Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED)

doi:10.1186/s12883-017-0792-7

Randomized Controlled Trial

. 2017 Feb 6;17(1):24.

doi: 10.1186/s12883-017-0792-7.

Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED)

Amytis Towfighi^{1

2

3}, Eric M Cheng⁴, Monica Ayala-Rivera^{5

4}, Heather McCreath⁴, Nerses Sanossian^{6

7}, Tara Dutta^{5

8}, Bijal Mehta^{4

9}, Robert Bryg^{4

10}, Neal Rao^{4

10}, Shlee Song¹¹, Ali Razmara^{5

12}, Magaly Ramirez¹³, Theresa Sivers-Teixeira^{6

5}, Jamie Tran⁹, Elizabeth Mojarro-Huang^{5

7}, Ana Montoya^{5

9

10}, Marilyn Corrales^{14

5}, Beatrice Martinez^{5

9}, Phyllis Willis¹⁵, Mireya Macias¹⁶, Nancy Ibrahim¹⁷, Shinyi Wu^{18

19}, Jeremy Wacksman²⁰, Hilary Haber²⁰, Adam Richards⁴, Frances Barry⁴, Valerie Hill⁵, Brian Mittman²¹, William Cunningham⁴, Honghu Liu⁴, David A Ganz^{4

19

21}, Diane Factor¹⁶, Barbara G Vickrey^{4

22}

Affiliations

¹ Los Angeles County Department of Health Services, Los Angeles, California, USA. towfighi@usc.edu.
² University of Southern California, Los Angeles, California, USA. towfighi@usc.edu.
³ Rancho Los Amigos National Rehabilitation Center, Downey, California, USA. towfighi@usc.edu.
⁴ University of California, Los Angeles (UCLA), Los Angeles, California, USA.
⁵ Rancho Los Amigos National Rehabilitation Center, Downey, California, USA.
⁶ University of Southern California, Los Angeles, California, USA.
⁷ Los Angeles County-University of Southern California (USC) Medical Center, Los Angeles, California, USA.
⁸ Kaiser Permanente, Sacramento, California, USA.
⁹ Harbor-UCLA Medical Center, Torrance, California, USA.
¹⁰ Olive View-UCLA Medical Center, Sylmar, California, USA.
¹¹ Cedars Sinai Medical Center, Los Angeles, California, USA.
¹² Kaiser Permanente, Irvine, California, USA.
¹³ Fielding School of Public Health, Department of Health Policy and Management, University of California, Los Angeles, Los Angeles, California, USA.
¹⁴ Los Angeles County Department of Health Services, Los Angeles, California, USA.
¹⁵ Watts Labor Community Action Committee, Watts, California, USA.
¹⁶ Worker Education and Resource Center, Los Angeles, California, USA.
¹⁷ Esperanza Community Housing, Los Angeles, California, USA.
¹⁸ School of Social Work, Edward R. Roybal Institute on Aging, and Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California, Los Angeles, California, USA.
¹⁹ RAND Corporation, Santa Monica, California, USA.
²⁰ Dimagi, Inc., Cambridge, Massachusetts, USA.
²¹ Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.
²² Icahn School of Medicine at Mount Sinai, New York, New York, USA.

PMID: 28166784
PMCID: PMC5294765
DOI: 10.1186/s12883-017-0792-7

Randomized Controlled Trial

Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED)

Amytis Towfighi et al. BMC Neurol. 2017.

. 2017 Feb 6;17(1):24.

doi: 10.1186/s12883-017-0792-7.

