Search

Telehealth has seen rapid expansion into chronic care management in the past 3 years because of the COVID-19 pandemic. Telehealth for acute care management has expanded access to equitable stroke care to many patients over the past two decades, but there is limited evidence for its benefit for addressing disparities in the chronic care of patients living with stroke. In this review, we discuss advantages and disadvantages of telehealth use for the outpatient management of stroke survivors. Further, we explore opportunities and potential barriers for telehealth in addressing disparities in stroke outcomes related to various social determinants of health. We discuss two ongoing large randomized trials that are utilizing telehealth and telemonitoring for management of blood pressure in diverse patient populations. Finally, we discuss strategies to address barriers to telehealth use in patients with stroke and in populations with adverse social determinants of health.

BACKGROUND: Prehospital tissue plasminogen activator dosing in a mobile stroke unit (MSU) is estimated by the paramedic and nurse. We aimed to determine the accuracy of the estimated weight method compared with the actual weight of patients treated with tissue plasminogen activator on the MSU. METHODS: We prospectively collected the estimated weight used on the MSU for treatment and the first-documented hospital-measured weight (bed scale) within 24 hours of hospital arrival. Median absolute and percent difference in weights were calculated; less than 10% of difference in weights was considered acceptable. To compare the estimated and measured weights, we conducted a Wilcoxon signed rank test and Fisher exact test to explore the association between weight difference of greater than 10% and patient outcomes. RESULTS: Among 337 patients, median estimated and hospital-measured weights were 79.0 kg (interquartile range [IQR], 66.0-94.5) and 78.5 kg (IQR, 65.0-91.7), respectively. The median of the absolute value of the difference in estimated versus measured weight was 2.7 kg (IQR, 0.6-7.6; P < .0001). The median percent difference in weight was 3.6% (IQR, 0.8%-9.4%). The median difference between the tissue plasminogen activator dosage administered on the MSU and the recommended dose based on the actual weight was 1.3 mg (IQR, 0.06-4.8) in absolute value. In 56 patients (16.6% of the entire sample) with overestimation of weight by greater than 10%, there were no symptomatic intracerebral hemorrhages. There was no association between weight difference and discharge modified Rankin score (P = .59). CONCLUSION: Weight estimation on an MSU can lead to similar tissue plasminogen activator dosing for 83.4% of subjects compared with if dosing were determined based on actual weight. Weight overestimation or underestimation had no detected impact on tissue plasminogen activator outcomes.

Background and ObjectivesIn response to the COVID-19 pandemic, outpatient stroke care delivery was rapidly transformed to outpatient evaluation through video (VTM) and telephone (TPH) telemedicine (TM) visits around the world. We sought to evaluate the sociodemographic differences in outpatient TM use among stroke patients.MethodsWe conducted a retrospective chart review of outpatients evaluated at 3 tertiary stroke centers in the early period of the pandemic, 3/16/2020 through 7/31/2020. We compared the use of TM by patient characteristics including age, sex, race/ethnicity, insurance status, stroke type, patient type, and site. The association between TM use and patient characteristics was measured using the relative risk (RR) from a modified Poisson regression, and site-specific effects were controlled using a multilevel analysis.ResultsA total of 2,024 visits were included from UTHealth (n = 878), MedStar Health (n = 269), and Columbia (n = 877). The median age was 64 [IQR 52–74] years, and 53% were female. Approximately half of the patients had private insurance, 36% had Medicare, and 15% had Medicaid. Two-thirds of the visits were established patients. TM accounted for 90% of total visits, and the use of TM over office visits was primarily associated with site, not patient characteristics. TM utilization was associated with Asian and other/unknown race. Among TM users, older age, Black race, Hispanic ethnicity, and Medicaid insurance were associated with lower VTM use. Black (aRR 0.88, 95% CI 0.86–0.91,p< 0.001) and Hispanic patients (aRR 0.92, 95% CI 0.87–0.98,p= 0.005) had approximately 10% lower VTM use, while Asian patients (aRR 0.98, 95% CI 0.89–1.07,p= 0.59) had similar VTM use compared with White patients. Patients with Medicaid were less likely to use VTM compared with those with private insurance (aRR 0.86, 95% CI 0.81–0.91,p< 0.001).DiscussionIn our diverse cohort across 3 centers, we found differences in TM visit type by race and insurance early during the COVID-19 pandemic. These findings suggest disparities in VTM access across different stroke populations. As VTM remains an integral part of outpatient neurology practice, steps to ensure equitable access are essential.

BACKGROUND Informal caregiving of stroke survivors often begins with intensity compared with the linear caregiving trajectories in progressive conditions. Informal caregivers of stroke survivors are often inadequately prepared for their caregiving role, which can have detrimental effects on their well-being. A greater depth of understanding about caregiving burden is needed to identify caregivers in most need of intervention. The purpose of this study was to examine caregiver burden and associated factors among a cohort of informal caregivers of stroke survivors. METHODS A cross-sectional study of 88 informal caregivers of stroke survivors was completed. Caregiver burden was determined with the Zarit Burden Interview, caregiver depressive symptoms were measured with the Patient Health Questionnaire-9, and stroke survivor functional disability was assessed with the Barthel Index. Ordinal logistic regression was used to identify independent factors associated with caregiver burden. RESULTS Forty-three informal caregivers (49%) reported minimal or no caregiver burden, 30 (34%) reported mild to moderate caregiver burden, and 15 (17%) reported moderate to severe caregiver burden. Stroke survivor functional disability was associated with informal caregiver burden (P = .0387). The odds of having mild to moderate caregiver burden were 3.7 times higher for informal caregivers of stroke survivors with moderate to severe functional disability than for caregivers of stroke survivors with no functional disability. The presence of caregiver depressive symptoms was highly correlated with caregiver burden (P < .001). CONCLUSION Caregivers of stroke survivors with functional disabilities and caregivers experiencing depressive symptoms may have severer caregiver burden. Trials of interventions aimed at decreasing informal caregiver burden should consider the potential impact of stroke survivors' functional disability and the presence of depressive symptoms.

