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Skolarus LE, Lin CC, Bi R, Bailey S, Corches CL, Sales AE, Springer MV, Burke JF. Reduction in Racial Differences in Stroke Thrombolytics in Flint, Michigan. Stroke 2024; 55:e24-e26. [PMID: 38152959 PMCID: PMC10872391 DOI: 10.1161/strokeaha.123.044663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Affiliation(s)
- Lesli E. Skolarus
- Northwestern University, Davee Department of Neurology, Chicago IL
- University of Michigan, Department of Neurology, Ann Arbor, MI
| | - Chun Chieh Lin
- Ohio State University, Department of Neurology, Columbus, OH
| | - Ran Bi
- Ohio State University, Department of Neurology, Columbus, OH
| | | | | | - Anne E. Sales
- Sinclair School of Nursing and Department of Family and Community Medicine, University of Missouri
- VA Ann Arbor Healthcare System, Ann Arbor, MI
| | | | - James F. Burke
- Ohio State University, Department of Neurology, Columbus, OH
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Golbus JR, Jeganathan VSE, Stevens R, Ekechukwu W, Farhan Z, Contreras R, Rao N, Trumpower B, Basu T, Luff E, Skolarus LE, Newman MW, Nallamothu BK, Dorsch MP. A Physical Activity and Diet Just-in-Time Adaptive Intervention to Reduce Blood Pressure: The myBPmyLife Study Rationale and Design. J Am Heart Assoc 2024; 13:e031234. [PMID: 38226507 PMCID: PMC10926831 DOI: 10.1161/jaha.123.031234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 09/13/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND Smartphone applications and wearable devices are promising mobile health interventions for hypertension self-management. However, most mobile health interventions fail to use contextual data, potentially diminishing their impact. The myBPmyLife Study is a just-in-time adaptive intervention designed to promote personalized self-management for patients with hypertension. METHODS AND RESULTS The study is a 6-month prospective, randomized-controlled, remotely administered trial. Participants were recruited from the University of Michigan Health in Ann Arbor, Michigan or the Hamilton Community Health Network, a federally qualified health center network in Flint, Michigan. Participants were randomized to a mobile application with a just-in-time adaptive intervention promoting physical activity and lower-sodium food choices as well as weekly goal setting or usual care. The mobile study application encourages goal attainment through a central visualization displaying participants' progress toward their goals for physical activity and lower-sodium food choices. Participants in both groups are followed for up for 6 months with a primary end point of change in systolic blood pressure. Exploratory analyses will examine the impact of notifications on step count and self-reported lower-sodium food choices. The study launched on December 9, 2021, with 484 participants enrolled as of March 31, 2023. Enrollment of participants was completed on July 3, 2023. After 6 months of follow-up, it is expected that results will be available in the spring of 2024. CONCLUSIONS The myBPmyLife study is an innovative mobile health trial designed to evaluate the effects of a just-in-time adaptive intervention focused on improving physical activity and dietary sodium intake on blood pressure in diverse patients with hypertension. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT05154929.
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Affiliation(s)
- Jessica R. Golbus
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Integrated Center for Health Analytics and Medical PredictionUniversity of MichiganAnn ArborMIUSA
| | - V. Swetha E. Jeganathan
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Rachel Stevens
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Weena Ekechukwu
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Zahera Farhan
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Rocio Contreras
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Nikhila Rao
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Brad Trumpower
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Tanima Basu
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Evan Luff
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
| | - Lesli E. Skolarus
- Division of Vascular Neurology, Department of Neurology–Internal MedicineNorthwestern UniversityEvanstonILUSA
| | - Mark W. Newman
- School of Information and Computer Science, College of EngineeringUniversity of MichiganAnn ArborMIUSA
| | - Brahmajee K. Nallamothu
- Division of Cardiovascular Medicine, Department of Internal MedicineUniversity of MichiganAnn ArborMIUSA
- Michigan Integrated Center for Health Analytics and Medical PredictionUniversity of MichiganAnn ArborMIUSA
- The Center for Clinical Management and ResearchAnn ArborMIUSA
| | - Michael P. Dorsch
- Department of Clinical Pharmacy, College of PharmacyUniversity of MichiganAnn ArborMIUSA
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Skolarus LE, Farhan Z, Mishra SR, Rao N, Bowie K, Bailey S, Dorsch MP, Newman MW, Nallamothu BK, Golbus JR. Resource Requirements for Participant Enrollment From a University Health System and a Federally Qualified Health Center Network in a Mobile Health Study: The myBPmyLife Trial. J Am Heart Assoc 2024; 13:e030825. [PMID: 38226521 PMCID: PMC10926785 DOI: 10.1161/jaha.123.030825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/26/2023] [Indexed: 01/17/2024]
Affiliation(s)
| | - Zahera Farhan
- Department of Emergency MedicineUniversity of MichiganAnn ArborMI
| | | | - Nikhila Rao
- Department of CardiologyUniversity of MichiganAnn ArborMI
| | - Kaitlyn Bowie
- Department of Emergency MedicineUniversity of MichiganAnn ArborMI
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Hellem A, Whitfield C, Mansour M, Curran Y, Dinh M, Warden K, Skolarus LE. Determinants of Bluetooth-Enabled Self-Measured Blood Pressure Monitoring in Federally Qualified Health Centers. J Prim Care Community Health 2024; 15:21501319241229921. [PMID: 38400549 PMCID: PMC10894531 DOI: 10.1177/21501319241229921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/11/2024] [Accepted: 01/13/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND In 2021, the Health Resources and Services Administration (HRSA) launched the National Hypertension Control Initiative (HTN Initiative) with the goal to enhance HTN control through Bluetooth-enabled self-measured blood pressure (BT-SMBP) monitoring and use this data to inform clinical decisions in Federally Qualified Health Centers (FQHCs) with a large proportion of their population with uncontrolled blood pressure (BP). We sought to understand the experience of Michigan-based FQHCs in implementing the HTN initiative. METHODS Staff from three Michigan-based FQHCs were invited to participate in semi-structured interviews from September to November 2022. Interviews were conducted in-person and were based on the Tailored Implementation in Chronic Diseases framework. Content analysis was performed by three coders. RESULTS Ten staff participated in interviews (FQHC 1: n = 6, FQHC 2: n = 1, FQHC 3: n = 3). The FQHCs differed in their stage of implementation and their approach. FQHC 1 created a large-scale, community health worker driven program, FQHC 2 created a small-scale, short term, BP device loan program, and FQHC 3 created a primarily outsourced, large-scale program through a contracted partner. Positive staff attitudes and outcome expectations, previous experience with SMBP grants, supportive clinic leadership, social support, and free BP cuff resources were identified as facilitators to implementation. Patients' high social needs, SMBP-related Technology, and insufficient workforce and staff capacity were identified as barriers. CONCLUSION BT-SMBP among FQHC patients is promising but challenges in integrating SMBP data into clinic workflow, workforce capacity to support the high social needs of participants, and to assist in reacting to the more frequent BP data remain to be overcome.
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Affiliation(s)
- Abby Hellem
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Candace Whitfield
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Maria Mansour
- Department of Neurology, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Yvonne Curran
- Davee Department of Neurology, Northwestern University, Chicago, IL, USA
| | - Mackenzie Dinh
- Department of Emergency Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Lesli E Skolarus
- Davee Department of Neurology, Northwestern University, Chicago, IL, USA
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de Havenon A, Skolarus LE, Mac Grory B, Bangad A, Sheth KN, Burke JF, Creutzfeldt CJ. National- and State-Level Trends in Medicare Hospice Beneficiaries for Stroke During 2013 to 2019 in the United States. Stroke 2024; 55:131-138. [PMID: 38063013 PMCID: PMC10752263 DOI: 10.1161/strokeaha.123.045021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 11/10/2023] [Indexed: 12/24/2023]
Abstract
BACKGROUND Stroke is the fifth leading cause of death in the United States, one of the leading contributors to Medicare cost, including through Medicare hospice benefits, and the rate of stroke mortality has been increasing since 2013. We hypothesized that hospice utilization among Medicare beneficiaries with stroke has increased over time and that the increase is associated with trends in stroke death rate. METHODS Using Medicare Part A claims data and Centers for Disease Control mortality data at a national and state level from 2013 to 2019, we report the proportion and count of Medicare hospice beneficiaries with stroke as well as the stroke death rate (per 100 000) in Medicare-eligible individuals aged ≥65 years. RESULTS From 2013 to 2019, the number of Medicare hospice beneficiaries with stroke as their primary diagnosis increased 104.1% from 78 812 to 160 884. The number of stroke deaths in the United States in individuals aged ≥65 years also increased from 109 602 in 2013 to 129 193 in 2019 (17.9% increase). In 2013, stroke was the sixth most common primary diagnosis for Medicare hospice, while in 2019 it was the third most common, surpassed only by cancer and dementia. The correlation between the change from 2013 to 2019 in state-level Medicare hospice for stroke and stroke death rate for Medicare-eligible adults was significant (Spearman ρ=0.5; P<0.001). In a mixed-effects model, the variance in the state-level proportion of Medicare hospice for stroke explained by the state-level stroke death rate was 48.2%. CONCLUSIONS From 2013 to 2019, the number of Medicare hospice beneficiaries with a primary diagnosis of stroke more than doubled and stroke jumped from the sixth most common indication for hospice to the third most common. While increases in stroke mortality in the Medicare-eligible population accounts for some of the increase of Medicare hospice beneficiaries, over half the variance remains unexplained and requires additional research.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, Center for Brain & Mind Health, Yale University, New Haven, CT (A.d.H., A.B., K.N.S.)
| | - Lesli E Skolarus
- Department of Neurology, Northwestern University, Chicago, IL (L.E.S.)
| | - Brian Mac Grory
- Department of Neurology, Duke University, Durham, NC (B.M.G.)
| | - Aaron Bangad
- Department of Neurology, Center for Brain & Mind Health, Yale University, New Haven, CT (A.d.H., A.B., K.N.S.)
| | - Kevin N Sheth
- Department of Neurology, Center for Brain & Mind Health, Yale University, New Haven, CT (A.d.H., A.B., K.N.S.)
| | - James F Burke
- Department of Neurology, Ohio State University, Columbus (J.F.B.)
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Lin CC, Callaghan BC, Burke JF, Kerber KA, Bicket MC, Esper GJ, Skolarus LE, Hill CE. Prescription Opioid Initiation for Neuropathy, Headache, and Low Back Pain: A US Population-based Medicare Study. J Pain 2023; 24:2268-2282. [PMID: 37468023 DOI: 10.1016/j.jpain.2023.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 07/07/2023] [Accepted: 07/08/2023] [Indexed: 07/21/2023]
Abstract
Neuropathy, headache, and low back pain (LBP) are common conditions requiring pain management. Yet little is known regarding whether access to specialists impacts opioid prescribing. We aimed to identify factors associated with opioid initiation among opioid-naïve older adults and evaluate how access to particular specialists impacts prescribing. This retrospective cohort study used a 20% Medicare sample from 2010 to 2017. Opioid initiation was defined as a first opioid prescription filled within 12 months after a diagnosis encounter. Disease-related opioid initiation was defined as a first opioid prescription filled within 7 days following a disease-specific claim. Logistic regression using generalized estimating equations was used to determine the association of patient demographics, provider types, and regional physician specialty density with disease-related opioid initiation, accounting for within-region correlation. We found opioid initiation steadily declined from 2010 to 2017 (neuropathy: 26-19%, headache: 31-20%, LBP: 45-32%), as did disease-related opioid initiation (4-3%, 12-7%, 29-19%) and 5 to 10% of initial disease-related prescriptions resulted in chronic opioid use within 12 months of initiation. Certain specialist visits were associated with a lower likelihood of disease-related opioid initiation compared with primary care. Residence in high neurologist density regions had a lower likelihood of disease-related opioid initiation (headache odds ratio [OR] .76 [95% CI: .63-.92]) and LBP (OR .7 [95% CI: .61-.81]) and high podiatrist density regions for neuropathy (OR .56 [95% CI: .41-.78]). We found that specialist visits and greater access to specialists were associated with a lower likelihood of disease-related opioid initiation. These data could inform strategies to perpetuate reductions in opioid use for these common pain conditions. PERSPECTIVE: This article presents how opioid initiation for opioid-naïve patients with newly diagnosed neuropathy, headache, and LBP varies across providers. Greater access to certain specialists decreased the likelihood of opioid initiation. Future work may consider interventions to support alternative treatments and better access to specialists in low-density regions.
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Affiliation(s)
- Chun Chieh Lin
- Department of Neurology, The Ohio State University, Columbus, Ohio; Health Services Research Program, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Brian C Callaghan
- Health Services Research Program, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - James F Burke
- Department of Neurology, The Ohio State University, Columbus, Ohio
| | - Kevin A Kerber
- Department of Neurology, The Ohio State University, Columbus, Ohio
| | - Mark C Bicket
- Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan
| | | | - Lesli E Skolarus
- Department of Neurology, Northwestern University, Chicago, Illinois
| | - Chloe E Hill
- Health Services Research Program, Department of Neurology, University of Michigan, Ann Arbor, Michigan
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Lin CC, Hill CE, Kerber KA, Burke JF, Skolarus LE, Esper GJ, de Havenon A, De Lott LB, Callaghan BC. Patient Travel Distance to Neurologist Visits. Neurology 2023; 101:e1807-e1820. [PMID: 37704403 PMCID: PMC10634641 DOI: 10.1212/wnl.0000000000207810] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 07/10/2023] [Indexed: 09/15/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The density of neurologists within a given geographic region varies greatly across the United States. We aimed to measure patient travel distance and travel time to neurologist visits, across neurologic conditions and subspecialties. Our secondary goal was to identify factors associated with long-distance travel for neurologic care. METHODS We performed a cross-sectional analysis using a 2018 Medicare sample of patients with at least 1 outpatient neurologist visit. Long-distance travel was defined as driving distance ≥50 miles 1-way to the visit. Travel time was measured as driving time in minutes. Multilevel generalized linear mixed models with logistic link function, which accounted for clustering of patients within hospital referral region and allowed modeling of region-specific random effects, were used to determine the association of patient and regional characteristics with long-distance travel. RESULTS We identified 563,216 Medicare beneficiaries with a neurologist visit in 2018. Of them, 96,213 (17%) traveled long distance for care. The median driving distance and time were 81.3 (interquartile range [IQR]: 59.9-144.2) miles and 90 (IQR: 69-149) minutes for patients with long-distance travel compared with 13.2 (IQR: 6.5-23) miles and 22 (IQR: 14-33) minutes for patients without long-distance travel. Comparing across neurologic conditions, long-distance travel was most common for nervous system cancer care (39.6%), amyotrophic lateral sclerosis [ALS] (32.1%), and MS (22.8%). Many factors were associated with long-distance travel, most notably low neurologist density (first quintile: OR 3.04 [95% CI 2.41-3.83] vs fifth quintile), rural setting (4.89 [4.79-4.99]), long-distance travel to primary care physician visit (3.6 [3.51-3.69]), and visits for ALS and nervous system cancer care (3.41 [3.14-3.69] and 5.27 [4.72-5.89], respectively). Nearly one-third of patients bypassed the nearest neurologist by 20+ miles, and 7.3% of patients crossed state lines for neurologist care. DISCUSSION We found that nearly 1 in 5 Medicare beneficiaries who saw a neurologist traveled ≥50 miles 1-way for care, and travel burden was most common for lower-prevalence neurologic conditions that required coordinated multidisciplinary care. Important potentially addressable predictors of long-distance travel were low neurologist density and rural location, suggesting interventions to improve access to care such as telemedicine or neurologic subspecialist support to local neurologists. Future work should evaluate differences in clinical outcomes between patients with long-distance travel and those without.
