.
  8. Koo BB, Bravata DM, Tobias LA, Mackey JS, Miech EJ, Matthias MS, Stahl SM, Sico JJ, Vaz Fragoso CA, Williams LS, Lampert R, Qin L, Yaggi HK. Observational Study of Obstructive Sleep Apnea in Wake-Up Stroke: The SLEEP TIGHT Study. Cerebrovascular Diseases (Basel, Switzerland). 2016 Jan 27; 41(5-6):233-41.
  9. Stahl SM, Yaggi HK, Taylor S, Qin L, Ivan CS, Austin C, Ferguson J, Radulescu R, Tobias L, Sico J, Vaz Fragoso CA, Williams LS, Lampert R, Miech EJ, Matthias MS, Kapoor J, Bravata DM. Infarct location and sleep apnea: evaluating the potential association in acute ischemic stroke. Sleep Medicine. 2015 Oct 1; 16(10):1198-203.
  10. Sico JJ, Chang CC, So-Armah K, Justice AC, Hylek E, Skanderson M, McGinnis K, Kuller LH, Kraemer KL, Rimland D, Bidwell Goetz M, Butt AA, Rodriguez-Barradas MC, Gibert C, Leaf D, Brown ST, Samet J, Kazis L, Bryant K, Freiberg MS, Veterans Aging Cohort Study. HIV status and the risk of ischemic stroke among men. Neurology. 2015 May 12; 84(19):1933-40.
  11. Schmid AA, Yaggi HK, Burrus N, McClain V, Austin C, Ferguson J, Fragoso C, Sico JJ, Miech EJ, Matthias MS, Williams LS, Bravata DM. Circumstances and consequences of falls among people with chronic stroke. Journal of rehabilitation research and development. 2013 Dec 1; 50(9):1277-86.
  12. Sico JJ, Phipps MS, Concato J, Wells CK, Lo AC, Nadeau SE, Williams LS, Peixoto AJ, Gorman M, Boice JL, Bravata DM. Thrombocytopenia and in-hospital mortality risk among ischemic stroke patients. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2013 Oct 1; 22(7):e99-e102.
  13. Sico JJ, Concato J, Wells CK, Lo AC, Nadeau SE, Williams LS, Peixoto AJ, Gorman M, Boice JL, Bravata DM. Anemia is associated with poor outcomes in patients with less severe ischemic stroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2013 Apr 1; 22(3):271-8.
Conference Presentations

  1. Sico JJ, Myers L, Williams LS, Bravata DM. Coronary Heart Disease Screening: Are Ischemic Stroke Patients Receiving Guideline Concordant Care? Poster session presented at: American Neurological Association Annual Meeting; 2014 Oct 12; Baltimore, MD.
  2. Sico JJ, Bravata DM. Coronary Heart Disease Screening: Are Ischemic Stroke Patients Receiving Guideline Concordant Care? Poster session presented at: American Heart Association Annual Scientific Sessions; 2013 Nov 18; Dallas, TX.
  3. Sico J. The Association of Hematocrit and Mortality among Ischemic Stroke Patients. Paper presented at: American Neurological Association Annual Meeting; 2013 Oct 15; New Orleans, LA.


DRA: Mental, Cognitive and Behavioral Disorders, Aging, Older Veterans' Health and Care, Cardiovascular Disease
DRE: Treatment - Observational, Technology Development and Assessment
Keywords: Career Development
MeSH Terms: none

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