Introduction: Embolic Stroke of Undetermined Source (ESUS) describes non-lacunar ischemic strokes, with no definite etiology after minimal standard work-up. Approximately 17% of ischemic strokes are ESUS, and patients are generally younger with mild strokes and higher Quality-Adjusted Life Years at stake, given annual 5% recurrence. Additional cardiac evaluation is often required for ESUS evaluation. A Multi-Disciplinary Clinic (MDC) employing vascular neurology and cardiology may improve diagnosis and outcomes, facilitate shared decision-making, and provide an enhanced clinical experience for patients with ESUS. We describe our experience. Methods: The UTHealth ESUS clinic was established in April 2019, as a monthly half-day clinic. Patients with ESUS (and without known PFO) are referred following ischemic stroke hospitalization or after evaluation in the stroke clinic. Patients are seen by a vascular neurologist and a cardiologist (EP specialist) in a single visit to ensure standardized, appropriate secondary stroke prevention. The specialists review cardiac imaging and monitoring data and discuss the need for additional work-up. While some patients present to the clinic with an event monitor or implantable loop recorder (ILR) in place, others are referred for long-term monitoring following the encounter. Patients are also screened for clinical trials, and stroke fellows rotate through the clinic to gain experiences managing this patient population. Results: A total of 36 patients have been evaluated at the ESUS clinic. Median age was 63 (52-71) and 15 (41%) patients were women. Patients were seen a median of 30 days from discharge/referral. Long-term cardiac monitoring was performed in (95%) of patients, including with either a 30-day event monitor (n=15) or ILR (n=20). Two patients were found to have atrial fibrillation, and a different potential cause (PFO, large vessel disease) was detected in 3 others. Five patients were consented for the ARCADIA clinical trial. Conclusion: A Multidisciplinary ESUS Clinic offers a patient-centered approach which may facilitate care coordination for stroke prevention and clinical trial enrollment, while providing learning opportunities for trainees.

Introduction: The COVID-19 pandemic has led to rapid implementation of telemedicine (TM) care in outpatient neurology clinics. Early follow-up after acute stroke hospitalization has been associated with decreased readmission and improved care transitions. Stroke survivors may face multiple barriers to in-person follow-up, including inability to drive, limited mobility, and reliance on working caregivers; therefore TM may be preferred. We sought to evaluate the impact of TM care provision during the COVID-19 pandemic on patient follow-up. Methods: Using our clinic EMR, we included patients scheduled for stroke hospitalization follow-up in the Stroke Transitions, Education, and Prevention (STEP) clinic from 10/1/2019 till 7/31/2019. We calculated arrival rates, no-show rates, and cancellation rates for the pre-COVID time period (10/1/19 - 3/13/20) and the period following the implementation of TM services (3/17/20 - 7/31/20). Results: We identified 593 eligible patients with 282 patients scheduled in the pre-COVID period and 311 patients in the COVID period. Arrival, cancellation, and same day no-show rates were 63.1%, 23.0%, and 12.4% in the pre-COVID period and 54.0%, 37.9%, and 7.07% in the COVID period, respectively. The arrival rate decreased significantly (p=0.03) and the cancellation rate increased significantly (p Conclusion: Despite the availability of TM services, the arrival rate for stroke patients scheduled for follow-up during the pandemic decreased significantly, largely because of cancellations. Low no-show rates do not explain the full picture of follow-up. Increased cancellations might be explained by several factors including barriers to technology, apprehension regarding TM, reliance on caregivers to participate in TM visits while practicing social distancing. Identification of barriers to TM follow-up should be further investigated to prevent the deleterious impact of poor care transitions on stroke patients.

Background Web-based interventions have shown promise for chronic disease management but have not been widely applied to populations with stroke. Existing barriers may inhibit the adoption of web-based interventions among stroke survivors and necessitate the involvement of informal caregivers. However, limited information is available on internet accessibility and usability among stroke survivors and their caregivers. Objective This study aims to investigate internet access and usage in a cohort of stroke survivors and their caregivers. Methods A cross-sectional survey was conducted with 375 participants (248 stroke survivors and 127 caregivers). Descriptive statistics were generated using cross-tabulation. Comparisons with categorical data were conducted using the chi-square test, whereas the Mann-Whitney U test was used for comparisons involving ordinal variables. Results Overall, 86.1% (323/375) of the participants reported having internet access. Caregivers were more likely than stroke survivors to access the internet (N=375, χ21=18.5, P12 months after a stroke reported higher internet access than those who survived Conclusions Future feasibility and acceptability studies should consider the role of the informal caregiver, participant age, race and ethnicity, the use of smartphone apps, email and text correspondence, and the amount of time elapsed since the stroke event in the design and implementation of web-based interventions for populations with stroke.