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Affiliation(s)
- Chun Chieh Lin
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT.
| | - Chloe E Hill
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Kevin A Kerber
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - James F Burke
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Lesli E Skolarus
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Gregory J Esper
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Adam de Havenon
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Lindsey B De Lott
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
| | - Brian C Callaghan
- From the Department of Neurology (C.C.L., C.E.H., L.B.D.L., B.C.C.), University of Michigan, Ann Arbor; Department of Neurology (C.C.L., K.A.K., J.F.B.), the Ohio State University, Columbus; Department of Neurology (L.E.S.), Northwestern University, Chicago, IL; Department of Neurology (G.J.E.), Emory University, Atlanta, GA; and Department of Neurology (A.H.), Yale University, New Haven, CT
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Hill CE, Lin CC, Terman SW, Zahuranec D, Parent JM, Skolarus LE, Burke JF. Predictors of referral for long-term EEG monitoring for Medicare beneficiaries with drug-resistant epilepsy. Epilepsia Open 2023; 8:1096-1110. [PMID: 37423646 PMCID: PMC10472378 DOI: 10.1002/epi4.12789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 07/02/2023] [Indexed: 07/11/2023] Open
Abstract
OBJECTIVE For people with drug-resistant epilepsy, the use of epilepsy surgery is low despite favorable odds of seizure freedom. To better understand surgery utilization, we explored factors associated with inpatient long-term EEG monitoring (LTM), the first step of the presurgical pathway. METHODS Using 2001-2018 Medicare files, we identified patients with incident drug-resistant epilepsy using validated criteria of ≥2 distinct antiseizure medication (ASM) prescriptions and ≥1 drug-resistant epilepsy encounter among patients with ≥2 years pre- and ≥1 year post-diagnosis Medicare enrollment. We used multilevel logistic regression to evaluate associations between LTM and patient, provider, and geographic factors. We then analyzed neurologist-diagnosed patients to further evaluate provider/environmental characteristics. RESULTS Of 12 044 patients with incident drug-resistant epilepsy diagnosis identified, 2% underwent surgery. Most (68%) were diagnosed by a neurologist. In total, 19% underwent LTM near/after drug-resistant epilepsy diagnosis; another 4% only underwent LTM much prior to diagnosis. Patient factors most strongly predicting LTM were age <65 (adjusted odds ratio 1.5 [95% confidence interval 1.3-1.8]), focal epilepsy (1.6 [1.4-1.9]), psychogenic non-epileptic spells diagnosis (1.6 [1.1-2.5]) prior hospitalization (1.7, [1.5-2]), and epilepsy center proximity (1.6 [1.3-1.9]). Additional predictors included female gender, Medicare/Medicaid non-dual eligibility, certain comorbidities, physician specialties, regional neurologist density, and prior LTM. Among neurologist-diagnosed patients, neurologist <10 years from graduation, near an epilepsy center, or epilepsy-specialized increased LTM likelihood (1.5 [1.3-1.9], 2.1 [1.8-2.5], 2.6 [2.1-3.1], respectively). In this model, 37% of variation in LTM completion near/after diagnosis was explained by individual neurologist practice and/or environment rather than measurable patient factors (intraclass correlation coefficient 0.37). SIGNIFICANCE A small proportion of Medicare beneficiaries with drug-resistant epilepsy completed LTM, a proxy for epilepsy surgery referral. While some patient factors and access measures predicted LTM, non-patient factors explained a sizable proportion of variance in LTM completion. To increase surgery utilization, these data suggest initiatives targeting better support of neurologist referral.
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Affiliation(s)
- Chloe E. Hill
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Chun Chieh Lin
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
- Department of NeurologyThe Ohio State UniversityColumbusOhioUSA
| | - Samuel W. Terman
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Darin Zahuranec
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | - Jack M. Parent
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | | | - James F. Burke
- Department of NeurologyThe Ohio State UniversityColumbusOhioUSA
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Towfighi A, Berger RP, Corley AMS, Glymour MM, Manly JJ, Skolarus LE. Recommendations on Social Determinants of Health in Neurologic Disease. Neurology 2023; 101:S17-S26. [PMID: 37580147 DOI: 10.1212/wnl.0000000000207562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 05/09/2023] [Indexed: 08/16/2023] Open
Abstract
Social determinants of health (SDOH) are increasingly recognized as important drivers of inequities in neurologic disease and outcomes. However, our understanding of the biopsychosocial mechanisms by which SDOH affect neurologic disease remains in its infancy. The most robust epidemiologic research has been on the associations between education, schooling, and place-based social determinants on cognition, dementia, and cerebrovascular disease later in life. Further research is needed to more deeply understand the complex interplay of SDOH on neurologic disease. Few SDOH screening tools have been validated in populations with neurologic disease. In addition, comparison across studies and populations is hampered by lack of standardized common data elements. Experiences of populations historically underrepresented in research should be centered in future research studies, and changes should be made in recruitment expectations and measurement choices. For research on inequities, it is critical to support and incentivize institutional infrastructure to foster meaningful engagement with populations affected by research. Finally, it remains to be seen whether individual-level health or behavioral interventions or place-level, systemic or policy interventions to reduce population burden will be most effective in reducing inequities in neurologic disease and outcomes. Although numerous clinical trials have focused on addressing downstream SDOH such as health literacy and health behaviors (e.g., medication adherence, physical activity, diet), few have addressed upstream, structural determinants which may have a more profound impact on addressing inequities in neurologic disease. Ultimately, further research is needed to determine which specific SDOH should be targeted and how, when, and by whom they should be addressed to improve neurologic outcomes.
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Affiliation(s)
- Amytis Towfighi
- From the Departments of Neurology and Population and Public Health Sciences (A.T.), University of Southern California, Los Angeles; Department of Pediatrics (R.P.B.), Children's Hospital of Pittsburgh, University of Pittsburg Medical Center (UPMC), PA; Division of General and Community Pediatrics (A.M.S.C.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; The Center for Health and Community (M.M.G.), University of California, San Francisco; Department of Neurology (J.J.M.), Vagelos College of Physicians and Surgeons, Columbia University, New York; and Department of Neurology (L.S.), Northwestern University, Chicago, IL.
| | - Rachel P Berger
- From the Departments of Neurology and Population and Public Health Sciences (A.T.), University of Southern California, Los Angeles; Department of Pediatrics (R.P.B.), Children's Hospital of Pittsburgh, University of Pittsburg Medical Center (UPMC), PA; Division of General and Community Pediatrics (A.M.S.C.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; The Center for Health and Community (M.M.G.), University of California, San Francisco; Department of Neurology (J.J.M.), Vagelos College of Physicians and Surgeons, Columbia University, New York; and Department of Neurology (L.S.), Northwestern University, Chicago, IL
| | - Alexandra M S Corley
- From the Departments of Neurology and Population and Public Health Sciences (A.T.), University of Southern California, Los Angeles; Department of Pediatrics (R.P.B.), Children's Hospital of Pittsburgh, University of Pittsburg Medical Center (UPMC), PA; Division of General and Community Pediatrics (A.M.S.C.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; The Center for Health and Community (M.M.G.), University of California, San Francisco; Department of Neurology (J.J.M.), Vagelos College of Physicians and Surgeons, Columbia University, New York; and Department of Neurology (L.S.), Northwestern University, Chicago, IL
| | - M Maria Glymour
- From the Departments of Neurology and Population and Public Health Sciences (A.T.), University of Southern California, Los Angeles; Department of Pediatrics (R.P.B.), Children's Hospital of Pittsburgh, University of Pittsburg Medical Center (UPMC), PA; Division of General and Community Pediatrics (A.M.S.C.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; The Center for Health and Community (M.M.G.), University of California, San Francisco; Department of Neurology (J.J.M.), Vagelos College of Physicians and Surgeons, Columbia University, New York; and Department of Neurology (L.S.), Northwestern University, Chicago, IL
| | - Jennifer J Manly
- From the Departments of Neurology and Population and Public Health Sciences (A.T.), University of Southern California, Los Angeles; Department of Pediatrics (R.P.B.), Children's Hospital of Pittsburgh, University of Pittsburg Medical Center (UPMC), PA; Division of General and Community Pediatrics (A.M.S.C.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; The Center for Health and Community (M.M.G.), University of California, San Francisco; Department of Neurology (J.J.M.), Vagelos College of Physicians and Surgeons, Columbia University, New York; and Department of Neurology (L.S.), Northwestern University, Chicago, IL
| | - Lesli E Skolarus
- From the Departments of Neurology and Population and Public Health Sciences (A.T.), University of Southern California, Los Angeles; Department of Pediatrics (R.P.B.), Children's Hospital of Pittsburgh, University of Pittsburg Medical Center (UPMC), PA; Division of General and Community Pediatrics (A.M.S.C.), Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, OH; The Center for Health and Community (M.M.G.), University of California, San Francisco; Department of Neurology (J.J.M.), Vagelos College of Physicians and Surgeons, Columbia University, New York; and Department of Neurology (L.S.), Northwestern University, Chicago, IL
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10
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Griffith DM, Towfighi A, Manson SM, Littlejohn EL, Skolarus LE. Determinants of Inequities in Neurologic Disease, Health, and Well-being: The NINDS Social Determinants of Health Framework. Neurology 2023; 101:S75-S81. [PMID: 37580154 PMCID: PMC10605947 DOI: 10.1212/wnl.0000000000207566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 05/09/2023] [Indexed: 08/16/2023] Open
Abstract
A National Institute of Neurological Disorders and Stroke working group developed the Determinants of Inequities in Neurological Disease, Health, and Well-being framework. Our goal was to guide and inspire a new generation of neurologic research that pushes the field to design and test new approaches in pursuit of health equity, population health, and social justice. We seek to expand the lens of those looking to reduce or eliminate racial, socioeconomic status, and other inequities in neurologic disease, health, and well-being to improve our collective ability to create research, programs, and policies that lead to larger, more impactful, and more sustainable change in neurologic disease patterns. In this context, we outline a framework that includes and highlights "upstream" factors in the hopes of enhancing the focus of research, programmatic, and policy efforts to reduce and eliminate inequities in neurologic health and well-being. We explicitly discuss racism and other structural factors to clarify that social determinants are not natural and unchangeable. Populations with a disproportionate burden of neurologic disease are not inherently deficient, despite what some approaches to framing health inequities imply. The framework is presented linearly, but the pathways linking the determinants of neurologic disease, health, and well-being are far more complex than those demonstrated by the arrows included in the figure. The framework highlights the different levels and scale of causation, including the structural and intermediary social determinants and their impact on neurologic health. We offer this framework to refine efforts to contextualize the interpretation of neurologic research findings and suggest new avenues for their application. We illustrate how behavioral and biological factors occur in a social and economic context, factors that have been understudied as points of intervention to reduce inequities in neurologic disease. Considering social and structural determinants of health provides promising new opportunities to achieve neurologic health equity, reach social justice, and improve our science. Extending our work in this fashion is not simply about health equity or social justice but to fundamentally improve the quality of neurologic research by enhancing underlying theory and improving study design and implementation.