Authors

Affiliations

¹ Los Angeles County Department of Health Services, Los Angeles, California, USA. towfighi@usc.edu.
² University of Southern California, Los Angeles, California, USA. towfighi@usc.edu.
³ Rancho Los Amigos National Rehabilitation Center, Downey, California, USA. towfighi@usc.edu.
⁴ University of California, Los Angeles (UCLA), Los Angeles, California, USA.
⁵ Rancho Los Amigos National Rehabilitation Center, Downey, California, USA.
⁶ University of Southern California, Los Angeles, California, USA.
⁷ Los Angeles County-University of Southern California (USC) Medical Center, Los Angeles, California, USA.
⁸ Kaiser Permanente, Sacramento, California, USA.
⁹ Harbor-UCLA Medical Center, Torrance, California, USA.
¹⁰ Olive View-UCLA Medical Center, Sylmar, California, USA.
¹¹ Cedars Sinai Medical Center, Los Angeles, California, USA.
¹² Kaiser Permanente, Irvine, California, USA.
¹³ Fielding School of Public Health, Department of Health Policy and Management, University of California, Los Angeles, Los Angeles, California, USA.
¹⁴ Los Angeles County Department of Health Services, Los Angeles, California, USA.
¹⁵ Watts Labor Community Action Committee, Watts, California, USA.
¹⁶ Worker Education and Resource Center, Los Angeles, California, USA.
¹⁷ Esperanza Community Housing, Los Angeles, California, USA.
¹⁸ School of Social Work, Edward R. Roybal Institute on Aging, and Daniel J. Epstein Department of Industrial and Systems Engineering, University of Southern California, Los Angeles, California, USA.
¹⁹ RAND Corporation, Santa Monica, California, USA.
²⁰ Dimagi, Inc., Cambridge, Massachusetts, USA.
²¹ Department of Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA.
²² Icahn School of Medicine at Mount Sinai, New York, New York, USA.

PMID: 28166784
PMCID: PMC5294765
DOI: 10.1186/s12883-017-0792-7

Abstract

Background: Recurrent strokes are preventable through awareness and control of risk factors such as hypertension, and through lifestyle changes such as healthier diets, greater physical activity, and smoking cessation. However, vascular risk factor control is frequently poor among stroke survivors, particularly among socio-economically disadvantaged blacks, Latinos and other people of color. The Chronic Care Model (CCM) is an effective framework for multi-component interventions aimed at improving care processes and outcomes for individuals with chronic disease. In addition, community health workers (CHWs) have played an integral role in reducing health disparities; however, their effectiveness in reducing vascular risk among stroke survivors remains unknown. Our objectives are to develop, test, and assess the economic value of a CCM-based intervention using an Advanced Practice Clinician (APC)-CHW team to improve risk factor control after stroke in an under-resourced, racially/ethnically diverse population.

Methods/design: In this single-blind randomized controlled trial, 516 adults (≥40 years) with an ischemic stroke, transient ischemic attack or intracerebral hemorrhage within the prior 90 days are being enrolled at five sites within the Los Angeles County safety-net setting and randomized 1:1 to intervention vs usual care. Participants are excluded if they do not speak English, Spanish, Cantonese, Mandarin, or Korean or if they are unable to consent. The intervention includes a minimum of three clinic visits in the healthcare setting, three home visits, and Chronic Disease Self-Management Program group workshops in community venues. The primary outcome is blood pressure (BP) control (systolic BP <130 mmHg) at 1 year. Secondary outcomes include: (1) mean change in systolic BP; (2) control of other vascular risk factors including lipids and hemoglobin A1c, (3) inflammation (C reactive protein [CRP]), (4) medication adherence, (5) lifestyle factors (smoking, diet, and physical activity), (6) estimated relative reduction in risk for recurrent stroke or myocardial infarction (MI), and (7) cost-effectiveness of the intervention versus usual care.

Discussion: If this multi-component interdisciplinary intervention is shown to be effective in improving risk factor control after stroke, it may serve as a model that can be used internationally to reduce race/ethnic and socioeconomic disparities in stroke in resource-constrained settings.

Trial registration: ClinicalTrials.gov Identifier NCT01763203 .

Keywords: Biomarkers; Blood pressure; Community health worker; Coordinated care; Disparities; Intracerebral hemorrhage; NINDS Common Data Elements; Stroke; Transient ischemic attack; Vascular risk.