Background: In response to the COVID-19 pandemic, stroke outpatient care was transformed to telemedicine (TM) through video (VTM) and telephonic (TPH) visits. While TM offers potential benefits over in-person visits for stroke patients, accessibility of VTM may be limited for patients at highest risk for poor outcomes. We recommended VTM for all patients, but offered TPH visits if patients did not have adequate equipment or declined VTM. We examined whether demographic variables influenced the TM visit type completed (VTM vs TPH) for patients seen during the pandemic. Methods: We conducted a retrospective review of charts for patients seen in our stroke clinic between 3/16/20 (fully operational TM) and 5/31/20. We determined visit type: VTM vs in-person vs TPH and abstracted demographic and clinical data. We focused on TM visits and used t-tests, Fisher’s exact tests, and chi-squared as appropriate for univariate analyses and logistic regression for multivariate analyses. Results: Among 463 visits, 47 in-person visits were excluded, leaving 416 (328 VTM and 88 TPH). Mean age was 61.5 and by race/ethnicity: 42.9% non-Hispanic white (NHW), 36.9% non-Hispanic Black (NHB), 11.6% Hispanic, 4.3% Asian, and 4.3% other (Table 1). In univariate analyses, visit type was significantly associated with race (p = 0.024), insurance type (p=0.001), and visit type (new vs established). In adjusted analysis, NHB race was associated with 1.90 times higher odds (95% CI 1.09-3.32) of TPH vs VTM compared to NHW. Medicaid insurance was associated with 3.90 times higher odds (95% CI 1.54-9.88) of TPH vs VTM visit compared to private insurance. Conclusions: We found that NHB patients and patients with Medicaid were less likely to complete VTM visits compared to TPH. This suggests barriers to VTM based on race and insurance type and deserves further study. If video visits are superior to TPH visits for clinical care, these barriers may widen disparities in secondary stroke prevention during the pandemic.

BACKGROUND Web-based interventions have shown promise for chronic disease management but have not been widely applied to populations with stroke. Existing barriers may inhibit the adoption of web-based interventions among stroke survivors and necessitate the involvement of informal caregivers. However, limited information is available on internet accessibility and usability among stroke survivors and their caregivers. OBJECTIVE This study aims to investigate internet access and usage in a cohort of stroke survivors and their caregivers. METHODS A cross-sectional survey was conducted with 375 participants (248 stroke survivors and 127 caregivers). Descriptive statistics were generated using cross-tabulation. Comparisons with categorical data were conducted using the chi-square test, whereas the Mann-Whitney U test was used for comparisons involving ordinal variables. RESULTS Overall, 86.1% (323/375) of the participants reported having internet access. Caregivers were more likely than stroke survivors to access the internet (N=375, χ21=18.5, P21=14.7, P12 months after a stroke reported higher internet access than those who survived PP CONCLUSIONS Future feasibility and acceptability studies should consider the role of the informal caregiver, participant age, race and ethnicity, the use of smartphone apps, email and text correspondence, and the amount of time elapsed since the stroke event in the design and implementation of web-based interventions for populations with stroke.

BACKGROUND Web-based telehealth interventions have shown promise for chronic disease management but have not been widely applied to stroke populations. Limited information is known about the accessibility and usability of web-based electronics post-stroke. The purpose was to explore internet access and use of web-based electronics in stroke survivors (SS) and their informal caregivers (IC). OBJECTIVE To describe access and usage of web-based electronics in a cohort of SS and IC. METHODS A cross-sectional survey of 378 participants (SS=251; IC=127). Descriptive statistics were generated. RESULTS Internet-users were on average 8 years younger than non-users (Mean years; SS 59; IC 51) and the majority were Non-Hispanic White men. Two hundred (81%) stroke survivors reported internet access compared to 123 (97%) caregivers (p CONCLUSIONS Web-based telehealth stroke interventions should consider participant age and race/ethnicity, the role of the IC to positively impact SS internet accessibility and usability, and the use of smartphone applications.

Background and Purpose: Web-based interventions have shown promise as a cost-effective and convenient delivery platform for supporting chronic disease self-management. However, studies suggest that web-based interventions are not widely available. The purpose of this study was to describe access and usage of web-based electronics in a cohort of stroke survivors (SS) and their informal caregivers (IC). Methods: A 14-question electronic usage survey was created with input from experts in neurology, nursing and bioinformatics. Two urban sites recruited participants from inpatient stroke centers, outpatient stroke clinics and stroke support groups. Surveys were completed in person or via telephone. Descriptive data were generated to evaluate internet access and usage. Results: Data were analyzed from 251 SS and 127 IC. Participants were primarily recruited from outpatient settings, with inpatient recruits constituting 15%. Internet users were on average 8 years younger than non-users in both groups. African Americans constituted a third in each group and 1 out of 8 were Hispanic. Compared to an estimate that 89% of American adults have internet access, 200 (81%) SS (p < .001) and 123 (97%) IC (p = .005) had internet access. Conclusions: In our diverse cohort of relatively young SS, we found IC had more internet access than SS, and more so than the general population. This study is an important step towards delineating the potential use of web-based environments as a platform for interventions to improve stroke risk factor management and stroke recovery.