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Affiliation(s)
- Derek M Griffith
- From the Department of Health Management and Policy, School of Health, Georgetown University (D.M.G.), Washington, DC; Department of Neurology (A.T.), Keck School of Medicine of the University of Southern California, Los Angeles; University of Colorado Anschutz Medical Campus (S.M.M.), Aurora; National Institute of Neurological Disorders and Stroke (E.L.L.), NIH, Bethesda, MD; and Davee Department of Neurology, Northwestern University, Feinberg School of Medicine (L.E.S.), Chicago, IL.
| | - Amytis Towfighi
- From the Department of Health Management and Policy, School of Health, Georgetown University (D.M.G.), Washington, DC; Department of Neurology (A.T.), Keck School of Medicine of the University of Southern California, Los Angeles; University of Colorado Anschutz Medical Campus (S.M.M.), Aurora; National Institute of Neurological Disorders and Stroke (E.L.L.), NIH, Bethesda, MD; and Davee Department of Neurology, Northwestern University, Feinberg School of Medicine (L.E.S.), Chicago, IL
| | - Spero M Manson
- From the Department of Health Management and Policy, School of Health, Georgetown University (D.M.G.), Washington, DC; Department of Neurology (A.T.), Keck School of Medicine of the University of Southern California, Los Angeles; University of Colorado Anschutz Medical Campus (S.M.M.), Aurora; National Institute of Neurological Disorders and Stroke (E.L.L.), NIH, Bethesda, MD; and Davee Department of Neurology, Northwestern University, Feinberg School of Medicine (L.E.S.), Chicago, IL
| | - Erica L Littlejohn
- From the Department of Health Management and Policy, School of Health, Georgetown University (D.M.G.), Washington, DC; Department of Neurology (A.T.), Keck School of Medicine of the University of Southern California, Los Angeles; University of Colorado Anschutz Medical Campus (S.M.M.), Aurora; National Institute of Neurological Disorders and Stroke (E.L.L.), NIH, Bethesda, MD; and Davee Department of Neurology, Northwestern University, Feinberg School of Medicine (L.E.S.), Chicago, IL
| | - Lesli E Skolarus
- From the Department of Health Management and Policy, School of Health, Georgetown University (D.M.G.), Washington, DC; Department of Neurology (A.T.), Keck School of Medicine of the University of Southern California, Los Angeles; University of Colorado Anschutz Medical Campus (S.M.M.), Aurora; National Institute of Neurological Disorders and Stroke (E.L.L.), NIH, Bethesda, MD; and Davee Department of Neurology, Northwestern University, Feinberg School of Medicine (L.E.S.), Chicago, IL
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11
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Skolarus LE, Bailey S, Corches CL, Sales AE, Lin CC, Bi R, Springer MV, Oliver A, Robles MC, Brooks T, Tupper M, Jaggi M, Al-Qasmi M, Trevithick BA, Barber K, Majjhoo A, Zimmerman MA, Meurer WJ, Brown DL, Morgenstern LB, Burke JF. Association of the Stroke Ready Community-Based Participatory Research Intervention With Incidence of Acute Stroke Thrombolysis in Flint, Michigan. JAMA Netw Open 2023; 6:e2321558. [PMID: 37399011 PMCID: PMC10318478 DOI: 10.1001/jamanetworkopen.2023.21558] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 05/17/2023] [Indexed: 07/04/2023] Open
Abstract
Importance Acute stroke treatment rates in the US lag behind those in other high-income nations. Objective To assess whether a hospital emergency department (ED) and community intervention was associated with an increased proportion of patients with stroke receiving thrombolysis. Design, Setting, and Participants This nonrandomized controlled trial of the Stroke Ready intervention took place in Flint, Michigan, from October 2017 to March 2020. Participants included adults living in the community. Data analysis was completed from July 2022 to May 2023. Intervention Stroke Ready combined implementation science and community-based participatory research approaches. Acute stroke care was optimized in a safety-net ED, and then a community-wide, theory-based health behavior intervention, including peer-led workshops, mailers, and social media, was conducted. Main Outcomes and Measures The prespecified primary outcome was the proportion of patients hospitalized with ischemic stroke or transient ischemic attack from Flint who received thrombolysis before and after the intervention. The association between thrombolysis and the Stroke Ready combined intervention, including the ED and community components, was estimated using logistic regression models, clustering at the hospital level and adjusting for time and stroke type. In prespecified secondary analyses, the ED and community intervention were explored separately, adjusting for hospital, time, and stroke type. Results In total, 5970 people received in-person stroke preparedness workshops, corresponding to 9.7% of the adult population in Flint. There were 3327 ischemic stroke and TIA visits (1848 women [55.6%]; 1747 Black individuals [52.5%]; mean [SD] age, 67.8 [14.5] years) among patients from Flint seen in the relevant EDs, including 2305 in the preintervention period from July 2010 to September 2017 and 1022 in the postintervention period from October 2017 to March 2020. The proportion of thrombolysis usage increased from 4% in 2010 to 14% in 2020. The combined Stroke Ready intervention was not associated with thrombolysis use (adjusted odds ratio [OR], 1.13; 95% CI, 0.74-1.70; P = .58). The ED component was associated with an increase in thrombolysis use (adjusted OR, 1.63; 95% CI, 1.04-2.56; P = .03), but the community component was not (adjusted OR, 0.99; 95% CI, 0.96-1.01; P = .30). Conclusions and Relevance This nonrandomized controlled trial found that a multilevel ED and community stroke preparedness intervention was not associated with increased thrombolysis treatments. The ED intervention was associated with increased thrombolysis usage, suggesting that implementation strategies in partnership with safety-net hospitals may increase thrombolysis usage. Trial Registration ClinicalTrials.gov Identifier: NCT036455900.
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Affiliation(s)
- Lesli E. Skolarus
- Davee Department of Neurology, Stroke and Vascular Neurology, Northwestern University, Chicago, Illinois
- Department of Neurology, University of Michigan, Ann Arbor
| | | | | | - Anne E. Sales
- Department of Family and Community Medicine, Sinclair School of Nursing, University of Missouri, Columbia
- VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Chun Chieh Lin
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Neurology, Ohio State University, Columbus
| | - Ran Bi
- Department of Neurology, University of Michigan, Ann Arbor
| | | | | | | | - Tia Brooks
- Department of Neurology, University of Michigan, Ann Arbor
| | - Michael Tupper
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan
| | - Michael Jaggi
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan
| | - Mohammed Al-Qasmi
- Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan
| | | | - Kimberly Barber
- Department of Clinical & Academic Research, Genesys Regional Medical Center, Grand Blanc, Michigan
| | - Aniel Majjhoo
- Department of Neurology, McLaren Flint Hospital, Flint, Michigan
| | | | | | - Devin L. Brown
- Department of Neurology, University of Michigan, Ann Arbor
| | - Lewis B. Morgenstern
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Emergency Medicine, University of Michigan, Ann Arbor
- School of Public Health, University of Michigan, Ann Arbor
| | - James F. Burke
- Department of Neurology, University of Michigan, Ann Arbor
- Department of Neurology, Ohio State University, Columbus
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12
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Springer MV, Skolarus LE, Feng C, Burke JF. Predictors of not maintaining regular medical follow-up after stroke. BMC Neurol 2023; 23:238. [PMID: 37340356 PMCID: PMC10280879 DOI: 10.1186/s12883-023-03262-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 05/26/2023] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND Regular medical follow-up after stroke is important to reduce the risk of post-stroke complications and hospital readmission. Little is known about the factors associated with stroke survivors not maintaining regular medical follow-up. We sought to quantify the prevalence and predictors of stroke survivors not maintaining regular medical follow-up over time. METHODS We conducted a retrospective cohort study of stroke survivors in the National Health and Aging Trends Study (2011-2018), a national longitudinal sample of United States Medicare beneficiaries. Our primary outcome was not maintaining regular medical follow-up. We performed a cox regression to estimate predictors of not maintaining regular medical follow-up. RESULTS There were 1330 stroke survivors included, 150 of whom (11.3%) did not maintain regular medical follow-up. Stroke survivor characteristics associated with not maintaining regular medical follow-up included not having restrictions in social activities (HR 0.64, 95% CI 0.41, 1.01 for having restrictions in social activities compared to not having restrictions in social activities), greater limitations in self-care activities (HR 1.13, 95% CI 1.03, 1.23), and probable dementia (HR 2.23, 95% CI 1.42, 3.49 compared to no dementia). CONCLUSIONS The majority of stroke survivors maintain regular medical follow-up over time. Strategies to retain stroke survivors in regular medical follow-up should be directed towards stroke survivors who do not have restrictions in social activity participation, those with greater limitations in self-care activities, and those with probable dementia.
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Affiliation(s)
- Mellanie V. Springer
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, Michigan, MI 48109-5855 USA
| | - Lesli E. Skolarus
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, Michigan, MI 48109-5855 USA
| | - Chunyang Feng
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, Michigan, MI 48109-5855 USA
| | - James F. Burke
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, Michigan, MI 48109-5855 USA
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Towfighi A, Boden-Albala B, Cruz-Flores S, El Husseini N, Odonkor CA, Ovbiagele B, Sacco RL, Skolarus LE, Thrift AG. Strategies to Reduce Racial and Ethnic Inequities in Stroke Preparedness, Care, Recovery, and Risk Factor Control: A Scientific Statement From the American Heart Association. Stroke 2023. [PMID: 37183687 DOI: 10.1161/str.0000000000000437] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Stroke is a disease of disparities, with tremendous racial and ethnic inequities in incidence, prevalence, treatment, and outcomes. The accumulating literature on the relationship between stroke and social determinants of health (ie, the structural conditions of the places where people live, learn, work, and play) contributes to our understanding of stroke inequities. Several interventions have been tested concurrently to reduce racial and ethnic inequities in stroke preparedness, care, recovery, and risk factor control. It is regrettable that no common theoretical framework has been used to facilitate comparison of interventions. In this scientific statement, we summarize, across the stroke continuum of care, trials of interventions addressing racial and ethnic inequities in stroke care and outcomes. We reviewed the literature on interventions to address racial and ethnic inequities to identify gaps and areas for future research. Although numerous trials tested interventions aimed at reducing inequities in prehospital, acute care, transitions in care, and poststroke risk factor control, few addressed inequities in rehabilitation, recovery, and social reintegration. Most studies addressed proximate determinants (eg, medication adherence, health literacy, and health behaviors), but upstream determinants (eg, structural racism, housing, income, food security, access to care) were not addressed. A common theoretical model of social determinants can help researchers understand the heterogeneity of social determinants, inform future directions in stroke inequities research, support research in understudied areas within the continuum of care, catalyze implementation of successful interventions in additional settings, allow for comparison across studies, and provide insight into whether addressing upstream or downstream social determinants has the strongest effect on reducing inequities in stroke care and outcomes.
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Skolarus LE, Dinh M, Kidwell KM, Lin CC, Buis LR, Brown DL, Oteng R, Giacalone M, Warden K, Trimble DE, Whitfield C, Farhan Z, Flood A, Borgialli D, Montas S, Jaggi M, Meurer WJ. Reach Out Emergency Department: A Randomized Factorial Trial to Determine the Optimal Mobile Health Components to Reduce Blood Pressure. Circ Cardiovasc Qual Outcomes 2023; 16:e009606. [PMID: 37192282 DOI: 10.1161/circoutcomes.122.009606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/13/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND Mobile health (mHealth) strategies initiated in safety-net Emergency Departments may be one approach to address the US hypertension epidemic, but the optimal mHealth components or dose are unknown. METHODS Reach Out is an mHealth, health theory-based, 2×2×2 factorial trial among hypertensive patients evaluated in a safety-net Emergency Department in Flint, Michigan. Reach Out consisted of 3 mHealth components, each with 2 doses: (1) healthy behavior text messaging (yes versus no), (2) prompted self-measured blood pressure (BP) monitoring and feedback (weekly versus daily), and (3) facilitated primary care provider appointment scheduling and transportation (yes versus no). The primary outcome was a change in systolic BP from baseline to 12 months. In a complete case analysis, we fit a linear regression model and accounted for age, sex, race, and prior BP medications to explore the association between systolic BP and each mHealth component. RESULTS Among 488 randomized participants, 211 (43%) completed follow-up. Mean age was 45.5 years, 61% were women, 54% were Black people, 22% did not have a primary care doctor, 21% lacked transportation, and 51% were not taking antihypertensive medications. Overall, systolic BP declined after 6 months (-9.2 mm Hg [95% CI, -12.2 to -6.3]) and 12 months (-6.6 mm Hg, -9.3 to -3.8), without a difference across the 8 treatment arms. The higher dose of mHealth components were not associated with a greater change in systolic BP; healthy behavior text messages (point estimate, mmHG=-0.5 [95% CI, -6.0 to 5]; P=0.86), daily self-measured BP monitoring (point estimate, mmHG=1.9 [95% CI, -3.7 to 7.5]; P=0.50), and facilitated primary care provider scheduling and transportation (point estimate, mmHG=0 [95% CI, -5.5 to 5.6]; P=0.99). CONCLUSIONS Among participants with elevated BP recruited from an urban safety-net Emergency Department, BP declined over the 12-month intervention period. There was no difference in change in systolic BP among the 3 mHealth components. Reach Out demonstrated the feasibility of reaching medically underserved people with high BP cared for at a safety-net Emergency Departments, yet the efficacy of the Reach Out mHealth intervention components requires further study. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03422718.
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Affiliation(s)
- Lesli E Skolarus
- Davee Department of Neurology, Northwestern University, Feinberg School of Medicine Chicago, IL (L.E.S.)
| | - Mackenzie Dinh
- Department of Emergency Medicine (M.D., R.O., D.E.T., C.W., Z.F., A.F., S.M., W.J.M.), University of Michigan, Ann Arbor
| | - Kelley M Kidwell
- Department of Statistics, University of Michigan School of Public Health, Ann Arbor (K.M.K.)
| | - Chun Chieh Lin
- Health Services Research Program (C.C.L.), University of Michigan, Ann Arbor
| | - Lorraine R Buis
- Institute for Healthcare Policy and Innovation (L.R.B.), University of Michigan, Ann Arbor
- Department of Family Medicine (L.R.B.), University of Michigan, Ann Arbor
| | - Devin L Brown
- Department of Neurology (D.L.B., W.J.M.), University of Michigan, Ann Arbor
- Stroke Program (D.L.B., W.J.M.), University of Michigan, Ann Arbor
| | - Rockefeller Oteng
- Department of Emergency Medicine (M.D., R.O., D.E.T., C.W., Z.F., A.F., S.M., W.J.M.), University of Michigan, Ann Arbor
- Department of Emergency Medicine, Hurley Medical Center, Flint, MI (R.O., D.B., M.J.)
| | | | | | - Deborah E Trimble
- Department of Emergency Medicine (M.D., R.O., D.E.T., C.W., Z.F., A.F., S.M., W.J.M.), University of Michigan, Ann Arbor
| | - Candace Whitfield
- Department of Emergency Medicine (M.D., R.O., D.E.T., C.W., Z.F., A.F., S.M., W.J.M.), University of Michigan, Ann Arbor
| | - Zahera Farhan
- Department of Emergency Medicine (M.D., R.O., D.E.T., C.W., Z.F., A.F., S.M., W.J.M.), University of Michigan, Ann Arbor
| | - Adam Flood
- Department of Emergency Medicine (M.D., R.O., D.E.T., C.W., Z.F., A.F., S.M., W.J.M.), University of Michigan, Ann Arbor
| | - Dominic Borgialli
- Department of Emergency Medicine, Hurley Medical Center, Flint, MI (R.O., D.B., M.J.)
