One year after hospital discharge, the DESERVE behavioral intervention led to a statistically significant 9.9 mm Hg greater decrease in systolic blood pressure among Hispanic patients who had a mild or moderate stroke or transient ischemic attack (TIA), according to Bernadette Boden-Albala, DrPH, MPH, of NYU College of Global Public Health in New York City, and colleagues.
However, the intervention did not lead to a significant difference in systolic blood pressure among non-Hispanic white or black populations, and was not powered to assess subgroups, as reported in JAMA Neurology.
“Hispanic individuals — the fastest growing immigrant population in the United States — are at an increased risk for stroke, but are less likely to be aware of whether they have hypertension and less likely to adhere to their medication,” Boden-Albala said in a statement. “The fact that we saw a reduction in blood pressure among Hispanic participants suggests that the intervention addressed some of these gaps.”
In the U.S., nearly one in four strokes is recurrent. These strokes are particularly fatal and disabling and disproportionately affect African American and Hispanic patients.
Previous interventions have focused on educating patients about risk factors, but knowledge alone may not lead to behavior changes, Boden-Albala noted. “Our findings show the promise of focusing on skills that people can really use — enhancing communication with their physician, or clarifying their medication regimen — so they feel they can do something to reduce their risk of stroke,” she said. “By training patients to take ownership of controlling risk factors, this intervention allows the process to be sustainable beyond the healthcare system.”
In the DESERVE (Discharge Educational Strategies for Reduction of Vascular Events) trial, 552 mild or moderate stroke or TIA patients — including 151 non-Hispanic white, 183 non-Hispanic black, and 180 Hispanic individuals — at four New York City hospitals were randomized to receive either a culturally tailored intervention, or usual discharge instructions and American Heart Association pamphlets, from August 2012 to May 2016. The average age of participants was about 65 and 51% were women. Most patients had a history of hypertension and were overweight or obese.
The DESERVE intervention was created with input from African American and Hispanic community members. Before hospital discharge, community health coordinators led patients in the DESERVE arm in an interactive educational session that included a workbook and video emphasizing three skills-based themes: patient-physician communication, medication adherence, and accurate stroke risk perception. For Hispanic patients, the video framed recovery in the context of faith and spirituality. For African American patients, it presented recovery after stroke as a matter of self-determination.
Health coordinators followed up with phone calls to patients 3 days after discharge, then 1 month (typically right before a neurology appointment) and 3 months later. In these conversations, they helped patients identify any confusion about their treatment and create a checklist of questions to ask their doctors.
At 1-year follow-up, researchers assessed participants’ blood pressure. They found no significant difference in systolic blood pressure reduction overall between the DESERVE intervention and usual care groups (beta 2.5 mm Hg, 95% CI -1.9 to 6.9).
Although the study was not powered for subgroup analysis, Hispanic patients in the DESERVE arm showed a greater mean systolic blood pressure drop than those in the usual care group (beta 9.9 mm Hg, 95% CI 1.8 to 18.0), which translates to a nearly 40% risk reduction for secondary stroke events, Boden-Albala and colleagues noted. Of note, systolic blood pressure increased in the usual-care Hispanic group, which was not observed in the other control groups.
No significant differences between arms emerged among non-Hispanic white (beta 3.3 mm Hg, 95% CI -4.1 to 10.7) and non-Hispanic black (beta mm Hg -1.6, 95% CI -10.1 to 6.8) patients.
While there have been many studies about managing risk factors after stroke, this is one of few targeted at disadvantaged populations, observed Joosup Kim, PhD, and Amanda Thrift, PhD, both of Monash University in Clayton, Australia, in an accompanying editorial.
“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. “The authors cite evidence of low stroke-specific health literacy and awareness of hypertension status among Hispanic individuals and patient-physician communication barriers within this group.” Addressing these disparities may be why results differed for Hispanic patients, they noted.
The study‘s major weakness is its lack of power to detect subgroup differences, Kim and Thrift added. The study also had other limitations, the study authors said. The usual-care group received health literate, linguistically appropriate educational materials, which may not always occur in the real world; this may have attenuated the intervention’s effect. Also, some follow-up blood pressure measurements came from physician records instead of from the researchers.
The researchers reported no conflicts of interest.
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Dori F. Zaleznik, MD Associate Clinical Professor of Medicine (Retired), Harvard Medical School, Boston and Dorothy Caputo, MA, BSN, RN, Nurse Planner
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