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Original Investigation
January 2019

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

Author Affiliations
  • 1Department of Epidemiology, College of Global Public Health, New York University, New York
  • 2Department of Global Health, College of Global Public Health, New York University, New York
  • 3Department of Neurology, Langone School of Medicine, New York University, New York
  • 4Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York
  • 5Department of Social and Behavioral Sciences, College of Global Public Health, New York University, New York
  • 6Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
  • 7Department of Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
  • 8Department of Preventive Medicine and Public Health, University of Kansas Medical Center, Kansas City
JAMA Neurol. 2019;76(1):20-27. doi:10.1001/jamaneurol.2018.2926
Key Points

Question  What is the effect of a skills-based discharge intervention on blood pressure reduction among patients with mild/moderate stroke and transient ischemic attack?

Findings  This randomized clinical trial of 552 patients found that a culturally tailored, skills-based discharge program with follow-up reinforcement led to a nonsignificant 2.5 mm Hg–greater systolic blood pressure reduction at 12 months postdischarge compared with usual care. There was a statistically significant 9.9 mm Hg–greater systolic blood pressure reduction in the intervention group compared with usual care among Hispanic individuals.

Meaning  Further investigation may identify whether culturally tailored, skills-based education improves long-term vascular risk reduction for individuals who have had mild/moderate stroke/transient ischemic attack in different populations.

Abstract

Importance  Despite secondary prevention strategies with proven efficacy, recurrent stroke rates remain high, particularly in racial/ethnic minority populations who are disproportionately affected by stroke.

Objective  To determine the efficacy of a culturally tailored skills-based educational intervention with telephone follow-up compared with standard discharge care on systolic blood pressure reduction in a multiethnic cohort of patients with mild/moderate stroke/transient ischemic attack.

Design, Setting, and Participants  Randomized clinical trial with 1-year follow-up. Participants were white, black, and Hispanic patients with mild/moderate stroke/transient ischemic attack prospectively enrolled from 4 New York City, New York, medical centers during hospitalization or emergency department visit between August 2012 and May 2016. Through screening of stroke admissions and emergency department notifications, 1083 eligible patients were identified, of whom 256 declined to participate and 275 were excluded for other reasons. Analyses were intention to treat.

Interventions  The Discharge Educational Strategies for Reduction of Vascular Events (DESERVE) intervention is a skills-based, culturally tailored discharge program with follow-up calls delivered by a community health coordinator. This intervention was developed using a community engagement approach.

Main Outcomes and Measures  The primary outcome was systolic blood pressure reduction at 12 months postdischarge.

Results  A total of 552 participants were randomized to receive intervention or usual care (281 women [51%]; mean [SD] age, 64.61 [2.9] years; 180 Hispanic [33%], 151 non-Hispanic white [27%], and 183 non-Hispanic black [33%]). At 1-year follow-up, no significant difference in systolic blood pressure reduction was observed between intervention and usual care groups (β = 2.5 mm Hg; 95% CI, −1.9 to 6.9). Although not powered for subgroup analysis, we found that among Hispanic individuals, the intervention arm had a clinically and statically significant 9.9 mm Hg–greater mean systolic blood pressure reduction compared with usual care (95% CI, 1.8-18.0). There were no significant differences between arms among non-Hispanic white (β = 3.3; 95% CI, −4.1 to 10.7) and non-Hispanic black participants (β = −1.6; 95% CI, −10.1 to 6.8).

Conclusions and Relevance  Few behavioral intervention studies in individuals who have had stroke have reported clinically meaningful reductions in blood pressure at 12 months, and fewer have focused on a skills-based approach. Results of secondary analyses suggest that culturally tailored, skills-based strategies may be an important alternative to knowledge-focused approaches in achieving sustained vascular risk reduction and addressing racial/ethnic stroke disparities; however, these findings should be tested in future studies.

Trial Registration  ClinicalTrials.gov identifier: NCT01836354.

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