| | - Sacha Montas
- Department of Emergency Medicine (M.D., R.O., D.E.T., C.W., Z.F., A.F., S.M., W.J.M.), University of Michigan, Ann Arbor
| | - Michael Jaggi
- Department of Emergency Medicine, Hurley Medical Center, Flint, MI (R.O., D.B., M.J.)
| | - William J Meurer
- Department of Emergency Medicine (M.D., R.O., D.E.T., C.W., Z.F., A.F., S.M., W.J.M.), University of Michigan, Ann Arbor
- Department of Neurology (D.L.B., W.J.M.), University of Michigan, Ann Arbor
- Stroke Program (D.L.B., W.J.M.), University of Michigan, Ann Arbor
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15
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de Havenon A, Bangad A, Skolarus LE, Aldridge CM, Braun RG, Cole JW, Cramer SC, Lindgren AG, Abimbola Sunmonu N, Worrall BB, Lohse KR. Understanding Patterns of Missingness in Acute Ischemic Stroke Trials: A Secondary Analysis of Pooled Participant-Level Follow-Up Data. Stroke 2023; 54:e201-e202. [PMID: 36896708 PMCID: PMC10133020 DOI: 10.1161/strokeaha.122.042168] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/19/2023] [Indexed: 03/11/2023]
Affiliation(s)
| | | | | | | | | | - John W. Cole
- Baltimore Veterans Affairs Medical Center and the University of Maryland
| | - Steven C. Cramer
- University of California, Los Angeles and California Rehabilitation Institute
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16
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Elafros MA, Callaghan BC, Skolarus LE, Vileikyte L, Lawrenson JG, Feldman EL. Patient and health care provider knowledge of diabetes and diabetic microvascular complications: a comprehensive literature review. Rev Endocr Metab Disord 2023; 24:221-239. [PMID: 36322296 PMCID: PMC10202021 DOI: 10.1007/s11154-022-09754-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 11/05/2022]
Abstract
Diabetic retinopathy, neuropathy, and nephropathy occur in more than 50% of people with diabetes, contributing substantially to morbidity and mortality. Patient understanding of these microvascular complications is essential to ensure early recognition and treatment of these sequalae as well as associated symptoms, yet little is known about patient knowledge of microvascular sequalae. In this comprehensive literature review, we provide an overview of existing knowledge regarding patient knowledge of diabetes, retinopathy, neuropathy, and nephropathy. We also discuss health care provider's knowledge of these sequalae given that patients and providers must work together to achieve optimal care. We evaluated 281 articles on patient and provider knowledge of diabetic retinopathy, neuropathy, and nephropathy as well as predictors of improved knowledge and screening practices. Results demonstrated that patient and provider knowledge of microvascular sequalae varied widely between studies, which may reflect sociocultural or methodologic differences. Knowledge assessment instruments varied between studies with limited validation data and few studies controlled for confounding. Generally, improved patient knowledge was associated with greater formal education, longer diabetes duration, and higher socioeconomic status. Fewer studies examined provider knowledge of sequalae, yet these studies identified multiple misconceptions regarding appropriate screening practices for microvascular complications and the need to screen patients who are asymptomatic. Further investigations are needed that use well validated measures, control for confounding, and include diverse populations. Such studies will allow identification of patients and providers who would benefit from interventions to improve knowledge of microvascular complications and, ultimately, improve patient outcomes.
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Affiliation(s)
| | | | - Lesli E Skolarus
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Loretta Vileikyte
- Division of Diabetes, Endocrinology, and Gastroenterology, University of Manchester, Manchester, UK
- Department of Endocrinology and Dermatology, University of Miami, Miami, FL, USA
| | - John G Lawrenson
- School of Health and Psychological Sciences, City, University of London, London, UK
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA.
- Department of Neurology, Michigan Medicine, University of Michigan, 48109, Ann Arbor, MI, USA.
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Robles MC, O'Brien A, Islam N, McBride AC, Corches CL, Mansour M, Bailey S, Thrash-Sall E, Skolarus LE. Exploring Social Determinants of Health in Healthy Aging Among Older Adults: A Qualitative Study. Prog Community Health Partnersh 2023. [DOI: 10.1353/cpr.2023.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/21/2023]
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Skolarus LE, Brown D, Reynolds E, Shi Y, Volow A, Burke JF, Sudore R. Abstract TP72: Advance Care Planning Engagement May Increase Among Stroke Survivors: Results From The Prepare For Your Care Trial. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp72] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Despite their high risk of mortality, recurrent stroke, and dementia, stroke survivors underutilize ACP. In a non-prespecified subgroup analysis of a randomized trial to increase ACP, we compared the efficacy of the PREPARE for Your Care (PREPARE) plus an easy-to-read advance directive (AD) to an AD alone among stroke survivors.
Methods:
PREPARE is an interactive digital program with easy-to-read, state-specific ADs, and video stories. Stroke survivors in the PREPARE trial were identified using the
International Classification of Diseases
codes. The primary outcome was new ACP documentation in the electronic medical record after 12 months; secondary outcome was self-reported ACP completion of: (1) signing official papers naming a surrogate decision maker; (2) discussion of patients’ wishes with surrogates; (3) discussion of patients’ wishes with medical providers; and (4) an AD, scored 0-4. We calculated the change from baseline to 12-month follow-up. Mixed-effects regression models were used, adjusted for health literacy (adequate or limited), baseline ACP documentation, and clustering by physician.
Results:
Of 986 PREPARE trial participants, 91 (9.2%) were stroke survivors and 72 had complete data. The mean age was 64 years (SD, 6.8 years), 47% were women, 74% identified as a minority race/ethnicity, 40% were Spanish-speaking, 49% had limited health literacy, and 41% had ACP before enrollment. There was a trend toward greater ACP documentation in the PREPARE-arm (table). The PREPARE-arm had significantly greater increase in completed ACP elements than the AD-only arm.
Discussion:
The PREPARE program shows promise to engage ethnically diverse stroke survivors in ACP and should be studied further. Addition of stroke-specific content and engagement of acute stroke survivors in adaptations may increase the impact of the program.
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Affiliation(s)
| | | | | | - Ying Shi
- Univ of California, San Francisco, CA
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19
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Springer MV, Hodges T, Lanning C, Tupper M, Skolarus LE. Using qualitative data to inform the adaptation of a stroke preparedness health intervention. Qual Res Med Healthc 2023. [DOI: 10.4081/qrmh.2022.10639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Qualitative research methods are often used to develop health interventions, but few researchers report how their qualitative data informed intervention development. Improved completeness of reporting may facilitate the development of effective behavior change interventions. Our objective was to describe how we used qualitative data to develop our stroke education intervention consisting of a pamphlet and video. First, we created a questionnaire grounded in the theory of planned behavior to determine reasons people delay in activating emergency medical services and presenting to the hospital after stroke symptom onset. From our questionnaire data, we identified theoretical constructs that affect behavior which informed the active components of our intervention. We then conducted cognitive interviews to determine emergency department patients’ understanding of the intervention pamphlet and video. Our cognitive interview data provided insight into how our intervention might produce behavior change. Our hope is that other researchers will similarly reflect upon and report on how they used their qualitative data to develop health interventions.
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20
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Springer MV, Skolarus LE, Patel M. Food Insecurity and Perceived Financial Stress are Associated with Cost-related Medication Non-adherence in Stroke. J Health Care Poor Underserved 2023; 34:625-639. [PMID: 37464522 PMCID: PMC10361605 DOI: 10.1353/hpu.2023.0054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
OBJECTIVE To determine whether food insecurity and perceived financial stress contribute to cost-related medication non-adherence (CRN) in stroke. METHODS We conducted a retrospective study of adult stroke survivors in the National Health Interview Survey (2014-2018). Weighted prevalence of food insecurity, perceived financial stress, and CRN by age was calculated. Multiple logistic regression was conducted between food insecurity or perceived financial stress and CRN, adjusting for demographic and clinical variables. RESULTS Prevalence of food insecurity, perceived financial stress, and CRN respectively were 38%, 75%, and 26% (age 18-44), 38%, 76%, and 21% (age 45-64) and 17%, 43%, and 6% (age≥ 65). Food insecurity and perceived financial stress respectively were associated with CRN in stroke survivors aged 45-64 [odds ratio (95% CI) 1.35 (1.18-1.54) and 1.44 (1.29-1.61)] and age ≥ 65 [1.77 (1.52-2.06) and 1.51 (1.37-1.67)]. CONCLUSION Food insecurity and perceived financial stress are prevalent in stroke survivors and associated with CRN.
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21
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Kerber KA, Bi R, Skolarus LE, Burke JF. Trajectories in physical performance and fall prediction in older adults: A longitudinal population-based study. J Am Geriatr Soc 2022; 70:3413-3423. [PMID: 36527411 PMCID: PMC10086801 DOI: 10.1111/jgs.17995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/24/2022] [Accepted: 07/09/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND A physical performance evaluation can inform fall risk in older people, however, the predictiveness of a one-time assessment is limited. The trajectory of physical performance over time has not been well characterized and might improve fall prediction. We aimed to characterize trajectories in physical performance and determine if fall prediction improves using trajectories of performance. METHODS This was a cohort design using data from the National Health and Aging Trends Study. Physical performance was measured by the short physical performance battery (SPPB) with scores ranging from 0 (worst) to 12 (best). The trajectory of SPPB was categorized using latent class modeling and slope-based multilevel linear regression. We used Cox proportional hazards models with an outcome of time to ≥2 falls from annual self-report to assess predictiveness after adding SPPB trajectories to models of baseline SPPB and established non-physical-performance-based variables. RESULTS The sample was 5969 community-dwelling Medicare beneficiaries aged ≥65 years. The median number of annual SPPB evaluations was 4 (IQR, 3-7). Mean baseline SPPB was 9.2 (SD, 3.0). The latent class model defined SPPB trajectories over a range of two to nineteen categories. The mean slope from the slope-based model was -0.01 SPPB points/year (SD, 0.14). Discrimination of the baseline SPPB model to predict time to ≥2 falls was fair (Harrell's C, 0.65) and increased after adding the non-performance-based predictors (Harrell's C, 0.70). Discrimination slightly improved with the SPPB trajectory category variable that had the best fit (Harrell's C, 0.71) but did not improve with the SPPB linear slope. Calibration with and without the trajectory categories was similar. CONCLUSIONS We found that the trajectory of physical performance did not meaningfully improve upon fall prediction from a baseline physical performance assessment and established non-performance-based information. These results do not support longitudinal SPPB assessments for fall prediction.
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Affiliation(s)
| | - Ran Bi
- Department of NeurologyUniversity of MichiganAnn ArborMichiganUSA
| | | | - James F. Burke
- Department of NeurologyOhio State UniversityColumbusOhioUSA
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22
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Skolarus LE, Brown DL, Reynolds E, Shi Y, Volow AM, Burke JF, Sudore RL. Advance Care Planning Engagement May Increase Among Stroke Survivors: Results From the PREPARE for Your Care Trial. Stroke 2022; 53:e477-e478. [PMID: 36254707 PMCID: PMC9613593 DOI: 10.1161/strokeaha.122.040386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lesli E Skolarus
- Neurology Department, University of Michigan, Ann Arbor (L.E.S., D.L.B., E.R.)
| | - Devin L Brown
- Neurology Department, University of Michigan, Ann Arbor (L.E.S., D.L.B., E.R.)
| | - Evan Reynolds
- Neurology Department, University of Michigan, Ann Arbor (L.E.S., D.L.B., E.R.)
| | - Ying Shi
- Division of Geriatrics, University of California, San Francisco (Y.S., A.M.V., R.L.S.)
| | - Aiesha M Volow
- Division of Geriatrics, University of California, San Francisco (Y.S., A.M.V., R.L.S.)
| | - James F Burke
- Neurology Department, Ohio State University, Columbus (J.F.B.)
| | - Rebecca L Sudore
- Division of Geriatrics, University of California, San Francisco (Y.S., A.M.V., R.L.S.)
- San Francisco Veterans Affairs, California (R.L.S.)
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23
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Affiliation(s)
- Prateeti Khazanie
- Division of Cardiology, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO (P.K.)
| | - Lesli E Skolarus
- Davee Department of Neurology, Northwestern University, Feinberg School of Medicine Chicago, IL (L.E.S.)
| | - Geoffrey D Barnes
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI (G.D.B.)
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24
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Skolarus LE, Lin CC, Kelley AS, Burke JF. National End-of-Life-Treatment Preferences are Stable Over Time: National Health and Aging Trends Study. J Pain Symptom Manage 2022; 64:e189-e194. [PMID: 35764201 DOI: 10.1016/j.jpainsymman.2022.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 06/16/2022] [Accepted: 06/20/2022] [Indexed: 11/21/2022]
Abstract
CONTEXT Advance Care Planning is a process of understanding and sharing preferences regarding future medical care. OBJECTIVE To explore individual and national stability of end-of-life treatment preferences among a sample of older adults. METHODS National Health and Aging Trends Study is a nationally representative sample of older adults. In 2012, a random sample, and in 2018, the entire sample were queried on end-of-life treatment preferences defined as acceptance or rejection of life prolonging treatment (LPT) if they had a serious illness and were at the end of their life and in severe pain or had severe disability. Using a cohort design, we explored individual trends in preferences for LPT among those with responses in both waves (pain scenario: N = 606, disability scenario: N = 628) and, using a serial cross-sectional design, national trends in LPT among the entire sample (1702 older adults in wave 2 and 4342 in wave 8). RESULTS In the cohort study, individual preferences were stable over time (overall percent agreement = 86% for disability and 76% for pain scenarios), particularly for older adults who would reject LPT in wave 2 (overall agreement 92% for disability and 86% for pain). In the serial cross-sectional study, national trends in preferences for receipt of LPT were stable over time in the pain (27.4% vs. 27.0%, P = 0.80) and disability (15.8% vs. 15.7%, P = 0.99) scenarios. CONCLUSIONS We found that national trends in preferences for end-of-life treatment did not substantially change over time and may be stable within individual older adults.