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Figures

**Fig. 1**
Conceptual model of SUCCEED intervention

**Fig. 2**
Participant flow in intervention

**Fig. 3**
a Screenshot of CommCare application for APC. b Screenshot of CommCare application for CHW

**Fig. 4**
Risk factor goal card: trifold wallet card

**Fig. 5**
Enrollment of subjects and schedule for collecting evaluation data

See this image and copyright information in PMC

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References

1. Bodenheimer T, Berry-Millett R. Follow the money—controlling expenditures by improving care for patients needing costly services. N Engl J Med. 2009;361(16):1521–1523. doi: 10.1056/NEJMp0907185. - DOI - PubMed
1. Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff (Millwood) 2013;32(11):1881–1886. doi: 10.1377/hlthaff.2013.0234. - DOI - PubMed
1. Reuben DB. Physicians in supporting roles in chronic disease care: the CareMore model. J Am Geriatr Soc. 2011;59(1):158–160. doi: 10.1111/j.1532-5415.2010.03237.x. - DOI - PubMed
1. Milstein A, Gilbertson E. American medical home runs. Health Aff (Millwood) 2009;28(5):1317–1326. doi: 10.1377/hlthaff.28.5.1317. - DOI - PubMed
1. Bell JF, Krupski A, Joesch JM, West II, Atkins DC, Court B, Mancuso D, Roy-Byrne P. A randomized controlled trial of intensive care management for disabled Medicaid beneficiaries with high health care costs. Health Serv Res. 2015;50(3):663–689. doi: 10.1111/1475-6773.12258. - DOI - PMC - PubMed

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[1] Bodenheimer T, Berry-Millett R. Follow the money—controlling expenditures by improving care for patients needing costly services. N Engl J Med. 2009;361(16):1521–1523. doi: 10.1056/NEJMp0907185. - DOI - PubMed

[2] Bodenheimer T, Berry-Millett R. Follow the money—controlling expenditures by improving care for patients needing costly services. N Engl J Med. 2009;361(16):1521–1523. doi: 10.1056/NEJMp0907185. - DOI - PubMed

[3] Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff (Millwood) 2013;32(11):1881–1886. doi: 10.1377/hlthaff.2013.0234. - DOI - PubMed

[4] Bodenheimer TS, Smith MD. Primary care: proposed solutions to the physician shortage without training more physicians. Health Aff (Millwood) 2013;32(11):1881–1886. doi: 10.1377/hlthaff.2013.0234. - DOI - PubMed

[5] Reuben DB. Physicians in supporting roles in chronic disease care: the CareMore model. J Am Geriatr Soc. 2011;59(1):158–160. doi: 10.1111/j.1532-5415.2010.03237.x. - DOI - PubMed

[6] Reuben DB. Physicians in supporting roles in chronic disease care: the CareMore model. J Am Geriatr Soc. 2011;59(1):158–160. doi: 10.1111/j.1532-5415.2010.03237.x. - DOI - PubMed

[7] Milstein A, Gilbertson E. American medical home runs. Health Aff (Millwood) 2009;28(5):1317–1326. doi: 10.1377/hlthaff.28.5.1317. - DOI - PubMed

[8] Milstein A, Gilbertson E. American medical home runs. Health Aff (Millwood) 2009;28(5):1317–1326. doi: 10.1377/hlthaff.28.5.1317. - DOI - PubMed

[9] Bell JF, Krupski A, Joesch JM, West II, Atkins DC, Court B, Mancuso D, Roy-Byrne P. A randomized controlled trial of intensive care management for disabled Medicaid beneficiaries with high health care costs. Health Serv Res. 2015;50(3):663–689. doi: 10.1111/1475-6773.12258. - DOI - PMC - PubMed

[10] Bell JF, Krupski A, Joesch JM, West II, Atkins DC, Court B, Mancuso D, Roy-Byrne P. A randomized controlled trial of intensive care management for disabled Medicaid beneficiaries with high health care costs. Health Serv Res. 2015;50(3):663–689. doi: 10.1111/1475-6773.12258. - DOI - PMC - PubMed

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Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED)

Affiliations

Randomized controlled trial of a coordinated care intervention to improve risk factor control after stroke or transient ischemic attack in the safety net: Secondary stroke prevention by Uniting Community and Chronic care model teams Early to End Disparities (SUCCEED)

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