Background and Purpose: Despite the high prevalence of post-stroke depression (PSD) and negative impact on stroke survivors (SS) and their informal caregivers ([IC]; e.g., unpaid spouses), treatment of PSD is inadequate. Meditation has been associated with improved psychological outcomes. The purpose of this study was to establish the feasibility and acceptability of a 12-week randomized controlled trial (RCT) of a meditation intervention with SS and IC. Secondary objectives were to explore the effects of the intervention on symptoms of PSD, anxiety, and pain. Methods: Participants were randomized to the 4-week meditation intervention (n=27 SS; n=16 IC) or expressive writing control (n=14 SS; n=7 IC). Descriptive statistics were used to examine feasibility. Acceptability data included interviews and field notes. Repeated measures analysis with linear mixed models were used to test for change over time in Center for Epidemiological Studies Depression Scale (CES-D), State-Trait Anxiety Inventory (STAI), and Brief Pain Inventory (BPI) Severity and Intensity subscale scores. Results: Of the 92 eligible, 71 (77%) enrolled. Of the 64 randomized (7 were lost-to-follow-up or withdrawn due to ineligibility prior to randomization), 25 (39%) completed the study. The mean intervention attendance rate was 55%. Assessment completion rate for the intervention was 96%. For intervention SS, BPI severity scores were significantly lower at 8 weeks (p=.0270), while non-significant reductions across CES-D and STAI scores were noted. For intervention IC, a significant reduction in STAI-Trait scores was noted at 4 weeks (p=.0262). Data indicated distance was a primary barrier; however, the majority voiced favorable responses to the meditation. Conclusions: A meditation RCT in the post-stroke environment is acceptable; however, consideration needs to be given to the feasibility of an in-person, multiple-visit intervention. Further efficacy testing is needed in a larger RCT.

Introduction: The purpose of the Houston Mobile Stroke Unit (MSU) is to expedite stroke care by treating patients in the pre-hospital setting where obtaining a measured body weight, critical for accurate pre-hospital tPA dosing, is challenging and impossible. The paramedic and nurse on the MSU subjectively estimate by assessment (with patient report if possible) the weight for calculating tPA dosing. We aimed to determine the accuracy of the estimated weight method compared to the actual weight of patients treated with tPA on the MSU. Methods: Data were prospectively collected for MSU tPA-treated patients as part of the BEST-MSU study comparing MSU to standard EMS management. We collected the first-documented hospital-measured weight (bed scale) within 24 hours of hospital arrival, and the estimated weight used on the MSU for treatment. Mean absolute and percent difference in weights were calculated; less than 10% difference in weights was considered acceptable. To compare the estimated and measured weights, we conducted a Wilcoxon signed-rank test. Differences between weights were set as 0 if both weights were above 100kg. Fisher’s exact test was used to explore association between weight difference > 10% and patient outcomes. Results: Among 337 patients, mean age was 67.8 (15.6) and average measured weight was 81.2 kg (SD 22.3). Median absolute difference in measured versus estimated weight was 2.70 kg (IQR 0.55-7.60), and both weights were significantly different from each other (p value < 0.0001). The average absolute percent difference in weight was 7.04% (SD 9.11%). The absolute mean difference in tPA dosage was 3.49 mg (SD 6.06). Among patients whose estimated and measured weights were not both ≥100 kg, 56 (16.6%) had weight difference >10%. In patients with overestimation of weight by >10%, there were no symptomatic intracerebral hemorrhages. There was no association between weight difference and discharge modified Rankin score (p value = 0.5921). Conclusion: Weight estimation on a mobile stroke unit can lead to similar tPA dosing for 82% of subjects compared to if dosing were determined based on actual weight. Weight over- or under-estimation had no detected significant impact on tPA outcomes.

BACKGROUND: Post-stroke depression (PSD) affects one-third of stroke patients and is linked with higher stroke morbidity, mortality, and recurrence. Current guidelines do not direct when to screen for PSD, and predictors of PSD are not well understood. We sought to understand progression of PSD symptoms early after ischemic stroke, identify predictors of PSD, and describe the use of antidepressants in PSD. METHODS: We collected demographic, clinical, and PSD (Patient Health Questionnaire-9; PHQ-9) data from ischemic stroke patients hospitalized at our Comprehensive Stroke Center and followed up in our clinic. PHQ-9 was obtained during hospitalization and again in clinic within 180 days of discharge. We performed univariate analysis and logistic regression to detect variables associated with PSD. RESULTS: Among 201 patients, PSD symptoms (PHQ-9 > 4) were identified in 30% of patients during hospitalization and 46% during follow-up (54% of which had no symptoms during hospitalization). At follow-up, 36% were worse by PHQ-9 category. In univariate analysis, follow-up modified Rankin Scale (mRS) ≥2 (p=0.03) and antidepressant prescription (p

