Efficacy of a Chronic Care-Based Intervention on Secondary Stroke Prevention Among Vulnerable Stroke Survivors: A Randomized Controlled Trial.

BACKGROUND: Disparities of care among stroke survivors are well documented. Effective interventions to improve recurrent stroke preventative care in vulnerable populations are lacking. METHODS AND RESULTS: In a randomized controlled trial, we tested the efficacy of components of a chronic care model-based intervention versus usual care among 404 subjects having an ischemic stroke or transient ischemic attack within 90 days of enrollment and receiving care within the Los Angeles public healthcare system. Subjects had baseline systolic blood pressure (SBP) ≥120 mm Hg. The intervention included a nurse practitioner/physician assistant care manager, group clinics, self-management support, report cards, decision support, and ongoing care coordination. Outcomes were collected at 3, 8, and 12 months, analyzed as intention-to-treat, and used repeated-measures mixed-effects models. Change in SBP was the primary outcome. Low-density lipoprotein reduction, antithrombotic medication use, smoking cessation, and physical activity were secondary outcomes. Average age was 57 years; 18% were of black race; 69% were of Hispanic ethnicity. Mean baseline SBP was 150 mm Hg in both arms. SBP decreased to 17 mm Hg in the intervention arm and 14 mm Hg in the usual care arm; the between-arm difference was not significant (-3.6 mm Hg; 95% confidence interval, -9.2 to 2.2). Among secondary outcomes, the only significant difference was that persons in the intervention arm were more likely to lower their low-density lipoprotein <100 md/dL (2.0 odds ratio; 95% confidence interval, 1.1-3.5). CONCLUSIONS: This intervention did not improve SBP control beyond that attained in usual care among vulnerable stroke survivors. A community-centered component could strengthen the intervention impact. CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov. Unique identifier: NCT00861081.

Impact of an urban community hypertension screening program on participating high school students.

BACKGROUND: Hypertension is increasingly being recognized as a major health problem in adolescents, particularly those of minority ethnicity. We assessed elevated blood pressure (BP) prevalence and predictors, as well as the impact of participating in a community hypertension screening program among high school students in an urban school district. METHODS: In 2008, 603 predominantly Hispanic students from nine Los Angeles high schools in predominantly Hispanic communities were recruited and trained to screen for high BP (> or = 140/90 mm Hg) in their communities. As part of the program, students measured one another's blood pressure and completed a pre- and post-assessment (2 weeks later), which measured hypertension risk factors, knowledge, interest in health careers, and empowerment. A multivariable analysis using logistic regression evaluated the association between several factors and presence of elevated BP. RESULTS: Eighty-two (14%) of students had BP readings in the hypertensive range, with 78 (95%) of whom had no prior diagnosis of hypertension. Being overweight (OR 2.85, 95% CI = 1.31-6.20) or obese (OR 8.90, 95% CI = 3.83-20.69) were the only factors independently associated with elevated BP. Significant increases were observed in student knowledge regarding hypertension and interest pursuing three of five health professions (P < .05), but no significant change in student empowerment was noted. CONCLUSIONS: One in six urban district high school students screened in this study had presence of elevated BP, the overwhelming majority of whom had no prior hypertension diagnosis. Program participation slightly boosted health career interest and hypertension knowledge. Involvement of urban high school students in self-screening hypertension programs may be of benefit.

Randomized, controlled trial of an intervention to enable stroke survivors throughout the Los Angeles County safety net to "stay with the guidelines".

BACKGROUND: Stroke is the leading cause of adult disability. Inpatient programs optimize secondary stroke prevention care at the time of hospital discharge, but such care may not be continued after hospital discharge. METHODS: To improve the delivery of secondary stroke preventive services after hospital discharge, we have designed a chronic care model-based program called SUSTAIN (Systemic Use of STroke Averting INterventions). This care intervention includes group clinics, self-management support, report cards, decision support through care guides and protocols, and coordination of ongoing care. The first specific aim is to test, in a randomized, controlled trial, whether SUSTAIN improves blood pressure control among an analytic sample of 268 patients with a recent stroke or transient ischemic attack discharged from 4 Los Angeles County public hospitals. Secondary outcomes consist of control of other stroke risk factors, lifestyle habits, medication adherence, patient perceptions of care quality, functional status, and quality of life. A second specific aim is to conduct a cost analysis of SUSTAIN from the perspective of the Los Angeles County Department of Health Services by using direct costs of the intervention, cost equivalents of associated utilization of county system resources, and cost equivalents of the observed and predicted averted vascular events. CONCLUSIONS: If SUSTAIN is effective, we will have the expertise and findings to advocate for its continued support at Los Angeles County hospitals and to disseminate the SUSTAIN program to other settings serving indigent, minority populations. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00861081.

Educating and mobilizing youth to detect undiagnosed elevated blood pressure: searching for the silent killer.

BACKGROUND: Hispanic individuals with high blood pressure are less likely than other ethnic groups to be aware of their high blood pressure or to be on medication for the condition. We investigated the feasibility of using high school students in predominantly Hispanic neighborhoods to conduct a large-scale blood pressure screening and education outreach in their communities. METHODS: In 2005, 960 students from Los Angeles high schools in predominantly Hispanic communities were trained to conduct blood pressure screening and provide educational materials and referrals. A multivariable analysis using logistic regression was conducted to analyze the association between self-reported cardiovascular risk factors and elevated blood pressure. RESULTS: Students presented educational materials to 5395 persons and screened 5165 persons in their communities. Of 5395 individuals screened, 299 (6%) were found to have elevated blood pressure, of which only 77 (26%) were taking antihypertensive medication. Of those with elevated blood pressure on screening, 46% indicated they had a history of hypertension, and 3% of the entire screened community were identified as having elevated blood pressure for the first time. Older age, male sex, heavy alcohol consumption, and history of hypertension were all independently associated with elevated blood pressure. CONCLUSIONS: Training high school students to identify persons with elevated blood pressure is feasible and could reach large numbers of ethnic minorities unaware of their blood pressure status.