BY LIZETTE BORRELI
A behavioral intervention program that taught stroke patients of different racial/ethnic groups how to lower their blood pressure and prevent a secondary stroke led to a decrease in systolic blood pressure 12 months post-discharge among certain groups, according to a randomized, clinical trial published online on October 8 in JAMA Neurology.
In DESERVE (Discharge Educational Strategies for Reduction of Vascular Events), Hispanic patients who had a mild or moderate stroke or transient ischemic attack (TIA) experienced a 9.9 mm HG greater decrease in systolic blood pressure.
"The SBP [systolic blood pressure] reduction in Hispanic individuals translates to nearly 40% risk reduction for secondary stroke events," the researchers, led by Bernadette Boden-Albala, DrPH, MPH, of NYU College of Global Public Health in New York City, wrote.
The behavioral intervention did not lead to a significant difference in systolic blood pressure among non-Hispanic white or black populations, however.
The randomized trial aimed to investigate whether a behavioral intervention program could improve long-term vascular risk reduction among different racial/ethnic groups who had mild/moderate stroke/transient ischemic attack. The team followed 151 non-Hispanic white, 83 non-Hispanic black, and 180 Hispanic individuals at four New York City hospitals. The patients were randomized to receive either a culturally tailored, skills-based education intervention, or usual care-discharge instructions and American Heart Association pamphlets, from August 2012 to May 2016.
Prior to hospital discharge, patients in the DESERVE arm received an interactive educational session that included a patient-paced workbook and video emphasizing three skills-based thematic areas: patient-physician communication, medication adherence, and accurate stroke risk perception with risk reduction skills.
The DESERVE intervention was designed with community input from African-American and Hispanic community members. Among Hispanic patients, the educational video framed recovery in the context of faith and spirituality, whereas for African-American patients, recovery was framed as a matter of self-determination.
Participants in the DESERVE arm also received follow-up calls from a coordinator at 72 hours, one month, usually right before a neurology appointment, and three months to enhance strategies for patient-physician communication, clarify medication regimens, and provide social support to motivate behavior change.
Health coordinators helped participants identify areas of confusion about their treatment and create a checklist of questions for their doctors. They also helped to reinforce these skills prior to doctor visits through phone calls. The researchers believed this would be a more effective way for patients to achieve control of risk factors.
Researchers measured participants' blood pressure at one-year follow-up. The findings revealed no significant difference in systolic blood pressure reduction between the intervention and the usual care groups (beta 2.5 mm Hg, 95% CI -1.9 to 6.9). However, systolic blood pressure did increase in Hispanic patients in the usual care group. This effect was not observed in other control populations.
The researchers were not sure why Hispanic patients in the DESERVE arm had the most significant reduction in systolic blood pressure.
"We hypothesize that the intervention was beneficial for Hispanic participants because it was based on the needs of patients and was closely evidence based," they wrote.
Recurrent strokes disproportionately affect African Americans and Hispanic patients compared to non-Hispanic white patients, the researchers pointed out. Persistent racial/ethnic disparities in secondary prevention, mostly due to cultural and behavioral factors not addressed in standard prevention programs, and a lack of integration into community resources, can contribute to failure to comply with secondary stroke prevention, they wrote.
The researchers stressed that their trial was not powered to identify differences in subgroup intervention effects. But, they did conclude culturally tailored, skills-based interventions may help with secondary stroke prevention and address racial/ethnic disparities in stroke. The findings warrant further research to replicate the results.
Study limitations included the inability to identify subgroup differences and distributing health literate and linguistically appropriate educational materials, which may not occur in real-world settings.
The National Institute of Neurological Disorders and Stroke of the National Institutes of Health supported the research.
The researchers reported no conflicts of interest.
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Boden-Albala B, Goldmann E, Parikh NS, et al. Efficacy of a discharge educational strategy vs standard discharge care on reduction of vascular risk in patients with stroke and transient ischemic attack: The DESERVE randomized clinical trial. JAMA Neurol 2018; Epub 2018 Oct 8.