Background and Purpose: Reductions in blood pressure (BP) after stroke are associated with dramatic reductions in stroke risk. African Americans (AA) have higher risk of recurrent stroke than Whites and higher rates of uncontrolled BP after stroke. Prior studies have shown under-representation of minorities in secondary prevention trials. We identified studies of BP control for secondary stroke prevention and explored minority representation in the trials. Methods: Relevant MeSH headings were used to conduct a PubMed search of randomized trials for secondary prevention of ischemic and hemorrhagic stroke and TIA, focused on BP reduction. We included studies published 1998 to 2018 that included participants from the US. We categorized articles according to timing post stroke, stroke type, intervention type, race/ethnic distribution, and mentioned efforts to increase minority proportions. Results: Of 703 abstracts identified from PubMed, 42 studies were retained, and 8 met criteria after manuscript review. Six were US based and 2 international. All included ischemic stroke and/ or TIA patients. None focused on hemorrhagic stroke. Six trials included behavioral modification as a component of the intervention. Enrollment period ranged from 0 to 180 days post-stroke. For US based studies, 5 reported AA race (race reporting complete for 3 studies). The proportion of AA participants ranged from 8.4% to 41.5% Three studies recruited from diverse populations. There was no specific mention of oversampling of AAs in any trial. Conclusion: Despite strong data to support BP reduction after stroke, there is a lack of US-based studies for secondary stroke prevention. More studies of BP control interventions to test medications and behavioral strategies for secondary stroke prevention in diverse patient populations are urgently needed.

Introduction: Post-stroke depression (PSD), which affects one-third of stroke patients, is an important psychosocial consequence after stroke linked with higher stroke morbidity, mortality, and recurrence. Current guidelines do not direct when to screen for PSD. Using hospital and clinic PSD screening, we sought to identify predictors of PSD symptoms, factors associated with worsening PSD symptoms, and use of antidepressants in PSD. Methods: In a retrospective review of patients hospitalized with ischemic stroke from 01/2014-11/2016, patients completed a Patient Health Questionnaire-9 (PHQ-9) inpatient and again in clinic follow-up within 180 days (median 45 days). PHQ-9 score was categorized as no symptoms (0-4), mild (5-9), moderate (10-14) and severe (15-27). Baseline and follow-up data were analyzed by t-test and Fisher’s exact test for univariate analyses and logistic regression model for multivariable analyses. Results: Among 201 patients, depressive symptoms (PHQ-9 > 4) were seen in 30% of patients during hospitalization and 46% in clinic (54% of which had no symptoms inpatient). At follow-up, 64% of patients had stable/improved symptoms and 36% were worse by PHQ-9 category. In univariate analysis, clinic modified Rankin Scale (mRS) ≥2 (p=0.027) and clinic antidepressant prescription (p=0.0004) were associated with worsening PHQ-9 category. In logistic regression analysis, mRS ≥2 (p=0.022), posterior circulation stroke (p=0.029), and clinic antidepressant prescription (p=0.002) were associated with worsening. Conclusions: A substantial number of ischemic stroke patients develop or have worsening depression from hospitalization to follow-up. Post-stroke disability (mRs ≥2) and posterior circulation stroke were associated with worsening depression at follow-up. Worsening symptoms prompted a change in management in our clinic. Screening for PSD inpatient should be followed-up in clinic as both may impact treatment and outcomes.

Background and Purpose: Caregiver burden is commonly encountered in chronic disease management. Caregiver burden among informal caregivers of stroke survivors has potential to impact patient outcomes. We sought to assess the degree of caregiver burden and related factors among informal caregivers of patients followed in our Stroke Transitions Education and Prevention (STEP) clinic. Methods: We surveyed informal caregivers accompanying stroke patients to our STEP clinic visits within 2 years of ischemic or hemorrhagic stroke occurrence. Assessments included a caregiver demographic questionnaire, Zarit caregiver burden scale, patient health questionnaire-9 (PHQ-9, depression), Barthel index (BI -stroke survivor). Zarit score was dichotomized as no/minimal burden vs mild/moderate/severe burden. Univariate and multivariate analysis were conducted using logistic regression. Results: Among 71 surveys obtained, 69% of informal caregivers were women, despite a similar gender distribution of stroke survivors (54% women). While 49% of caregivers reported some degree of caregiver burden, 34% were classified as moderate-severe or severe. Caregiver burden was strongly associated with stroke survivor physical disability; odds of moderate or worse caregiver burden was 4.5 times higher (95% CI 1.52, 16.1) with BI < 75 compared to = 75. Additionally, odds of moderate-severe depression, as defined by PHQ-9 > 9, were 10 times higher (95% CI 2.06, 48.9). Conclusions: High levels of caregiver burden exist among informal caregivers of stroke survivors, and burden is associated with stroke survivor physical disability. Caregiver burden was associated with significantly greater odds of depression. Findings suggest the need for studies focused on characterization of informal caregiver needs and interventions to address the challenges they face.

