Leigh Quarles

Education Strategies for Stroke Prevention

Stroke is a major public health burden in the United States, with indications that stroke is emerging as a global epidemic. Furthermore, there exists an appreciation that focus on clinical treatment alone will not significantly reduce the burden of stroke, including morbidity and mortality. Emphasis needs to shift to acknowledging the importance of behavioral change science. The focus of this monograph is to provide insight into considerations for the development of theory-based interventions for reduction of stroke through behavioral change. The Science of Behavioral Change is a complex endeavor, and addressing the lifestyle changes during the life course needed to reduce the burden of stroke remains a significant challenge. Areas of exploration include an understanding of the acquisition of vascular risk behaviors; identifying and testing mechanisms for changing existing behaviors; identifying strategies that optimally support the maintenance of health behaviors; and choosing the appropriate level for behavioral change (ie, individual change versus population level or structural change). Part of understanding behaviors includes making predictions about why people behave the way they do. Behavioral theory used in the design of interventions allows us to assess an individual’s readiness to take action toward healthier behaviors. An accompanying theoretical platform, such as the transtheoretical model, provides the framework for the type of strategy or process needed to guide individual or system interventions through the stages of change, including action and maintenance. An important epidemiological feature of cerebrovascular disease concerns the sharp gradients in morbidity and mortality by race-ethnicity. Indeed, some of the earliest educational materials for stroke prevention have been suboptimal because of the generic nature of information without reference to place or culture. For example, trust is a concern among many African American and Hispanic communities and low-income populations. Effective interventions in minority communities have established trust by building relationships with community …

Discharge educational strategies for reduction of vascular events (DESERVE): design and methods

Rationale Stroke and vascular risk factors disproportionately affect minority populations, with Blacks and Hispanics experiencing a 2.5- and 2.0-fold greater risk compared with whites, respectively. Patients with transient ischemic attacks and mild, nondisabling strokes tend to have short hospital stays, rapid discharges, and inaccurate perceptions of vascular risk. Aim The primary aim of the Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) trial is to evaluate the efficacy of a novel community health worker-based multilevel discharge intervention vs. standard discharge care on vascular risk reduction among racially/ethnically diverse transient ischemic attack/mild stroke patients at one-year postdischarge. We hypothesize that those randomized to the discharge intervention will have reduced modifiable vascular risk factors as determined by systolic blood pressure compared with those receiving usual care. Sample size estimates Given 300 subjects per group and alpha of 0.05, the power to detect a 6 mmHg reduction in systolic blood pressure is 89%. Design DESERVE trial is a prospective, randomized, multicenter clinical trial of a novel discharge behavioral intervention. Patients with transient ischemic attack/mild stroke are randomized during hospitalization or emergency room visit to intervention or usual care. Intervention begins prior to discharge and continues postdischarge. Study outcomes The primary outcome is difference in systolic blood pressure reduction between groups at 12 months. Secondary outcomes include between-group differences in change in glycated hemoglobin, smoking rates, medication adherence, and recurrent stroke/transient ischemic attack at 12 months. Discussion DESERVE will evaluate whether a novel discharge education strategy leads to improved risk factor control in a racially diverse population.

Comparison of Acute Stroke Preparedness Strategies to Decrease Emergency Department Arrival Time in a Multiethnic Cohort: The Stroke Warning Information and Faster Treatment Study

Background and Purpose— Less than 25% of stroke patients arrive to an emergency department within the 3-hour treatment window. Stroke Warning Information and Faster Treatment (SWIFT) compared an interactive intervention (II) with enhanced educational (EE) materials on recurrent stroke arrival times in a prospective cohort of multiethnic stroke/transient ischemic attack survivors. Methods— A single-center randomized controlled trial (2005–2011) randomized participants to EE (bilingual stroke preparedness materials) or II (EE plus in-hospital sessions). We assessed differences by randomization in the proportion arriving to emergency department <3 hours, prepost intervention arrival <3 hours, incidence rate ratio for total events, and stroke knowledge and preparedness capacity. Results— SWIFT randomized 1193 participants (592 EE, 601 II): mean age 63 years; 50% female, 17% black, 51% Hispanic, 26% white. At baseline, 28% arrived to emergency department <3 hours. Over 5 years, first recurrent stroke (n=133), transient ischemic attacks (n=54), or stroke mimics (n=37) were documented in 224 participants. Incidence rate ratio=1.31 (95% confidence interval=1.05–1.63; II to EE). Among II, 40% arrived <3 hours versus 46% EE (P=0.33). In prepost analysis, there was a 49% increase in the proportion arriving <3 hours (P=0.001), greatest among Hispanics (63%, P<0.003). II had greater stroke knowledge at 1 month (odds ratio=1.63; 1.23–2.15). II had higher preparedness capacity at 1 month (odds ratio=3.36; 1.86, 6.10) and 12 months (odds ratio=7.64; 2.49, 23.49). Conclusions— There was no difference in arrival <3 hours overall between II and EE; the proportion arriving <3 hours increased in both groups and in race-ethnic minorities. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT00415389.