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Affiliation(s)
- Lesli E Skolarus
- Department of Neurology (L.E.S., C.C.L.), Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan, USA.
| | - Chun Chieh Lin
- Department of Neurology (L.E.S., C.C.L.), Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Amy S Kelley
- Department of Geriatrics and Palliative Medicine (A.S.K.), Icahn School of Medicine at Mount Sinai, New York, New York, USA; James J Peters VA Medical Center (A.S.K.), Bronx, New York, USA
| | - James F Burke
- Department of Neurology (J.F.B.), Health Services Research Program, Ohio State University, Columbus, Ohio, USA
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25
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Skolarus LE, Springer MV, Bailey S, Rossman N, Corches CL. Partnering With a Home Health Agency to Implement a Brief Stroke Preparedness Intervention: Stroke Ready-Home Health. J Am Heart Assoc 2022; 11:e027462. [PMID: 36172965 PMCID: PMC9673744 DOI: 10.1161/jaha.122.027462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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26
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Merid B, Robles MC, Nallamothu BK, Newman MW, Skolarus LE. Correction: “Viewing Mobile Health Technology Design Through the Lens of Amplification Theory”. JMIR Mhealth Uhealth 2022; 10:e40273. [PMID: 35763796 PMCID: PMC9277527 DOI: 10.2196/40273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Beza Merid
- School for the Future of Innovation in SocietyArizona State UniversityTempe, AZUnited States
| | - Maria Cielito Robles
- Department of NeurologyUniversity of Michigan Medical SchoolAnn Arbor, MIUnited States
| | - Brahmajee K Nallamothu
- Department of Internal MedicineUniversity of Michigan Medical SchoolAnn Arbor, MIUnited States
| | - Mark W Newman
- School of InformationUniversity of MichiganAnn Arbor, MIUnited States
| | - Lesli E Skolarus
- Department of NeurologyUniversity of Michigan Medical SchoolAnn Arbor, MIUnited States
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27
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Merid B, Cielito Robles M, Nallamothu BK, Newman MW, Skolarus LE. Viewing Mobile Health Technology Design Through the Lens of Amplification Theory. JMIR Mhealth Uhealth 2022; 10:e31069. [PMID: 35687411 PMCID: PMC9233258 DOI: 10.2196/31069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 03/31/2022] [Accepted: 04/29/2022] [Indexed: 12/03/2022] Open
Abstract
Digital health interventions designed to promote health equity can be valuable tools in the delivery of health care to hardly served patient populations. But if the design of these technologies and the interventions in which they are deployed do not address the myriad structural barriers to care that minoritized patients, patients in rural areas, and patients who have trouble paying for care often face, their impact may be limited. Drawing on our mobile health (mHealth) research in the arena of cardiovascular care and blood pressure management, this viewpoint argues that health care providers and researchers should tend to structural barriers to care as a part of their digital health intervention design. Our 3-step predesign framework, informed by the Amplification Theory of Technology, offers a model that interventionists can follow to address these concerns.
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Affiliation(s)
- Beza Merid
- School for the Future of Innovation in Society, Arizona State University, Tempe, AZ, United States
| | - Maria Cielito Robles
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Mark W Newman
- School of Information, University of Michigan, Ann Arbor, MI, United States
| | - Lesli E Skolarus
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
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28
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Robles MC, Newman MW, Doshi A, Bailey S, Huang L, Choi SJ, Kurien C, Merid B, Cowdery J, Golbus JR, Huang C, Dorsch MP, Nallamothu B, Skolarus LE. A Physical Activity Just-in-time Adaptive Intervention Designed in Partnership With a Predominantly Black Community: Virtual, Community-Based Participatory Design Approach. JMIR Form Res 2022; 6:e33087. [PMID: 35343906 PMCID: PMC9002607 DOI: 10.2196/33087] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 11/15/2021] [Accepted: 12/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background Black people are disproportionally impacted by hypertension. New approaches for encouraging healthy lifestyles are needed to reduce hypertension and promote health equity in Black communities. Objective In this report, we describe the early-stage, virtual design of a just-in-time adaptive intervention (JITAI) to increase physical activity in partnership with members of a low-income, predominantly Black community. Methods The hallmark of JITAIs is highly contextualized mobile app push notifications. Thus, understanding participants' context and determinants of physical activity are critical. During the height of the COVID-19 pandemic, we conducted virtual discovery interviews and analysis guided by the Behavior Change Wheel (which focuses on participants' capacity, opportunity, and motivation to engage in physical activity), as well as empathy mapping. We then formed a community-academic participatory design team that partnered in the design sprint, storyboarding, and paper prototyping. Results For this study, 5 community members participated in the discovery interviews, 12 stakeholders participated in the empathy mapping, 3 community members represented the community on the design team, and 10 community members provided storyboard or paper prototyping feedback. Only one community member had used videoconferencing prior to partnering with the academic team, and none had design experience. A set of 5 community-academic partner design principles were created: (1) keep users front and center, (2) tailor to the individual, (3) draw on existing motivation, (4) make physical activity feel approachable, and (5) make data collection transparent yet unobtrusive. To address community-specific barriers, the community-academic design team decided that mobile app push notifications will be tailored to participants’ baseline mobility level and community resources (eg, local parks and events). Push notifications will also be tailored based on the day (weekday versus weekend), time of day, and weather. Motivation will be enhanced via adaptive goal setting with supportive feedback and social support via community-generated notifications. Conclusions We completed early-stage virtual design of a JITAI in partnership with community participants and a community design team with limited design and videoconferencing experience. We found that designing JITAIs with the community enables these interventions to address community-specific needs, which may lead to a more meaningful impact on users' health.
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Affiliation(s)
| | - Mark W Newman
- School of Information, University of Michigan, Ann Arbor, MI, United States
| | - Aalap Doshi
- Michigan Institute for Clinical & Health Research, University of Michigan, Ann Arbor, MI, United States
| | - Sarah Bailey
- Bridges into the Future, Flint, MI, United States
| | - Linde Huang
- Michigan Institute for Clinical & Health Research, University of Michigan, Ann Arbor, MI, United States
| | - Soo Ji Choi
- School of Information, University of Michigan, Ann Arbor, MI, United States
| | - Chris Kurien
- School of Information, University of Michigan, Ann Arbor, MI, United States
| | - Beza Merid
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Joan Cowdery
- School of Health Promotion and Human Performance, Eastern Michigan University, Ypsilanti, MI, United States
| | - Jessica R Golbus
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Christopher Huang
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Michael P Dorsch
- College of Pharmacy, University of Michigan, Ann Arbor, MI, United States
| | - Brahmajee Nallamothu
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Lesli E Skolarus
- Department of Neurology, University of Michigan, Ann Arbor, MI, United States
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Springer MV, Skolarus LE, Feng C, Burke JF. Functional Impairment and Postacute Care Discharge Setting May Be Useful for Stroke Survival Prognostication. J Am Heart Assoc 2022; 11:e024327. [PMID: 35232223 PMCID: PMC9075325 DOI: 10.1161/jaha.121.024327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background The aim of this study was to discussions about post‐stroke outcomes related to post‐stroke function and post‐acute care discharge setting.inform patient‐provider. Methods and Results We conducted a retrospective cohort study of Medicare beneficiaries with acute ischemic stroke or intracerebral hemorrhage in 2013. Our primary outcome was mortality within at least 1‐year post discharge. We performed multivariate logistic regression to estimate 90‐day odds ratios (ORs) and Cox proportional hazards regression to estimate post 90‐day hazard ratios on mortality, adjusting for demographics, procedures, comorbidities, discharge setting (inpatient rehabilitation facility, skilled nursing facility, or home health care agency), post‐stroke function (measured by the Functional/Pseudo‐Functional Independence Measure) and setting‐function interactions. There were 167 000 patients with a mean follow‐up of 441 days. Mortality within 90 days was associated with post‐stroke function (OR, 0.23; 95% CI, 0.19–0.27 comparing highest to lowest quintile of post‐stroke function) and discharge setting (OR, 4.05; 95% CI, 3.78–4.33 for skilled nursing facility versus inpatient rehabilitation facility). Among the highest functioning patients, those discharged to inpatient rehabilitation facility had a 1‐year mortality of 9% and those discharged with home health had 11% mortality at 1 year. The lowest functioning survivors of stroke discharged to a skilled nursing facility had 64% mortality at 1 year and those discharged to an inpatient rehabilitation facility had 29.6% mortality at 1 year. Conclusions Nearly two thirds of the lowest functioning survivors of stroke discharged to a skilled nursing facility die within a year. This finding should inform discussions between providers and patients/caregivers in aligning goals of care with the care survivors of stroke receive.
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Affiliation(s)
- Mellanie V Springer
- Stroke Program Department of Neurology University of Michigan Medical School Ann Arbor MI
| | - Lesli E Skolarus
- Stroke Program Department of Neurology University of Michigan Medical School Ann Arbor MI
| | - Chunyang Feng
- Stroke Program Department of Neurology University of Michigan Medical School Ann Arbor MI
| | - James F Burke
- Stroke Program Department of Neurology University of Michigan Medical School Ann Arbor MI
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30
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Skolarus LE, Robles MC, Mansour M, Sudore RL, Reynolds EL, Burke JF, Corches CL, Brown DL. Low Engagement of Advance Care Planning Among Patients Who Had a Stroke or Transient Ischemic Attack. J Am Heart Assoc 2022; 11:e024436. [PMID: 35229620 PMCID: PMC9075305 DOI: 10.1161/jaha.121.024436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lesli E Skolarus
- Stroke Program University of Michigan Medical School Ann Arbor MI.,Neurology Health Services Research Program University of Michigan Medical School Ann Arbor MI
| | | | - Maria Mansour
- Stroke Program University of Michigan Medical School Ann Arbor MI
| | - Rebecca L Sudore
- Division of Geriatrics Department of Medicine University of California San Francisco CA.,San Francisco Veterans Affairs Health Care System San Francisco CA
| | - Evan L Reynolds
- Neurology Health Services Research Program University of Michigan Medical School Ann Arbor MI
| | - James F Burke
- Stroke Program University of Michigan Medical School Ann Arbor MI.,Neurology Health Services Research Program University of Michigan Medical School Ann Arbor MI.,Ann Arbor Veterans Affairs Health Care System Ann Arbor MI
| | - Casey L Corches
- Stroke Program University of Michigan Medical School Ann Arbor MI
| | - Devin L Brown
- Stroke Program University of Michigan Medical School Ann Arbor MI
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31
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Barnes GD, Skolarus LE, Khazanie P. Call to Action: Translating Scientific Research Into Real-World Change Through Implementation Science and Community-Engaged Research. Circ Cardiovasc Qual Outcomes 2022; 15:e009031. [PMID: 35232216 DOI: 10.1161/circoutcomes.122.009031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Geoffrey D Barnes
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor (G.D.B.)
| | - Lesli E Skolarus
- University of Michigan Cardiovascular Center, Ann Arbor, MI (L.E.S.)
| | - Prateeti Khazanie
- Division of Cardiology, Section of Advanced Heart Failure, Transplantation, and Mechanical Circulatory Support, University of Colorado Anschutz Medical Campus, Aurora (P.K.)
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32
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Springer MV, Bi R, Skolarus LE, Lin CC, Burke JF. Community Intent to Activate Emergency Medical Services May Be Associated with Regional tPA Treatment. Cerebrovasc Dis 2022; 51:207-213. [PMID: 34515063 PMCID: PMC8898989 DOI: 10.1159/000518729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/25/2021] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Acute stroke treatments are underutilized in the USA. Enhancing stroke preparedness, the recognition of stroke symptoms, and intent to call emergency medical services (EMS) could reduce delay in hospital arrival thereby increasing eligibility for time-sensitive stroke treatments. Whether higher stroke preparedness is associated with higher tissue plasminogen activator (tPA) treatment rates is however uncertain. We therefore set out to determine the contribution of stroke preparedness to regional variation in tPA treatment. METHODS The region was defined by hospital service area (HSA). Stroke preparedness was determined by using Behavioral Risk Factor Surveillance System survey questions assessing stroke symptom recognition and intent to call 911 in response to a stroke. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, and 2011, adjusting for number of stroke hospitalizations in each HSA (primary outcome). We performed multivariate linear regression to estimate the association of regional stroke preparedness on log-transformed tPA treatment rates controlling for demographic, EMS, and hospital characteristics. RESULTS The adjusted percentage of stroke patients receiving tPA ranged from 1.4% (MIN) to 11.3% (MAX) of stroke/TIA hospitalizations. Across HSAs, a median (IQR) of 86% (81-90%) of responses to a witnessed stroke indicated intent to call 911, and a median (IQR) of 4.4 (4.2-4.6) out of 6 stroke symptoms was recognized. Every 1% increase in an HSA's intent to call 911 was associated with a 0.44% increase in adjusted tPA treatment rate (p = 0.05). Lower accuracy of recognition of stroke symptoms was associated with higher adjusted tPA treatment rates (p = 0.05). CONCLUSIONS There was little regional variation in intent to call EMS and stroke symptom recognition. Intent to call EMS and stroke symptom recognition are modest contributors to regional variation in tPA treatment.
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Affiliation(s)
| | - Ran Bi
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lesli E. Skolarus
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Chun Chieh Lin
- University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James F. Burke
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan, USA
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33
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Springer MV, Conley KM, Sanchez BN, Resnicow K, Cowdery JE, Skolarus LE, Morgenstern LB, Brown DL. Process Evaluation of a Faith-Based Multicomponent Behavioral Intervention to Reduce Stroke Risk in Mexican Americans in a Catholic Church Setting: The SHARE (Stroke Health and Risk Education) Project. J Relig Health 2021; 60:3915-3930. [PMID: 33687633 PMCID: PMC9088157 DOI: 10.1007/s10943-021-01216-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/18/2021] [Indexed: 05/25/2023]
Abstract
Church-based stroke prevention programs for Hispanics are underutilized. The Stroke Health and Risk Education (SHARE) project, a multicomponent cluster-randomized trial, addressed key stroke risk factors among predominantly Mexican Americans in a Catholic Church setting. Process evaluation components (implementation, mechanisms of impact, and context) are described. Partner support promoted positive health behavior change. Motivational interviewing calls were perceived as helpful, however, barriers with telephone delivery were encountered. Intervention exposure was associated with theory constructs for targeted behaviors. We conclude that health behavior interventions to prevent stroke can be successfully implemented for Mexican Americans within a Catholic Church setting, with parish priest support.