Introduction: Recent studies show rising incidence of stroke in the young, for which risk factors are not well characterized. There is evidence of increased risk in certain race and ethnic groups. We sought to assess racial differences in risk factors, stroke etiology, and outcomes among young stroke patients. Methods: Using data from our inpatient registry for ischemic stroke, we reviewed patients aged 18-50 who were admitted 01/2013 to 04/2018. Race/ethnicity were characterized as non-Hispanic White (NHW), non-Hispanic Black(NHB), Hispanic(HIS) and other groups were excluded given small numbers ( Results: Among 862 patients admitted in the study period, mean age was 40.9 (SD 7.8), 57.3% were male, and 36.4% NHW, 42.8% NHB, 20.8% HIS. History of hypertension (HTN), type II diabetes (DM II), smoking, heart failure (CHF), prior stroke, end stage renal disease, and triglycerides varied significantly by race (Table 1). Compared to NHW, NHB had higher odds of HTN (OR 2.2, CI 1.6-3.0), CHF (OR 2.3, CI 1.1-4.6), and DMII (OR 1.81, CI 1.2-2.7) while HIS had higher odds of DMII (OR 2.26, CI 1.4-3.6) and lower odds of smoking (OR 0.5, 0.3-0.8). Arrival NIHSS was higher in NHB, but etiology and rates of tpA treatment and thrombectomy did not vary by race. Compared to NHW patients, NHB (OR 0.5, CI 0.3-0.9 ) and HIS (OR 0.4 CI 0.2-0.9) were less likely to have good functional outcome (mRS Conclusions: In this study, there was a higher prevalence of several modifiable risk factors in NHB and HIS young stroke patients and early functional outcome was worse in these groups. This suggests a need for targeted prevention efforts for younger populations at highest risk. The findings regarding outcomes deserve further study.

Background and Purpose: Prior data indicate that the profile of stroke survivors differs from those with anxiety in the absence of other clinical comorbidities. The purpose of this study was to determine the prevalence of PSA and to understand factors associated with PSA in a cohort of stroke survivors. Methods: A retrospective study (August 2017-May 2018) of electronic health records from 194 ischemic stroke survivors were examined. Stroke survivors were screened for PSA using the Generalized Anxiety Disorder 7-Item (GAD-7; range 0-21) scale two to eight weeks post-hospitalization for stroke during a stroke clinic visit. GAD-7 scores ≥ 10 indicated moderate to severe anxiety. Examples of factors examined included medical, social, stroke severity, excessive daytime sleepiness (Epworth Sleepiness Scale; ESS), and depression (Patient Health Questionnaire-9; PHQ-9). Univariable analysis were used to determine significance (p < 0.05). T-tests were used for continuous variables and the chi-square test for categorical variables. Results: Twenty-five percent of stroke survivors had a GAD-7 score ≥ 10 and significantly higher mean ESS (11 ± 5) and PHQ-9 (13 ± 6) scores (p Conclusions: PSA is common after ischemic stroke and may occur more frequently in women and those who are single, divorced, or widowed. Post-stroke trials of psychological interventions should consider PSA and its relationship to excessive daytime sleepiness and depression as well as treatment approaches for concurrent co-morbid conditions.

Background and Purpose: The STEP clinic was established to provide post-acute care for stroke patients. In this learning healthcare model, optimization of processes is enriched by evaluation of patient outcomes and patient and provider feedback. Trainee education and clinical trial recruitment are key. We describe the approach, patient population, and outcomes. Methods: STEP patients are assessed by a multidisciplinary care team within 6 weeks post-hospitalization. Patients complete depression, fatigue, and sleep apnea questionnaires. The team develops a personalized treatment and follow-up plan and provides risk factor counseling and education. We obtained data from the STEP clinical registry for patients enrolled from 10/2014 to 05/2017. Results: Among 605 enrolled patients following up at median of 47 days, 55% were male, mean age was 62.2 (SD 14.3), and stroke types included 76% ischemic/transient ischemic attack and 20% intracerebral hemorrhage. By race, 45% were non-Hispanic white, 27% non-Hispanic black, 19% Hispanic, and 3% Asian. Initial blood pressure (BP) was controlled for 66% (9 (abnormal), and 27% were sent for a sleep study. A total of 38 trainees rotated through the clinic and 91 patients were enrolled in studies. Four novel trials, 3 randomized clinical trials and 1 observational study, were derived from the clinic. Conclusions: The STEP clinic represents a learning healthcare model for post-stroke care. Learning healthcare models for post-stroke care are feasible and may be an effective approach to secondary and tertiary prevention.

Purpose The provision of conscientious nursing care is at the forefront of health quality. Unfortunately, a lack of standardization in the assignment of patients to nurses can lead to care inequities. Rehab MATRIX is a nursing-led tool that equitably assigns patients using select acuity variables. Design and methods In this initial study, we asked focus groups of 19 registered nurses and 8 patient care assistants to identify medical interventions that increase the effort of nursing care at a 24-bed inpatient rehabilitation facility (IRF). This IRF is affiliated with a comprehensive heart and vascular institute, a level I trauma center, and a The Joint Commission (TJC) Comprehensive Stroke Center. Findings Thirteen acuity variables were included in the Rehab MATRIX patient assignment grid. High-acuity patients with greater than 6 variables were color-coded "red," medium-acuity patients with 3 to 5 variables were color-coded "yellow," and low-acuity patients with less than 3 variables were color-coded "green." Each registered nurse and patient care assistant were assigned an equitable number of red-, yellow-, and green-coded patients per shift. New admissions were Rehab MATRIX color-coded during nursing report and assigned objectively. Conclusions Nursing staff at a wide-ranging IRF created Rehab MATRIX, an equitable patient assignment tool, representative of nursing effort needed to provide quality care. Clinical relevance Nursing-led patient assignment tools increase autonomy and provide the opportunity for all nursing staff to influence healthcare practice. These factors may lead to increased nursing satisfaction and decreased burnout.

