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PPO 15-404 – HSR&D Study

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PPO 15-404
Hypertension Improvement Pilot Intervention in Post-Stroke Veterans
Jason Sico MD MHS
VA Connecticut Healthcare System West Haven Campus, West Haven, CT
West Haven, CT
Funding Period: September 2017 - February 2019

BACKGROUND/RATIONALE:
Over 6,000 Veterans are admitted with an acute ischemic stroke annually within the VA Healthcare System. Nearly 25% of all strokes are recurrent events and constitute a leading cause of disability and death within our Veteran population, especially among the 75% of Veterans with stroke and hypertension.
Current VA/DoD and American Heart Association/American Stroke Association (AHA/ASA) guidelines stress the importance of delivering guideline concordant management of hypertension, given the strong association between goal blood pressure and decreased morbidity and mortality, especially during the six-month poststroke period, when most stroke and non-stroke related hospitalizations and deaths occur. Previous Quality Enhancement Research Initiative (QUERI) work has shown that many Veterans 6-months after their stroke do not have their blood pressure optimally controlled. Most Veterans receive their post-stroke risk hypertension care within VA Primary Care and Patient Aligned Care Teams (PACTs). Work performed during the current Health Services Research and Development (HSR&D) Career Development Award (CDA) period has identified
several areas for intervention that can assist outpatient providers in Primary Care/PACT to better manage hypertension using existing VA infrastructure, and has led to the development of a bundled, evidence-based, 'Post Stroke Hypertension Improvement Intervention.' Therefore, focusing on prevention of future strokes by implementing an intervention to effectively treat hypertension among Veterans with stroke is necessary to improve outcomes in this population.

OBJECTIVE(S):
To: (1) evaluate the feasibility and acceptability of a pilot intervention, implemented at a single VAMC providing suboptimal blood pressure management to post-stroke Veterans, during the 'high-risk,' 6-month period post-stroke, such that a more refined intervention can be developed and further informed by key
stakeholders, end users, and strategic partners; and (2) collect metrics related to hypertension control at the intervention and four control sites.

METHODS:
A pilot will be initiated within the VA North Texas Health Care System, Dallas campus. The Consolidated Framework for Implementation Research (CFIR) conceptual framework and Systems Redesign strategies will be used to
evaluate the implementation of the intervention.

The feasibility and acceptability of the implementation strategy will be assessed via qualitative interviews with end users of the intervention. Blood pressure will be measured at baseline, 3-months, and 6-months. The distributions and central tendencies of baseline demographic and patient-, provider-, and facility-level characteristics for continuous variables will be examined graphically and by summary statistics. Categorical variables will be examined by calculating frequency distributions. We will match, based on patient volume and mean facility-level blood pressure, our intervention and three virtual control sites (Houston, TX; Little Rock, AK; San Juan, PR).

VA Connecticut Healthcare System, West Haven campus will serve as the coordinating center with additional implementation science and qualitative research expertise to be provided by the Richard L. Roudebush VAMC.

FINDINGS/RESULTS:
In the 6-months prior to implementation of the intervention, 21% of Veterans discharged from the VA North Texas Healthcare System had obtained optimal blood pressure control in the 6-months after discharge. No patients were offered telehealth services for blood pressure monitoring. No patients were co-managed by a PACT-embedded clinical pharmacist.

As of 10/3/2018, 57 patients have been the recipient of the "CAre Transitions and Hypertension" management program. All patients have been discharged with primary care and PACT-clinical pharmacy appointments. Eleven of the 57 (19.3%) patients have been enrolled in home telehealth for blood pressure monitoring.

As this is a provider-level intervention, 51 providers (primary care providers, neurologists, clinical pharmacists) have been enrolled in the project.

In the 6-months prior to project implementation, facility-level blood pressure control among stroke survivors at our virtual control sites was comparable to VA North Texas (Houston, TX - 17%; Little Rock, AK - 22%, and San Juan, PR - 20%).


IMPACT:
Interventions that improve management of hypertension among Veterans with ischemic stroke are necessary to prevent recurrent strokes; implementation science strategies using Lean Six Sigma/Systems Redesign approaches can assess the uptake and sustainability of this intervention.

We believe that we can: (1) determine the feasibility and acceptability of a pilot intervention designed to improve post-stroke hypertension control 6-months after discharge; and (2) collect metrics related to hypertension control among Veterans participating in the intervention and four control sites to estimate effect
size for a future, larger trial.

We plan on submitting an HSR&D IIR proposal implementing the CATcH program for ischemic stroke for the June 2019 cycle.

PUBLICATIONS:
None at this time.


DRA: Brain and Spinal Cord Injuries and Disorders, Cardiovascular Disease
DRE: Treatment - Observational, Prognosis
Keywords: Cardiovascular Disease, Patient-Provider Interaction, Stroke
MeSH Terms: none