Video-Teleconference Self-management TO Prevent Stroke (V-STOP): A pilot study of self-management support for underserved stroke survivors in Texas
Telehealth is a model of care that has enormous potential to connect stroke patients with appropriate healthcare services and eliminate access barriers. The emergence of mobile wireless technology for telehealth delivery using iPads, smartphones, and tablets expands telehealth capabilities to reach stroke survivors in their homes. Video-teleconference Self-management TO Prevent Stroke (V-STOP II) is a study designed to test the feasibility of using video-teleconferencing (VT) to deliver self-management support and stroke prevention education to stroke survivors while at home on their smartphone or mobile device. The V-STOP intervention is a 6-week program that consists of 3 self-management support group classes and 3 follow-up clinic visits. The investigators are targeting stroke survivors that live in rural and poor urban areas in Texas.
Stroke is the leading cause of permanent disability in the US and having a stroke significantly increases the risk of a second stroke, especially with inadequate risk factor management. V-STOP II explores mobile health as a viable approach in the delivery of stroke prevention through self-management support to Texas residents living in rural and poor urban areas. The study is being implemented in three phases.
- Phase I is focused on establishing a telehealth infrastructure for delivery of V-STOP across Lone Star Stroke (LSS) sites. Phase I was completed in November of 2016.
- Phase II is focused on establishing the feasibility of mobile health delivery for self-management support and stroke prevention education to underserved stroke survivors in Texas. Phase II was completed in March of 2018.
- Phase III is currently in process and is focused on establishing preliminary efficacy and recruitment and retention strategies for a larger randomized controlled trial.
Phase I was initiated using a traditional hub/spoke delivery model where staff at each LSS hub site were trained to deliver self-management support to stroke survivors using the V-STOP intervention. All 6 V-STOP sessions were delivered to stroke patients receiving follow-up care at affiliate outpatient clinics via the LSS hub site’s internal VT network. Focus groups were conducted with participants and providers. All participants expressed satisfaction with the program but reported that a more flexible schedule would improve participation. Study staff at the hub/spoke facilities reported challenges with flexible scheduling due to competing clinical responsibilities. To address identified challenges, the delivery model for V-STOP was modified for phase II of the study. A centralized-delivery model using mobile health (mHealth) technology was applied. Trained healthcare professionals at Baylor College of Medicine (BCM) delivered the program remotely to stroke survivors in their home via their mobile device, or to stroke survivors at an LSS clinic site via the site’s internal VT network. This approach allowed the investigators to tailor program delivery based on the participants’ access needs and staffing at participating LSS sites.
Three LSS sites participated in phase II: Valley Baptist in Harlingen, Texas and CHI St. Luke’s Health Systems and Harris Health Systems, both in Houston, Texas. Adults with a history of stroke and/or Transient Ischemic Attack and with two or more uncontrolled stroke risk factors were eligible to participate. Study participants received free access to a VT application through BCM. The VT application was loaded on the participant’s smartphone, or mobile device, to connect with a trained professional at BCM for self-management support. During phase II, data on participants’ vital signs, psychosocial factors, stroke risk knowledge, and goal achievements were compared for differences at baseline, 6, 12, 18 weeks. A total of 66 participants were enrolled in phase II. Participants’ mean age was 57 (SD=10), with 42% female, 71% white, 17% Black or African American, and 62% Hispanic or Latino. Most participants had an annual income of less than $25,000 (54%) and no health insurance (63%). Significant improvements were observed from baseline to post-intervention for stroke risk knowledge, self-efficacy for managing chronic disease, and for overall exercise. There was a significant decrease in social role activity limitations, general anxiety scores, and systolic blood pressure. These findings are encouraging and may indicate that access to frequent follow-up after stroke via mHealth delivery is effective to provide risk factor management for stroke survivors.
Phase III (V-STOP III) is currently underway with participant recruitment in 3 LSS sites and solicitation of additional study sites. The centralized mHealth delivery approach is feasible to reach medically underserved stroke survivors in Texas and to provide self-management support for stroke risk factors. Upon completion of V-STOP III, the preliminary efficacy of the intervention will be established with a comparison of participants’ outcomes to a usual care stroke survivor cohort. These findings along with lessons learned on recruitment and retention strategies will be applied in preparation for a planned randomized controlled trial.
Plans for FY 2019
- The first manuscript related to V-STOP II and integration of cognitive behavioral therapy for stroke survivors with anxiety and depression has been accepted for publication in Clinical Case Studies.
- Results from Phase II have been submitted for presentation at the International Stroke Conference in February of 2019.
- Two manuscripts are in development to disseminate lessons learned and results to the scientific community.
- Grant funding of $198,764.00 was received from VHA Rehab Research & Development to integrate cognitive behavioral therapy with the V-STOP intervention to develop a new self-management support program for Veterans recovering from a stroke who also have anxiety, depression or post-traumatic stress disorder.