Introduction: Uncontrolled blood pressure (BP) is a major risk factor for recurrent stroke; however, up to 50% of stroke survivors have uncontrolled BP 6 months after stroke. Characterization of factors associated with uncontrolled BP early after stroke discharge (DC) may help to identify patients for BP interventions. Hypothesis: We sought to identify factors associated with uncontrolled BP in the first month after stroke discharge. We hypothesized that African American (AA) race, insurance status, medication complexity, and hospital BP prior to discharge would be associated with uncontrolled BP. Methods: We identified hypertensive patients with ischemic or hemorrhagic stroke or transient ischemic attack scheduled to follow-up in the stroke clinic 2 to 4 weeks after hospital DC. Office BP was obtained using BpTRU, an automated machine that averages five unattended BP measures. Uncontrolled BP was defined using 2017 American College of Cardiology Guidelines as BP ≥ 130/80 mmHg. We used univariate logistic regression to assess relationships between uncontrolled BP and selected variables. Variables with statistically significant associations in the univariate models and variables associated with uncontrolled BP in the literature were included in the multiple logistic regression model. Results: Of the 230 patients identified, 55.7% had uncontrolled BP at clinic follow-up. In univariate and multivariable analyses, AA race, young stroke (age < 50), and systolic BP (SBP) 24-hours prior to DC were significantly associated with uncontrolled BP early after stroke DC. BP medication complexity was not associated with uncontrolled BP in this study. Conclusions: AA race, young age, and elevate SBP in the 24 hours prior to of stroke DC were associated with uncontrolled BP early after stroke. These variables can be used to identify patients who may benefit from early interventions aimed at reducing the risk of uncontrolled BP after stroke and stroke recurrence.

Background and purpose Recent studies show rising incidence of stroke in the young, for which risk factors are not well characterized. There is evidence of increased risk in certain racial and ethnic groups. We assessed racial differences in risk factors, stroke etiology, and outcomes among young stroke patients. Methods Using data from our inpatient registry for ischemic stroke, we reviewed patients aged 18–50 who were admitted 01/2013 to 04/2018. Race/ethnicity were characterized as non-Hispanic White (NHW), non-Hispanic Black (NHB), Hispanic (HIS). For univariate comparisons Chi-square and Kruskal–Wallis tests were performed as appropriate. Multivariable logistic regression was used to assess impact of race on day seven modified Rankin score (mRS). Results Among 810 patients with race and outcome data who were admitted in the study period, median age was 43, 57.1% were male, and 36.5% NHW, 43.2% NHB, 20.2% HIS. History of hypertension (HTN), type II diabetes (DM II), smoking, heart failure (CHF), prior stroke, and end-stage renal disease varied significantly by race. Compared to NHW, NHB had higher odds of HTN (OR 2.28, 1.65–3.15), CHF (OR 2.17, 1.06–4.46), and DM II 1.92 (1.25–2.94) while HIS had higher odds of DM II (OR 2.52, 1.55–4.10) and lower odds of smoking (OR 0.56, 0.35–0.90). Arrival NIHSS was higher in NHB, but etiology and rates of tpA treatment and thrombectomy did not vary by race. Compared to NHW patients, NHB (OR 0.50 CI (0.31–0.78)) and HIS (OR 0.37 CI (0.21–0.67)) were less likely to have good functional outcome (mRS Conclusions In this study, there was a higher prevalence of several modifiable risk factors in NHB and HIS young stroke patients and early functional outcome was worse in these groups. Our study suggests a need for targeted prevention efforts for younger populations at highest risk for stroke.

Background and Purpose: Post-stroke anxiety (PSA) is common and disabling. PSA should be considered as an important outcome in stroke. However, there is a lack of understanding of factors that may be linked to PSA. The purpose of this study was to determine the frequency of PSA and sociodemographic and clinical factors associated with PSA in a cohort of racially and ethnically diverse stroke patients. Methods: We conducted a retrospective study of ischemic and hemorrhagic stroke patients seen in a stroke outpatient clinic from August 1, 2017 to June 30, 2018. Patients were eligible if a Generalized Anxiety Disorder 7-Item (GAD-7) instrument was available. GAD-7 scores greater than or equal to 10 indicated the presence of moderate to severe PSA. Multivariable logistic regression was used to identify independent sociodemographic and clinical factors associated with PSA. Results: Records from 289 stroke patients with a GAD-7 instrument were analyzed. PSA was common (21%; GAD-7 ≥ 10). Fifty-seven percent of females had a GAD-7 greater than or equal to 10 compared to 41% of females who had a GAD-7 less than 10 (P = .03). Multivariable analysis found that self-reported nonmarried status (odds ratio, 3.27; 95% confidence interval, 1.44-7.44), excessive fatigue (odds ratio, 4.46; 95% confidence interval, 1.87-10.63), and depression (odds ratio, 1.24; 95% confidence interval, 1.16-1.33) were independently associated with PSA. Conclusions: PSA may occur more frequently in those who report non-married, excessive fatigue, or depression. Trials of PSA interventions should consider the potential impact of social support, depression, and comorbid conditions contributing to post-stroke fatigue, including sleep apnea.