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Affiliation(s)
- Mellanie V Springer
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, SPC 5855, Ann Arbor, MI, 48109-5855, USA.
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Kathleen M Conley
- School of Health Promotion and Human Performance, Eastern Michigan University, Ypsilanti, MI, USA
| | - Brisa N Sanchez
- Department of Epidemiology and Biostatistics, Drexel University, Philadelphia, PA, USA
| | - Ken Resnicow
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Joan E Cowdery
- School of Health Promotion and Human Performance, Eastern Michigan University, Ypsilanti, MI, USA
| | - Lesli E Skolarus
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, SPC 5855, Ann Arbor, MI, 48109-5855, USA
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Lewis B Morgenstern
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, SPC 5855, Ann Arbor, MI, 48109-5855, USA
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Devin L Brown
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, SPC 5855, Ann Arbor, MI, 48109-5855, USA
- Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, USA
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Skolarus LE, Dinh M, Kidwell KM, Farhan Z, Whitfield C, Levine DA, Meurer WJ. Supplement study update for Reach Out: a multi-arm randomized trial of behavioral interventions for hypertension initiated in the emergency department: Reach Out Cognition. Trials 2021; 22:836. [PMID: 34819115 PMCID: PMC8611628 DOI: 10.1186/s13063-021-05806-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Reach Out is a factorial trial studying multicomponent behavioral interventions to reduce blood pressure in hypertensive emergency department patients. The original study protocol was published in June 2020. Here, we describe the updated protocol, including a supplemental study, Reach Out Cognition. Reach Out Cognition is a remote study that will assess the acceptability, feasibility, and satisfaction of digital, self-administered cognitive assessments and Bluetooth-enabled, self-measured blood pressure monitoring in the Reach Out population. We will also estimate the prevalence of mild cognitive impairment in Reach Out participants. Methods Reach Out Cognition includes remote enrollment and follow-up assessments. Reach Out Cognition extends Reach Out data collection past the current 12 months to 15 and 18 months. Participants will be Reach Out participants who complete their 12-month outcome assessments and opt to continue in the cohort study. Participants will continue to receive the Reach Out intervention, consisting of (1) daily healthy behavior text messaging and (2) weekly self-measured blood pressure monitoring. Blood pressure will be measured using Bluetooth-enabled self-measured blood pressure monitoring devices, and cognition will be measured using digital self-administered cognitive assessments at 12, 15, and 18 months. Discussion Reach Out Cognition will explore the potential of remote, digital, self-administered assessments of blood pressure and cognition among predominantly working-age Black Americans. Reach Out Cognition will inform future clinical trials and clinical remote monitoring of blood pressure and cognition that may lead to new approaches to treating and reducing hypertension and cognitive disparities. Trial registration ClinicalTrials.gov NCT03422718. The record was first available to the public on January 30, 2018, prior to the enrollment of patients on March 25, 2019.
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Affiliation(s)
- Lesli E Skolarus
- Department of Neurology, University of Michigan, Ann Arbor, USA.,Stroke Program, University of Michigan, Ann Arbor, USA
| | - Mackenzie Dinh
- Department of Emergency Medicine, University of Michigan, Ann Arbor, USA.
| | - Kelley M Kidwell
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, USA
| | - Zahera Farhan
- Department of Emergency Medicine, University of Michigan, Ann Arbor, USA
| | - Candace Whitfield
- Department of Emergency Medicine, University of Michigan, Ann Arbor, USA
| | - Deborah A Levine
- Department of Neurology, University of Michigan, Ann Arbor, USA.,Stroke Program, University of Michigan, Ann Arbor, USA.,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA
| | - William J Meurer
- Department of Neurology, University of Michigan, Ann Arbor, USA.,Stroke Program, University of Michigan, Ann Arbor, USA.,Department of Emergency Medicine, University of Michigan, Ann Arbor, USA.,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA.,Michigan Institute for Integrative Research in Critical Care (MCIRCC), University of Michigan, Ann Arbor, USA
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Willis A, Skolarus LE, Faigle R, Menon U, Redwine H, Brown AM, Felton E, Mendizabal A, Nath A, Jensen F, McArthur JC. Strengthened through Diversity: A Blueprint for Organizational Change. Ann Neurol 2021; 90:524-536. [PMID: 34236104 PMCID: PMC8478779 DOI: 10.1002/ana.26165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 07/06/2021] [Indexed: 11/09/2022]
Affiliation(s)
- Allison Willis
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
| | | | - Roland Faigle
- Department of Neurology, Johns Hopkins University, Baltimore, MD
| | - Uma Menon
- Ochsner Neuroscience Institute, Covington, LA
| | - Hannah Redwine
- University of the Incarnate Word School of Osteopathic Medicine, San Antonio, TX
| | - Amanda M Brown
- Department of Neurology, Johns Hopkins University, Baltimore, MD
| | | | - Adys Mendizabal
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA
| | | | - Frances Jensen
- Department of Neurology, University of Pennsylvania, Philadelphia, PA
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Hill CE, Lin CC, Terman SW, Rath S, Parent JM, Skolarus LE, Burke JF. Definitions of Drug-Resistant Epilepsy for Administrative Claims Data Research. Neurology 2021; 97:e1343-e1350. [PMID: 34266920 DOI: 10.1212/wnl.0000000000012514] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 07/01/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess accuracy of definitions of drug-resistant epilepsy applied to administrative claims data. METHODS We randomly sampled 450 patients from a tertiary health system with >1 epilepsy/convulsion encounter and >2 distinct antiseizure medications (ASMs) from 2014-2020 and >2 years of electronic medical records (EMR) data. We established a drug-resistant epilepsy diagnosis at a specific visit by reviewing EMR data and employing a rubric based in the 2010 International League Against Epilepsy definition. We performed logistic regressions to assess clinically-relevant predictors of drug-resistant epilepsy and to inform claims-based definitions. RESULTS Of 450 patients reviewed, 150 were excluded for insufficient EMR data. Of the 300 patients included, 98 (33%) met criteria for current drug-resistant epilepsy. The strongest predictors of current drug-resistant epilepsy were drug-resistant epilepsy diagnosis code (OR 16.9, 95% CI 8.8-32.2), >2 ASMs in the prior two years (OR 13.0, 95% CI 5.1-33.3), >3 non-gabapentinoid ASMs (OR 10.3, 95% CI 5.4-19.6), neurosurgery visit (OR 45.2, 95% CI 5.9-344.3), and epilepsy surgery (OR 30.7, 95% CI 7.1-133.3). We created claims-based drug-resistant epilepsy definitions to: 1) maximize overall predictiveness (drug-resistant epilepsy diagnosis; sensitivity 0.86, specificity 0.74, area under the receiver operating characteristics curve [AUROC] 0.80), 2) maximize sensitivity (drug-resistant epilepsy diagnosis or >3 ASMs; sensitivity 0.98, specificity 0.47, AUROC 0.72), and 3) maximize specificity (drug-resistant epilepsy diagnosis and >3 non-gabapentinoid ASMs; sensitivity 0.42, specificity 0.98, AUROC 0.70). CONCLUSIONS Our findings provide validation for several claims-based definitions of drug-resistant epilepsy that can be applied to a variety of research questions.
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Affiliation(s)
- Chloe E Hill
- Health Services Research Program, Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Chun Chieh Lin
- Health Services Research Program, Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Samuel W Terman
- Health Services Research Program, Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Subhendu Rath
- Department of Neurology, University of Michigan, Ann Arbor, MI
| | - Jack M Parent
- Department of Neurology, University of Michigan, Ann Arbor, MI.,Veterans Affairs Healthcare System, Ann Arbor, MI.,Michigan Neuroscience Institute, Ann Arbor, MI
| | - Lesli E Skolarus
- Health Services Research Program, Department of Neurology, University of Michigan, Ann Arbor, MI
| | - James F Burke
- Health Services Research Program, Department of Neurology, University of Michigan, Ann Arbor, MI.,Veterans Affairs Healthcare System, Ann Arbor, MI
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Skolarus LE, Brown DL, Corches CL, Reynolds E, Bailey S, Mansour M, Robles MC, Rice T, Springer MV, Burke JF, Sudore RL. Extending Advance Care Planning to Black Americans in the Community: A Pilot Study of the PREPARE Program. J Pain Symptom Manage 2021; 62:e4-e9. [PMID: 33647422 PMCID: PMC8435356 DOI: 10.1016/j.jpainsymman.2021.02.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/18/2021] [Accepted: 02/23/2021] [Indexed: 10/22/2022]
Abstract
CONTEXT Advance care planning (ACP) is underutilized, especially among Black Americans. Yet, no ACP interventions have been tested at the community level. OBJECTIVES Within an established academic and community partnership, we sought to determine whether ACP is a community-identified need and if so, to conduct a pilot study of an evidence-based ACP program, PREPARE (PrepareForYourCare.org). METHODS We conducted open discussions and in-depth interviews to determine the relevance of ACP to the community. We then conducted a pre- to 3-week postpilot study of a virtual peer facilitated brief session to introduce ACP and encourage participants to engage with PREPARE. We conducted thematic content analysis for qualitative data and used paired t-tests to assess within-participant changes in the validated ACP Engagement Survey measured on a 1-5 scale (5 = greatest engagement). RESULT We conducted two discussion groups with community leaders (n = 12) and key informant interviews (n = 6), including leaders in aging, public health, health care and faith. We concluded that ACP is a community priority. In the pilot study, we enrolled 13 Black Americans; 85% were women and the mean age was 59.7 years (SD 15.1). There was a trend toward increased ACP engagement after the peer facilitated PREPARE (mean 3.2 (SD 0.6) pre vs. 3.5 (SD 0.6) post, paired t-test P = 0.06). All participants found the intervention to be acceptable and were satisfied with it. CONCLUSION Community members identified ACP as important for their community. Peer facilitated PREPARE program is a promising community-based strategy to increase engagement in ACP and may promote health equity.
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Affiliation(s)
- Lesli E Skolarus
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan; Neurology Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Devin L Brown
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan
| | - Casey L Corches
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan
| | - Evan Reynolds
- Neurology Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Maria Mansour
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan
| | | | - Tia Rice
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan
| | - Mellanie V Springer
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan; Neurology Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan
| | - James F Burke
- Stroke Program, University of Michigan Medical School, Ann Arbor, Michigan; Neurology Health Services Research Program, University of Michigan Medical School, Ann Arbor, Michigan; Ann Arbor Veterans Affairs Health Care System, Ann Arbor, Michigan
| | - Rebecca L Sudore
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, California; San Francisco Veterans Affairs Health Care System, San Francisco, California
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Appukutty AJ, Skolarus LE, Springer MV, Meurer WJ, Burke JF. Increasing false positive diagnoses may lead to overestimation of stroke incidence, particularly in the young: a cross-sectional study. BMC Neurol 2021; 21:152. [PMID: 33832441 PMCID: PMC8028807 DOI: 10.1186/s12883-021-02172-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Accepted: 03/25/2021] [Indexed: 11/30/2022] Open
Abstract
Background Stroke incidence is reportedly increasing in younger populations, although the reasons for this are not clear. We explored possible reasons by quantifying trends in neurologically focused emergency department (ED) visits, classification of stroke vs. TIA, and imaging use. Methods We performed a retrospective, serial, cross-sectional study using the National Hospital Ambulatory Medical Care Survey to examine time trends in age-stratified primary reasons for visit, stroke/TIA diagnoses, and MRI utilization from 1995 to 2000 and 2005–2015. Results Five million eight hundred thousand ED visits with a primary diagnosis of stroke (CI 5.3 M–6.4 M) were represented in the data. The incidence of neurologically focused reason for visits (Neuro RFVs) increased over time in both the young and in older adults (young: + 111 Neuro RFVs/100,000 population/year, CI + 94 − + 130; older adults: + 70 Neuro RFVs/100,000 population/year, CI + 34 − + 108). The proportion of combined stroke and TIA diagnoses decreased over time amongst older adults with a Neuro RFV (OR 0.95 per year, p < 0.01, CI 0.94–0.96) but did not change in the young (OR 1.00 per year, p = 0.88, CI 0.95–1.04). Within the stroke/TIA population, no changes in the proportion of stroke or TIA were identified. MRI utilization rates amongst patients with a Neuro RFV increased for both age groups. Conclusions We found, but did not anticipate, increased incidence of neurologically focused ED visits in both age groups. Given the lower pre-test probability of a stroke in younger adults, this suggests that false positive stroke diagnoses may be increasing and may be increasing more rapidly in the young than in older adults. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02172-1.
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Affiliation(s)
- Abhinav J Appukutty
- University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Lesli E Skolarus
- Stroke Program, University of Michigan Medical School, Ann Arbor, MI, 48109, USA.,School of Public Health, University of Michigan, 1415 Washington Heights, Ann Arbor, MI, 48109, USA
| | - Mellanie V Springer
- Stroke Program, University of Michigan Medical School, Ann Arbor, MI, 48109, USA
| | - William J Meurer
- Stroke Program, University of Michigan Medical School, Ann Arbor, MI, 48109, USA.,Emergency Department, University of Michigan Medical School, 1500 E Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - James F Burke
- Stroke Program, University of Michigan Medical School, Ann Arbor, MI, 48109, USA. .,Department of Neurology, VA Ann Arbor Healthcare System, Ann Arbor, MI, 48105, USA.
