The Association of Race and Sex with the Underuse of Stroke Prevention Measures
ABSTRACT Underuse of effective stroke prevention measures has been demonstrated in the general population. Blacks and Hispanics are at increased risk of recurrent stroke relative to white non-Hispanics. More profound underuse of prevention measures may contribute to this disparity. In this study we attempted to compare the degree of underuse of diagnostic and treatment strategies in patients of these racial/ethnic groups with recent ischemic stroke.
At 4 participating urban hospitals, patient charts were reviewed with regard to the completeness of the diagnostic evaluation, discharge treatment regimen, and stroke risk factor and antithrombotic medication use at 6 months postdischarge.
Of 501 patients hospitalized with acute ischemic stroke, almost all received electrocardiograms and brain imaging, 75% had carotid artery evaluations, and 70% had serum lipid determinations. Blacks and women were less likely to have complete evaluations. At discharge, 88% of patients received antithrombotic medications and 89% of patients were prescribed antihypertensive medications appropriately, but only 65% were prescribed lipid-lowering medications appropriately, with blacks least likely to receive appropriate prescriptions. At 6 months poststroke, of the 200 patients with data available for evaluation, 72% exhibited underuse of at least one stroke prevention measure. Blacks (81.6%) were more likely to experience underuse than Hispanics (62.5%) or whites (66.7%). Women were more likely to receive incomplete inhospital evaluations and discharge regimens.
There is clinically important underuse of effective diagnostic and prevention measures in each of the groups studied, especially among blacks.
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ABSTRACT: Background and Purpose Efforts to reduce disparities in recurrent stroke among Black and Latino stroke survivors have met with limited success. We aimed to determine the effect of peer education on secondary stroke prevention among predominantly minority stroke survivors. Methods Between 2009 and 2012, we enrolled 600 stroke or transient ischemic attack survivors from diverse, low-income communities in New York City into a 2-arm randomized clinical trial that compared a 6 week (1 session/week), peer-led, community-based, stroke prevention self-management group workshop (N=301) to a wait-list control group (N=299). The primary outcome was the proportion with a composite of controlled blood pressure (<140/90 mm Hg), low-density lipoprotein cholesterol <100 mg/dL, and use of antithrombotic medications at 6 months. Secondary outcomes included control of the individual stroke risk factors. All analyses were by intent-to-treat. Results There was no difference in the proportion of intervention and control group participants achieving the composite outcome (34% versus 34%; P=0.98). The proportion with controlled blood pressure at 6 months was greater in the intervention group than in the control group (76% versus 67%; P=0.02). This corresponded to a greater change in systolic blood pressure in the intervention versus control group (-3.63 SD, 19.81 mm Hg versus +0.34 SD, 23.76 mm Hg; P=0.04). There were no group differences in the control of cholesterol or use of antithrombotics. Conclusions A low-cost peer education self-management workshop modestly improved blood pressure, but not low-density lipoprotein cholesterol or antithrombotic use, among stroke and transient ischemic attack survivors from vulnerable, predominantly minority urban communities. Clinical Trial Registration URL: http://www.clinicaltrials.gov/show/NCT0102727. Unique identifier: NCT01027273.Stroke 09/2014; 45(11). DOI:10.1161/STROKEAHA.114.006623 · 6.02 Impact Factor
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ABSTRACT: Black and Hispanic stroke survivors experience higher rates of recurrent stroke than whites. This disparity is partly explained by disproportionately higher rates of uncontrolled hypertension in these populations. Home blood pressure telemonitoring (HBPTM) and nurse case management (NCM) have proven efficacy in addressing the multilevel barriers to blood pressure (BP) control and reducing BP. However, the effectiveness of these interventions has not been evaluated in stroke patients. This study is designed to evaluate the comparative effectiveness, cost-effectiveness and sustainability of these two telehealth interventions in reducing BP and recurrent stroke among high-risk Black and Hispanic stroke survivors with uncontrolled hypertension. A total of 450 Black and Hispanic patients with recent nondisabling stroke and uncontrolled hypertension are randomly assigned to one of two 12-month interventions: 1) HBPTM with wireless feedback to primary care providers or 2) HBPTM plus individualized, culturally-tailored, telephone-based NCM. Patients are recruited from stroke centers and primary care practices within the Health and Hospital Corporations (HHC) Network in New York City. Study visits occur at baseline, 6, 12 and 24 months. The primary outcomes are within-patient change in systolic BP at 12 months, and the rate of stroke recurrence at 24 months. The secondary outcome is the comparative cost-effectiveness of the interventions at 12 and 24 months; and exploratory outcomes include changes in stroke risk factors, health behaviors and treatment intensification. Recruitment for the stroke telemonitoring hypertension trial is currently ongoing. The combination of two established and effective interventions along with the utilization of health information technology supports the sustainability of the HBPTM + NCM intervention and feasibility of its widespread implementation. Results of this trial will provide strong empirical evidence to inform clinical guidelines for management of stroke in minority stroke survivors with uncontrolled hypertension. If effective among Black and Hispanic stroke survivors, these interventions have the potential to substantially mitigate racial and ethnic disparities in stroke recurrence. ClinicalTrials.gov NCT02011685 . Registered 10 December 2013.Trials 12/2015; 16(1):605. DOI:10.1186/s13063-015-0605-5 · 2.12 Impact Factor
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ABSTRACT: Background Cardiovascular disease (CVD) is the leading cause of mortality for U.S. women. Racial minorities are a particularly vulnerable population. The increasing female veteran population has an higher prevalence of certain cardiovascular risk factors compared with non-veteran women; however, little is known about gender and racial differences in cardiovascular risk factor control among veterans. Methods We used analysis of variance, adjusting for age, to compare gender and racial differences in three risk factors that predispose to CVD (diabetes, hypertension, and hyperlipidemia) in a cohort of high-risk veterans eligible for enrollment in a clinical trial, including 23,955 men and 1,010 women. Findings Low-density lipoprotein (LDL) values were higher in women veterans than men with age-adjusted estimated mean values of 111.7 versus 97.6 mg/dL (p < .01). Blood pressures (BPs) were higher among African-American than White female veterans with age-adjusted estimated mean systolic BPs of 136.3 versus 133.5 mmHg, respectively (p < .01), and diastolic BPs of 82.4 versus 78.9 mmHg (p < .01). African-American veterans with diabetes had worse BP, LDL values, and hemoglobin A1c levels, although the differences were only significant among men. Conclusions Female veterans have higher LDL cholesterol levels than male veterans and African-American veterans have higher BP, LDL cholesterol, and A1c levels than Whites after adjusting for age. Further examination of CVD gender and racial disparities in this population may help to develop targeted treatments and strategies applicable to the general population.Women s Health Issues 10/2014; 24(5):477–483. DOI:10.1016/j.whi.2014.05.005 · 1.61 Impact Factor