The STOP Stroke Program is an evidence-based, comprehensive risk factor reduction program for patients with stroke. The program has been recently implemented in the Lone Star Stroke Consortium network using established video-teleconferencing networks and trained staff within individual LSS hub-site facilities for delivery to patients receiving stroke follow-up at their respective affiliate spoke sites. For this project, we propose applying lessons learned during the V-STOP II pilot to maximize the reach of STOP Stroke to all subscribing LSS hub/site facilities. We propose a randomized controlled trial to assess the effects of a subscription-based V-STOP model compared to usual follow-up care.
Scientific rationale for the study:
Recurrent strokes have poorer outcomes and are costlier than first strokes. Self-management is an approach to health care tailored to an individual’s barriers and needs and can be efficiently delivered through a group process. The investigators pioneered the use of tele-medicine to stroke self-management in their prior research. Based on our pilot experience within the LSS network, we propose the delivery of stroke secondary prevention and patient self-management support using a ‘subscription-type’ business model in which a larger urban facility offers services to subscribing hospitals and medical clinics.
Specifically, within the LSS network, the Baylor College of Medicine (BCM) will deliver the Self-management TO Prevent – (STOP) Stroke Program to subscribing facilities. A comprehensive stroke risk reduction program that incorporates clinical management, patient education, and patient self-management is vital to reduce both disability and the risk of stroke; and this is the focus of the STOP Stroke Program.
Self- management entails enhanced patient education that is based on patients developing self-efficacy (the confidence to achieve their stated goals) and involves the development of a strong patient-provider partnership. Increasing evidence shows that self-management support reduces hospitalizations, emergency department use, and overall managed care costs. Enhancing the patients’ active participation in their health care and increasing their self-management behaviors is a key factor to health outcomes improvement. Since stroke risk factors overlap other chronic disease processes, such as hypertension and diabetes, and involve lifestyle choices known to compound the risk of cardiovascular events, such as smoking, poor dietary choices, and physical inactivity, patient self-management education may be an important intervention to promote health and adherence to stroke prevention regimens. Although research is underway, there are currently no established evidence-based self-management programs specific for stroke survivors.
The STOP Stroke Program is part of a planned research agenda that incorporates telemedicine modalities for the delivery of stroke prevention and risk factor reduction for patients with a history of stroke, and are at risk secondary events due to poorly controlled risk factors. Over the course of the past 7 years we have developed and evaluated various aspects of the STOP Stroke Program.
The LSS V-STOP-II project formative stage is nearing completion and has already contributed to identifying a change in the model delivery of the V-STOP program would increase its efficiency within this network. The primary outcomes of the initial, formative stage within LSS indicated enthusiastic support for implementing a self-management program and are actively participating. The original model proposed involved identifying local clinicians to both deliver the care and support coordinators to facilitate the self- management program. It became clear that there are not enough clinicians in the local facilities to be able to actually deliver the V-STOP program, while they were able to facilitate recruitment and patient follow up. We have therefore modified Phase 2 of V-STOP-II to focus care delivery at a single hub while recruitment and delivery of the V-STOP program will be performed using local personnel supported by LSS. This model maximizes the strengths of the central hub, and its expertise in self-management while maximizing the skills of the local personnel in recruitment and retention of stroke patients. This model resembles a “subscription” model in which the local sites subscribe for the delivery of V-STOP while retaining implementation locally. The study proposed here, V-STOP-III is a randomized trial to definitely test the benefit of this program in reducing cardiovascular endpoints.
How will the results of the study change or improve clinical practice or patient outcomes?
The effectiveness of self-management in cardiovascular risk factor reduction is known, but its reach is limited by availability of trained personnel and distances that patients must travel. The use of VT technology to address these limitations has not been comprehensively studied. This project maximizes the unique attributes of the LSS network in efficiently connecting academic experts to widely distributed local providers to influence the care of a large number of Texans.