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Lin CC, Hill CE, Burke JF, Kerber KA, Hartley SE, Callaghan BC, Skolarus LE. Primary care providers perform more neurologic visits than neurologists among Medicare beneficiaries. J Eval Clin Pract 2021; 27:223-227. [PMID: 32754960 DOI: 10.1111/jep.13439] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 05/29/2020] [Accepted: 06/07/2020] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Little is known about which medical providers, other than neurologists, are involved in the care of neurologic conditions. We aimed to describe the current distribution of outpatient neurologic care by provider type. METHODS We conducted a restrospective, cross-sectional analysis using a 20% national sample claims database that contains information on medical care utilizations from adult Fee-for-Service Medicare beneficiaries in 2015. We identified patient visits for evaluation and management services for common neurologic conditions and by medical provider type. The main outcome was the proportion of visits for neurologic conditions by medical provider type, both in aggregate and across neurologic conditions. RESULTS 40% of neurologic visits were performed by primary care providers (PCPs) and 17.5% by neurologists. The most common neurologic conditions were back pain (49.3%), sleep disorders (8.0%), chronic pain/abnormality of gait (6.4%), peripheral neuropathy (5.9%), and stroke (5.5%). Neurologists cared for a large proportion of visits for Parkinson's disease (75.6% vs 20.8%), epilepsy (70.9% vs 26.6%), multiple sclerosis (63.9% vs 26.2%), other central NS disorders (54.2% vs 24.9%), and tremor/RLS/ALS (54.0% vs 31.2%) compared to PCPs. PCPs provided a greater proportion of visits for dizziness/vertigo (57.8% vs 9.3%) and headache/migraine (50.4% vs 35.0%) compared to neurologists. CONCLUSIONS PCPs perform more neurologic visits than neurologists. With the anticipated increased demand for neurologic care, strategies to optimize neurologic care delivery could consider expanding access to neurologists as well as supporting PCP care for neurologic conditions.
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Affiliation(s)
- Chun Chieh Lin
- Health Services Research Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Chloe E Hill
- Health Services Research Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James F Burke
- Health Services Research Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Kevin A Kerber
- Health Services Research Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Sarah E Hartley
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Brian C Callaghan
- Health Services Research Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Lesli E Skolarus
- Health Services Research Program, Department of Neurology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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Springer MV, Sales AE, Islam N, McBride AC, Landis-Lewis Z, Tupper M, Corches CL, Robles MC, Skolarus LE. A step toward understanding the mechanism of action of audit and feedback: a qualitative study of implementation strategies. Implement Sci 2021; 16:35. [PMID: 33794952 PMCID: PMC8017642 DOI: 10.1186/s13012-021-01102-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 03/19/2021] [Indexed: 01/05/2023] Open
Abstract
Background Audit and feedback (A&F) is a widely used implementation strategy. Understanding mechanisms of action of A&F increases the likelihood that the strategy will lead to implementation of an evidence-based practice. We therefore sought to understand one hospital’s experience selecting and implementing an A&F intervention, to determine the implementation strategies that were used by staff and to specify the mechanism of action of those implementation strategies using causal pathway models, with the ultimate goal of improving acute stroke treatment practices. Methods We selected an A&F strategy in a hospital, initially based on implementation determinants and staff consideration of their performance on acute stroke treatment measures. After 7 months of A&F, we conducted semi-structured interviews of hospital providers and administrative staff to understand how it contributed to implementing guideline-concordant acute stroke treatment (medication named tissue plasminogen activator). We coded the interviews to identify the implementation strategies that staff used following A&F and to assess their mechanisms of action. Results We identified five implementation strategies that staff used following the feedback intervention. These included (1) creating folders containing the acute stroke treatment protocol for the emergency department, (2) educating providers about the protocol for acute stroke, (3) obtaining computed tomography imaging of stroke patients immediately upon emergency department arrival, (4) increasing access to acute stroke medical treatment in the emergency department, and (5) providing additional staff support for implementation of the protocol in the emergency department. We identified enablement, training, and environmental restructuring as mechanisms of action through which the implementation strategies acted to improve guideline-concordant and timely acute stroke treatment. Conclusions A&F of a hospital’s acute stroke treatment practices generated additional implementation strategies that acted through various mechanisms of action. Future studies should focus on how initial implementation strategies can be amplified through internal mechanisms. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-021-01102-6.
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Affiliation(s)
- Mellanie V Springer
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Anne E Sales
- Department of Veteran Affairs Center for Clinical Management Research, Ann Arbor, MI, USA.,Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Nishat Islam
- School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Zach Landis-Lewis
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, MI, USA
| | - Michael Tupper
- University of Michigan Medical School, Ann Arbor, MI, USA
| | - Casey L Corches
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Maria Cielito Robles
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Lesli E Skolarus
- Stroke Program, University of Michigan Medical School, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
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Morgenstern LB, Zahuranec DB, Lim J, Shi X, Brown DL, Kerber KA, Meurer WJ, Skolarus LE, Adelman EE, Campbell MS, Case E, Lisabeth LD. Tissue-Based Stroke Definition Impacts Stroke Incidence but not Ethnic Differences. J Stroke Cerebrovasc Dis 2021; 30:105727. [PMID: 33761450 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES We explored how the new, tissue-based stroke definition impacted incidence estimates, including an ethnic comparison, in a population-based study. METHODS Stroke patients, May, 2014-May, 2016 in Nueces County, Texas were ascertained and validated using source documentation. Overall, ethnic-specific and age-specific Poisson regression models were used to compare first-ever ischemic stroke and intracerebral hemorrhage (ICH) incidence between old and new stroke definitions, adjusting for age, ethnicity, sex, and National Institutes of Health Stroke Scale score. RESULTS Among 1308 subjects, 1245 (95%) were defined as stroke by the old definition and 63 additional cases (5%) according to the new. There were 12 cases of parenchymal hematoma (PH1 or PH2) that were reclassified from ischemic stroke to ICH. Overall, incidence of ischemic stroke was slightly higher under the new compared to the old definition (RR 1.07; 95% CI 0.99-1.16); similarly higher in both Mexican Americans (RR 1.06; 95% CI 1.00-1.12) and Non Hispanic whites (RR 1.09, 95% CI 0.97-1.22), p(ethnic difference)=0.36. Overall, incidence of ICH was higher under the new definition compared to old definition (RR 1.16; 95% CI 1.05-1.29), similarly higher among both Mexican Americans (RR 1.14; 95% CI 1.06-1.23) and Non Hispanic whites (RR 1.20, 95% CI 1.03-1.39), p(ethnic difference)=0.25. CONCLUSION Modest increases in ischemic stroke and ICH incidence occurred using the new compared with old stroke definition. There were no differences between Mexican Americans and non Hispanic whites. These estimates provide stroke burden estimates for public health planning.
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Affiliation(s)
- Lewis B Morgenstern
- Stroke Program, Michigan Medicine, Ann Arbor, United States; Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, United States; Department of Emergency Medicine, Michigan Medicine, Ann Arbor, United States.
| | | | - Jaewon Lim
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, United States
| | - Xu Shi
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, United States
| | - Devin L Brown
- Stroke Program, Michigan Medicine, Ann Arbor, United States
| | - Kevin A Kerber
- Stroke Program, Michigan Medicine, Ann Arbor, United States
| | - William J Meurer
- Stroke Program, Michigan Medicine, Ann Arbor, United States; Department of Emergency Medicine, Michigan Medicine, Ann Arbor, United States
| | | | - Eric E Adelman
- Department of Neurology, University of Wisconsin, Madison, United States
| | | | - Erin Case
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, United States
| | - Lynda D Lisabeth
- Stroke Program, Michigan Medicine, Ann Arbor, United States; Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, United States
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Robles MC, Corches C, Bradford M, Rice T, Sukul D, Springer M, Bailey S, Oliver A, Skolarus LE. Abstract P871: Community and Academic Partner Creation of a Community-Informed, Behavior Theory-Based Music Video to Encourage Stroke Preparedness During the Covid-19 Pandemic. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Black Americans comprise 14% of Michigan’s population, but 30% of the COVID-19 cases and 40% of deaths. The accumulating national quantitative data on decreased presentation and increased pre-hospital delay during the pandemic confirmed our Flint, MI community partners’ impression of a decline in stroke presentations. Thus, we set out to understand the community’s perception of seeking acute stroke care during the pandemic which will inform the development and dissemination of public health messaging in a predominantly Black American community.
Method:
To honor social distancing orders, we conducted semi-structured interviews based on the Theory of Planned Behavior via HIPAA-approved teleconferencing with community members. Due to the clinical and public health implications of the pandemic, we employed a rapid assessment approach to streamline qualitative data analysis. Results were used to inform the creation of a music video. Lyrics were written by the academic team, set to a soundtrack and sung by a community partner. The music video theme was conceptualized by the academic team and performed by both academic and community partners.
Results:
We reached thematic saturation after completing 15 semi-structured interviews with Flint, MI community members. Mean duration of interviews was 40 minutes. Eighty percent of participants were Black; median age was 50; 74% were women and 47% reported some college or above. There was an unfavorable attitude towards seeking emergent stroke care via ambulance and at the hospital, due to concerns for viral transmission at the hospital, hospital capacity and ability to triage, and quality of care. Community and academic partners co-created a music video with verses addressing the community-identified barriers: “
stroke is an emergency all the time, even with COVID-19 / get to the hospital as soon as symptoms start, it’s so important to do your part, be Stroke Ready”
(https://youtu.be/lKefAiUM2W0) The video reached over 1,200 users on our community-academic partner Stroke Ready Facebook page.
Conclusion:
We found that community members’ attitudes and perceived behavioral control to seek emergent stroke care were impacted during the COVID-19 pandemic. We addressed these barriers in an academic-community partner created music video. Academic and community partnerships facilitated a timely, innovative response to seeking acute stroke care in the setting of the COVID-19 pandemic.
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Affiliation(s)
| | | | | | - Tia Rice
- Univ of Michigan Med Sch, Ann Arbor, MI
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Springer MV, Bi R, Skolarus LE, Lin CC, Burke JF. Abstract P23: The Contribution of Stroke Preparedness to Regional Variation in Tissue Plasminogen Activator Treatment. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Unexplained regional variation exists in tissue plasminogen activator (tPA) treatment for stroke. Whether regional differences in stroke preparedness (stroke knowledge and intent to call 911) exist and contribute to tPA administration is unknown. We therefore sought to determine the contribution of stroke preparedness to regional variation in stroke treatment, as an association might support region-specific stroke preparedness interventions.
Methods:
We performed a retrospective ecological cross-sectional study measuring the association of regional stroke preparedness and regional tPA administration. We used Medicare data to determine the percentage of tPA-treated hospitalized stroke patients in 2007, 2009, & 2011, adjusting for the number of stroke hospitalizations in each hospital service area (HSA) (primary outcome). We determined stroke preparedness from Behavior Risk Factor Surveillance System survey questions assessing stroke symptom knowledge (score range 0-6) and intent to call 911 (score range 0-1) (exposure of interest). The association between regional preparedness and tPA treatment was assessed using multiple linear regression, adjusting for regional characteristics (demographic factors, the presence of EMS bypass, number of primary stroke centers, and hospital stroke volume).
Results:
There were 1738 HSAs. The adjusted percentage of stroke patients receiving tPA ranged from 1.37% (MIN) to 11.29% (MAX). Across HSAs, a median (IQR) of 86% (81%-90%) of responses to a witnessed stroke indicated intent to call 911 and a median (IQR) of 4.42 (4.24-4.59) out of 6 stroke symptoms were correctly recognized. Every 1% increase in accuracy in the question assessing intent to call 911 was associated with a 0.44% increase in adjusted tPA rate (p=0.049). Accurate stroke symptom recognition was not significantly associated with adjusted tPA rates across regions (p=0.05).
Conclusions:
Overall, there was little regional variation in intent to call 911 and stroke symptom recognition. Intent to activate EMS in response to a witnessed stroke is likely a modest contributor to regional variation in tPA treatment.
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Affiliation(s)
| | - Ran Bi
- Univ of Michigan, Ann Arbor, MI
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Hill CE, Reynolds EL, Burke JF, Banerjee M, Kerber KA, Magliocco B, Esper GJ, Skolarus LE, Callaghan BC. Increasing Out-of-Pocket Costs for Neurologic Care for Privately Insured Patients. Neurology 2020; 96:e322-e332. [PMID: 33361253 DOI: 10.1212/wnl.0000000000011278] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 08/25/2020] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVE To measure the out-of-pocket (OOP) costs of evaluation and management (E/M) services and common diagnostic testing for neurology patients. METHODS Using a large, privately insured health care claims database, we identified patients with a neurologic visit or diagnostic test from 2001 to 2016 and assessed inflation-adjusted OOP costs for E/M visits, neuroimaging, and neurophysiologic testing. For each diagnostic service each year, we estimated the proportion of patients with OOP costs, the mean OOP cost, and the proportion of the total service cost paid OOP. We modeled OOP cost as a function of patient and insurance factors. RESULTS We identified 3,724,342 patients. The most frequent neurologic services were E/M visits (78.5%), EMG/nerve conduction studies (NCS) (7.7%), MRIs (5.3%), and EEGs (4.5%). Annually, 86.5%-95.2% of patients paid OOP costs for E/M visits and 23.1%-69.5% for diagnostic tests. For patients paying any OOP cost, the mean OOP cost increased over time, most substantially for EEG, MRI, and E/M. OOP costs varied considerably; for an MRI in 2016, the 50th percentile paid $103.10 and the 95th percentile paid $875.40. The proportion of total service cost paid OOP increased. High deductible health plan (HDHP) enrollment was associated with higher OOP costs for MRI, EMG/NCS, and EEG. CONCLUSION An increasing number of patients pay OOP for neurologic diagnostic services. These costs are rising and vary greatly across patients and tests. The cost sharing burden is particularly high for the growing population with HDHPs. In this setting, neurologic evaluation might result in financial hardship for patients.