Background and Purpose: Among stroke survivors, uncontrolled hypertension is a major risk factor for recurrent stroke. Blood pressure (BP) medication titration often relies on office BP measures, which may be inaccurate due to the white coat effect (WCE). We sought to determine the prevalence of the WCE in stroke survivors and to determine whether clinical and demographic factors were associated with WCE. Methods: We followed ischemic and hemorrhagic stroke and transient ischemic attack patients with prior hypertension presenting to our stroke clinic for a BP study. Sitting BP was obtained by a medical assistant using an office automated BP machine (OABP). Patients also underwent BP measurement using BPtru, an automated machine that measures and averages five BPs with the patient alone in a room. BPtru approximate BPs obtained by the gold standard ambulatory blood pressure machine. Systolic BP (SBP) obtained by BPtru was subtracted from that obtained by OABP. WCE was defined as SBP difference ≥ 10mmHg. Uncontrolled BP was defined as SBP ≥ 135 mmHg by BPtru or ≥ 140 mmHg by OABP. We used student t-tests (continuous) and chi-squared or Fischer’s exact tests (categorical) for univariate analyses. Results: Of 94 patients, mean age was 60 (SD 12), 60.6% were male, 26.6% were Non-Hispanic White, 46.8% were Black, and 23.4% were Hispanic. Systolic OABP was 13.2 mmHg (SD 19.3) higher than BPtru SBP (student t-test; p Conclusions: Among hypertensive stroke patients following in a clinic, WCE was highly prevalent and one-fifth of patients were misclassified as uncontrolled. Neither race nor other previously described predictors of WCE were associated with WCE in this study. Our findings suggest that in patients with elevated office BP, findings should be confirmed with an automated machine like BPtru in order to avoid over-titration of medication or incorrect assessment of BP control.

IntroductionHypertension is a major risk factor for recurrent stroke, and blood pressure (BP) reduction is associated with decreased risk of stroke recurrence. However, many stroke survivors have poorly controlled BP after their initial stroke. The Stroke Transitions Education and Prevention (STEP) Clinic was established to provide a comprehensive approach to stroke risk factor reduction.Methods and analysisThis randomised comparative effectiveness study was designed to assess the impact of care in the STEP clinic versus usual care on poststroke BP reduction. Eligible hospitalised patients with ischaemic stroke, haemorrhagic stroke or transient ischaemic attack are scheduled for a clinic screening visit within 4 weeks of discharge if they meet baseline inclusion criteria. At the clinic visit, patients who have uncontrolled BP, defined as automated office BP ≥135/85 mm Hg are randomised (1:1) to either the STEP clinic or usual care for management. STEP clinic patients receive instructions to self-monitor, a BP monitor, sleep apnoea screening, dietary counselling, review of BP monitoring records and adjustment of medications. Patients are followed by a neurologist and a stroke-trained nurse practitioner. Usual care participants are seen by a neurologist and recommendations for secondary prevention are sent to primary care providers. The primary outcome is the difference in mean daytime ambulatory systolic BP at 6 months, assessed using linear regression analysis. Secondary outcomes include 24 hours ambulatory BP, medication adherence and medication self-efficacy, and composite cardiovascular events.Ethics and disseminationThis study was approved by the Institutional Review Boards at the McGovern Medical School at the University of Texas Health Sciences Center and the Georgetown University School of Medicine. Uninsured and Spanish-speaking patients are included in the study.Trial registration numberNCT02591394; Pre-results.

Introduction: Depression screening may not be feasible for all stroke patients during their hospitalization, and depression may be missed if screening is not performed in the outpatient setting. Hypothesis: We sought to assess the proportion of patients with depression, and describe the severity of depressive symptoms in patients who could not be screened during hospitalization. We hypothesized that depressive symptoms can be missed in those who are not screened. Methods: Ischemic strokes (July 2014- July 2015) were identified from the clinic registry. In the clinic, we use Patient Health Questionnaire 9 (PHQ-9) to assess depressive symptoms for all patients. Univariate and multivariable linear regression analyses were used to evaluate associations between PHQ-9 and age, sex, race, baseline National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and antidepressant use for patients who missed inpatient depression screening. Results: Among 159 ischemic stroke patients, 136 completed outpatient PHQ-9 within 90 days from stroke onset. Of these 41 (30%) were missing inpatient PHQ-9. Reasons for missing scores included aphasia or cognitive impairment (20), failed inpatient attempt (16), or unspecified reasons (5). Among the 41 patients, median time to follow-up was 40 days (IQR 33 - 50). Mean (SD) age was 63.7 (13.8) and 51.2% were female. Mean (SD) PHQ-9 score was 8.0 (6.61). The overall proportion of patients having at least mild depression was 60.1% (95 % CI 45.3, 76.5) and PHQ-9 scores were distributed as follows: none to minimal depressive symptoms, 39.0%; mild to moderate, 43.9%, moderately severe to severe, 17.1%. In the regression model, mRS at follow-up (dichotomized < 3 & ≥ 3) was associated with severity of depressive symptoms after adjusting for age, sex, and baseline NIHSS, (coefficient 4.1, 95% CI 1.38, 6.82). Other variables were not associated with severity of depressive symptoms. Conclusions: Patients who cannot be screened for depression during hospitalization may have depressive symptoms and should be screened as soon as feasible after discharge. Alternative methods to screen cognitively impaired patients need to be developed.