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Affiliation(s)
- Chloe E Hill
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA.
| | - Evan L Reynolds
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - James F Burke
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Mousumi Banerjee
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Kevin A Kerber
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Brandon Magliocco
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Gregory J Esper
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Lesli E Skolarus
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
| | - Brian C Callaghan
- From the Health Services Research Program, Department of Neurology (C.E.H., E.L.R., J.F.B., K.A.K., L.E.S., B.C.C.), and School of Public Health (M.B.), University of Michigan; Veterans Affairs Healthcare System (J.F.B., B.C.C.), Ann Arbor, MI; American Academy of Neurology (B.M.), Minneapolis, MN; and Department of Neurology (G.J.E.), Emory University, Atlanta, GA
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Lin CC, Callaghan BC, Burke JF, Skolarus LE, Hill CE, Magliocco B, Esper GJ, Kerber KA. Geographic Variation in Neurologist Density and Neurologic Care in the United States. Neurology 2020; 96:e309-e321. [PMID: 33361251 DOI: 10.1212/wnl.0000000000011276] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 08/03/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To describe geographic variation in neurologist density, neurologic conditions, and neurologist involvement in neurologic care. METHODS We used 20% 2015 Medicare data to summarize variation by Hospital Referral Region (HRR). Neurologic care was defined as office-based evaluation/management visits with a primary diagnosis of a neurologic condition. RESULTS Mean density of neurologists varied nearly 4-fold from the lowest to the highest density quintile (9.7 [95% confidence interval (CI) 9.2-10.2] vs 43.1 [95% CI 37.6-48.5] per 100,000 Medicare beneficiaries). The mean prevalence of patients with neurologic conditions did not substantially differ across neurologist density quintile regions (293 vs 311 per 1,000 beneficiaries in the lowest vs highest quintiles, respectively). Of patients with a neurologic condition, 23.5% were seen by a neurologist, ranging from 20.6% in the lowest quintile regions to 27.0% in the highest quintile regions (6.4% absolute difference). Most of the difference comprised dementia, pain, and stroke conditions seen by neurologists. In contrast, very little of the difference comprised Parkinson disease and multiple sclerosis, both of which had a very high proportion (>80%) of neurologist involvement even in the lowest quintile regions. CONCLUSIONS The supply of neurologists varies substantially by region, but the prevalence of neurologic conditions does not. As neurologist supply increases, access to neurologist care for certain neurologic conditions (dementia, pain, and stroke) increases much more than for others (Parkinson disease and multiple sclerosis). These data provide insight for policy makers when considering strategies in matching the demand for neurologic care with the appropriate supply of neurologists.
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Affiliation(s)
- Chun Chieh Lin
- From the Health Services Research Program, Department of Neurology (C.C.L., B.C.C., J.F.B., L.E.S., C.E.H., K.A.K.), University of Michigan Medical School; Veterans Affairs Healthcare System (B.C.C., J.F.B., K.A.K.), Ann Arbor, MI; American Academy of Neurology (B.M., G.J.E.), Minneapolis, MN; and Department of Neurology (G.J.E.), School of Medicine, Emory University, Atlanta, GA.
| | - Brian C Callaghan
- From the Health Services Research Program, Department of Neurology (C.C.L., B.C.C., J.F.B., L.E.S., C.E.H., K.A.K.), University of Michigan Medical School; Veterans Affairs Healthcare System (B.C.C., J.F.B., K.A.K.), Ann Arbor, MI; American Academy of Neurology (B.M., G.J.E.), Minneapolis, MN; and Department of Neurology (G.J.E.), School of Medicine, Emory University, Atlanta, GA
| | - James F Burke
- From the Health Services Research Program, Department of Neurology (C.C.L., B.C.C., J.F.B., L.E.S., C.E.H., K.A.K.), University of Michigan Medical School; Veterans Affairs Healthcare System (B.C.C., J.F.B., K.A.K.), Ann Arbor, MI; American Academy of Neurology (B.M., G.J.E.), Minneapolis, MN; and Department of Neurology (G.J.E.), School of Medicine, Emory University, Atlanta, GA
| | - Lesli E Skolarus
- From the Health Services Research Program, Department of Neurology (C.C.L., B.C.C., J.F.B., L.E.S., C.E.H., K.A.K.), University of Michigan Medical School; Veterans Affairs Healthcare System (B.C.C., J.F.B., K.A.K.), Ann Arbor, MI; American Academy of Neurology (B.M., G.J.E.), Minneapolis, MN; and Department of Neurology (G.J.E.), School of Medicine, Emory University, Atlanta, GA
| | - Chloe E Hill
- From the Health Services Research Program, Department of Neurology (C.C.L., B.C.C., J.F.B., L.E.S., C.E.H., K.A.K.), University of Michigan Medical School; Veterans Affairs Healthcare System (B.C.C., J.F.B., K.A.K.), Ann Arbor, MI; American Academy of Neurology (B.M., G.J.E.), Minneapolis, MN; and Department of Neurology (G.J.E.), School of Medicine, Emory University, Atlanta, GA
| | - Brandon Magliocco
- From the Health Services Research Program, Department of Neurology (C.C.L., B.C.C., J.F.B., L.E.S., C.E.H., K.A.K.), University of Michigan Medical School; Veterans Affairs Healthcare System (B.C.C., J.F.B., K.A.K.), Ann Arbor, MI; American Academy of Neurology (B.M., G.J.E.), Minneapolis, MN; and Department of Neurology (G.J.E.), School of Medicine, Emory University, Atlanta, GA
| | - Gregory J Esper
- From the Health Services Research Program, Department of Neurology (C.C.L., B.C.C., J.F.B., L.E.S., C.E.H., K.A.K.), University of Michigan Medical School; Veterans Affairs Healthcare System (B.C.C., J.F.B., K.A.K.), Ann Arbor, MI; American Academy of Neurology (B.M., G.J.E.), Minneapolis, MN; and Department of Neurology (G.J.E.), School of Medicine, Emory University, Atlanta, GA
| | - Kevin A Kerber
- From the Health Services Research Program, Department of Neurology (C.C.L., B.C.C., J.F.B., L.E.S., C.E.H., K.A.K.), University of Michigan Medical School; Veterans Affairs Healthcare System (B.C.C., J.F.B., K.A.K.), Ann Arbor, MI; American Academy of Neurology (B.M., G.J.E.), Minneapolis, MN; and Department of Neurology (G.J.E.), School of Medicine, Emory University, Atlanta, GA
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Towfighi A, Skolarus LE. Inequities in Stroke Preparedness in Young Adults. Stroke 2020; 51:3479-3481. [DOI: 10.1161/strokeaha.120.032612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Amytis Towfighi
- Department of Neurology, University of Southern California, Los Angeles (A.T.)
- Los Angeles County Department of Health Services, CA (A.T.)
| | - Lesli E. Skolarus
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor (L.E.S.)
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Robles MC, Springer MV, Corches CL, Burke JF, Lin CC, Oliver A, Skolarus LE. Stroke Ready Very Brief Intervention Improves Immediate Postintervention Stroke Preparedness. Circ Cardiovasc Qual Outcomes 2020; 13:e006643. [PMID: 33238728 DOI: 10.1161/circoutcomes.120.006643] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Maria Cielito Robles
- Stroke Program, University of Michigan Medical School (M.C.R., M.V.S., C.L.C., J.F.B., C.C.L., L.E.S.)
| | - Mellanie V Springer
- Stroke Program, University of Michigan Medical School (M.C.R., M.V.S., C.L.C., J.F.B., C.C.L., L.E.S.)
| | - Casey L Corches
- Stroke Program, University of Michigan Medical School (M.C.R., M.V.S., C.L.C., J.F.B., C.C.L., L.E.S.)
| | - James F Burke
- Stroke Program, University of Michigan Medical School (M.C.R., M.V.S., C.L.C., J.F.B., C.C.L., L.E.S.)
| | - Chun Chieh Lin
- Stroke Program, University of Michigan Medical School (M.C.R., M.V.S., C.L.C., J.F.B., C.C.L., L.E.S.)
| | | | - Lesli E Skolarus
- Stroke Program, University of Michigan Medical School (M.C.R., M.V.S., C.L.C., J.F.B., C.C.L., L.E.S.)
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Robles MC, Corches CL, Bradford M, Rice TS, Sukul D, Springer MV, Bailey S, Oliver A, Skolarus LE. Understanding and Informing Community Emergency Cardiovascular Disease Preparedness during the COVID-19 Pandemic: Stroke Ready. J Stroke Cerebrovasc Dis 2020; 30:105479. [PMID: 33246207 PMCID: PMC7674014 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105479] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 11/10/2020] [Accepted: 11/14/2020] [Indexed: 12/22/2022] Open
Abstract
Introduction Acute stroke and acute myocardial infarction (AMI) treatments are time sensitive. Early data revealed a decrease in presentation and an increase in pre-hospital delay for acute stroke and AMI during the coronavirus disease 2019 (COVID-19) pandemic. Thus, we set out to understand community members’ perception of seeking acute stroke and AMI care during the COVID-19 pandemic to inform strategies to increase cardiovascular disease preparedness during the pandemic. Methods Given the urgency of the clinical and public health situation, through a community-based participatory research partnership, we utilized a rapid assessment approach. We developed an interview guide and data collection form guided by the Theory of Planned Behavior (TPB). Semi-structured interviews were recorded and conducted via phone and data was collected on structured collection forms and real time transcription. Direct content analysis was conducted guided by the TPB model and responses for AMI and stroke were compared. Results We performed 15 semi-structured interviews. Eighty percent of participants were Black Americans; median age was 50; 73% were women. Participants reported concerns about coronavirus transmission in the ambulance and at the hospital, hospital capacity and ability to triage, and quality of care. Change in employment and childcare also impacted participants reported control over seeking emergent cardiovascular care. Based on these findings, our community and academic team co-created online materials to address the community-identified barriers, which has reached over 8,600 users and engaged almost 600 users. Conclusions We found that community members’ attitudes and perceived behavioral control to seek emergent cardiovascular care were impacted by the COVID-19 pandemic. Community-informed, health behavior theory-based public health messaging that address these constructs may decrease prehospital delay.
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Affiliation(s)
- Maria Cielito Robles
- University of Michigan, Department of Neurology, Stroke Program, Ann Arbor, MI, USA
| | - Casey L Corches
- University of Michigan, Department of Neurology, Stroke Program, Ann Arbor, MI, USA
| | - Morgan Bradford
- University of Michigan, Department of Neurology, Stroke Program, Ann Arbor, MI, USA
| | - Tia S Rice
- University of Michigan, Department of Neurology, Stroke Program, Ann Arbor, MI, USA
| | - Devraj Sukul
- University of Michigan, Department of Internal Medicine, Division of Cardiovascular Medicine, Ann Arbor, MI, USA
| | - Mellanie V Springer
- University of Michigan, Department of Neurology, Stroke Program, Ann Arbor, MI, USA
| | | | | | - Lesli E Skolarus
- University of Michigan, Department of Neurology, Stroke Program, Ann Arbor, MI, USA.
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Corches CL, McBride AC, Robles MC, Rehman N, Bailey S, Oliver A, Skolarus LE. Development, Adaptation and Scale-up of a Community-wide, Health Behavior Theory-based Stroke Preparedness Intervention. Am J Health Behav 2020; 44:744-755. [PMID: 33081873 DOI: 10.5993/ajhb.44.6.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Objective: Acute stroke treatments reduce the likelihood of post-stroke disability, but are vastly underutilized. In this paper, we describe the development, adaptation, and scale-up of the Stroke Ready program - a health behavior theory-based stroke preparedness intervention that addresses underlying behavioral factors that contribute to acute stroke treatment underutilization. Methods: Through a community-based participatory research (CBPR) approach, we conducted needs and determinant assessments, which informed creation and pilot testing of Stroke Ready. Based on these results, we then scaled Stroke Ready to the entire community by greatly expanding the delivery system. Results: The scaled Stroke Ready program is a community-wide stroke preparedness education program consisting of peer-led workshops, print materials, and digital, social, and broadcast media campaigns. Whereas the Stroke Ready pilot workshop was delivered to 101 participants, 5945 participants have received the scaled Stroke Ready peer-led workshop to date. Additionally, we have sent mailers to over 44,000 households and reached approximately 35,000 people through our social media campaign. Conclusion: Strategies including an expanded community advisory board, adaptation of the intervention and community-engaged recruitment facilitated the scale-up of Stroke Ready, which may serve as a model to increase acute stroke treatment rates, particularly in majority African-American communities.
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Affiliation(s)
- Casey L. Corches
- Casey L. Corches, Project Manager, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States;,
| | - A. Camille McBride
- A. Camille McBride, Research Assistant, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Maria Cielito Robles
- Maria Cielito Robles, Research Area Specialist, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Narmeen Rehman
- Narmeen Rehman, Research Assistant, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Sarah Bailey
- Sarah Bailey, Bridges Into the Future, Flint, MI, United States
| | - Alina Oliver
- Alina Oliver, Bethlehem Temple Church, Flint, MI, United States
| | - Lesli E. Skolarus
- Lesli E. Skolarus, Associate Professor, Department of Neurology, University of Michigan Medical School, Ann Arbor, MI, United States
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Skolarus LE, Sharrief A, Gardener H, Jenkins C, Boden-Albala B. Considerations in Addressing Social Determinants of Health to Reduce Racial/Ethnic Disparities in Stroke Outcomes in the United States. Stroke 2020; 51:3433-3439. [PMID: 33104471 DOI: 10.1161/strokeaha.120.030426] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
We write this article amid a global pandemic and a heightened awareness of the underlying structural racism in the United States, unmasked by the recent killing of George Floyd and multiple other unarmed Black Americans (Spring 2020). Our purpose is to highlight the role of social determinants of health (SDOH) on stroke disparities, to inspire dialogue, to encourage research to deepen our understanding of the mechanism by which SDOH impact stroke outcomes, and to develop strategies to address SDOH and reduce stroke racial/ethnic disparities. We begin by defining SDOH and health disparities in today's context; we then move to discussing SDOH and stroke, particularly secondary stroke prevention, and conclude with possible approaches to addressing SDOH and reducing stroke disparities. These approaches include (1) building on prior work; (2) enhancing our understanding of populations and subpopulations, including intersectionality, of people who experience stroke disparities; (3) prioritizing populations and points along the stroke care continuum when racial/ethnic disparities are most prominent; (4) understanding how SDOH impact stroke disparities in order to test SDOH interventions that contribute to the disparity; (5) partnering with communities; and (6) exploring technological innovations. By building on the prior work and expanding efforts to address SDOH, we believe that stroke disparities can be reduced.
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Affiliation(s)
- Lesli E Skolarus
- Stroke Program, University of Michigan Medical School, Ann Arbor (L.E.S.)
| | - Anjail Sharrief
- Stroke Institute, Department of Neurology, McGovern Medical School at University of Texas Health Sciences Center Houston (A.S.)
| | - Hannah Gardener
- Department of Neurology, University of Miami Miller School of Medicine, FL (H.G.)
| | - Carolyn Jenkins
- College of Nursing and Graduate Studies, Medical University of South Carolina (C.J.)
| | - Bernadette Boden-Albala
- Department of Population Health and Disease Prevention and Department of Epidemiology, University of California, Irvine (B.B.-A.)
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