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Principal Investigator: Anjail Z Sharrief
Organization: UNIVERSITY OF TEXAS HLTH SCI CTR HOUSTON
Fiscal Year: 2024
Award: $159,200
Funding agency: National Institute on Minority Health and Health Disparities
A. SUMMARY AND SPECIFIC AIMS OF FUNDED PARENT GRANT
Hypertension is the most important risk factor for ischemic and hemorrhagic stroke, and reduction in blood
pressure (BP) after stroke is associated with reduced risk of stroke recurrence. For the majority of stroke
survivors (SS), hypertension remains poorly controlled early after an incident stroke. In the United States, Black
and Hispanic SS are more likely to have poorly controlled risk factors after stroke compared to White SS, and
Black and Hispanic SS have higher rates of stroke recurrence compared to White SS. Prior efforts to reduce
racial disparities in BP control among SS have been uniformly unsuccessful. Multicomponent care models that
include multidisciplinary approaches show promise for improving risk factor control after stroke. Social
determinants of health (SDOH) help to explain racial disparities in BP control and stroke recurrence, therefore
multidisciplinary post-stroke care models that target SDOH may be key to decreasing disparities in BP control.
Limited access to post-stroke outpatient care contributes to challenges in developing system-level interventions
for post-stroke BP control. Telemedicine and telemonitoring may be ideal approaches for improving access to
care in SS. The COVID-19 pandemic has led to rapid expansion of telemedicine for post-acute care in stroke
survivors; however, its effectiveness is unproven. Based on preliminary data at our center, we propose a
randomized trial testing an integrated multidisciplinary telehealth intervention, the Video-based Intervention to
Reduce Treatment and Outcome Disparities in Adults Living with Stroke or Transient Ischemic Attack
(VIRTUAL), in SS recently discharged home after inpatient hospitalization for ischemic stroke, hemorrhagic
stroke, or transient ischemic attack. The intervention will include post-discharge telehealth visits by a
multidisciplinary team, social risk assessments to facilitate social risk-targeted and social risk-informed care, and
home BP telemonitoring and management. The care team includes neurology providers (physician and nurse
practitioner), a pharmacist, and a social worker. Standard care will include follow-up with a neurologist and
primary care provider and pharmacist-assisted BP adjustment.
Aim 1: We will enroll 534 stroke survivors in a randomized comparative effectiveness trial of a 6-month
multidisciplinary telehealth intervention to test the impact of the intervention on key clinical outcomes, relative to
standard care.
Aim 1a: To examine the impact of the intervention on the primary outcome of BP control (24-hour ambulatory
BP <125/75 mmHg) assessed with ambulatory BP monitoring (ABPM) 6 months after hospital discharge.
Aim 1b: To evaluate the impact of the intervention on disparities in BP control at 6 months by examining
heterogeneity of effects on the primary clinical outcome (BP control) according to SS race and ethnicity.
Aim 1c: To assess the sustainability of intervention effect by examining the proportion of SS with BP control after
hospital discharge.
Aim 1d: To examine the impact of the intervention on a composite outcome of recurrent vascular events (stroke,
vascular death, coronary revascularization, myocardial infarction, heart failure) 12 months after hospital
discharge.
Aim 2: We will examine the impact of the intervention on care access and utilization, relative to standard care.
Aim 2a: To examine the impact of the intervention on the proportion of uninsured SS who have obtained
insurance coverage (including Medicaid, state programs, or commercial insurance) by 3- and 6-months following
hospital discharge.
Aim 2b: To examine the impact of the intervention on acute healthcare utilization (emergency department and
urgent care visits and hospital readmissions) 3 months, 6 months and 12 months after hospital discharge.
Aim 2c: To evaluate heterogeneity of effects of the intervention on care access and utilization at 3 months, 6
months, and 12 months according to SS race and ethnicity.
Aim 3: We will use predictive modeling to examine the independent impact of additional baseline SDOH
(neighborhood social vulnerability and segregation indices, food insecurity, experienced racism/discrimination,
healthcare-related racism/discrimination, preferred language, and social support) on 6-month BP control and 12-
month composite recurrent vascular events.
Terms: <21+ years old><Access to Care><Accident and Emergency department><Active Follow-up><Acute><Administrative Supplement><Adult><Adult Human><Ambulatory Blood Pressure Monitoring><Ambulatory Care><Apoplexy><BP control><BP management><BP reduction><Black><Black race><Blood Pressure><Blood Vessels><Brain TIA><Brain Vascular Accident><Brain hemorrhage><COVID crisis><COVID epidemic><COVID pandemic><COVID-19 crisis><COVID-19 epidemic><COVID-19 era><COVID-19 global health crisis><COVID-19 global pandemic><COVID-19 health crisis><COVID-19 pandemic><COVID-19 period><COVID-19 public health crisis><COVID-19 years><Cardiac infarction><Caring><Cerebral Stroke><Cerebrovascular Apoplexy><Cerebrovascular Stroke><Cessation of life><Clinical><Cognitive Discrimination><Coronary><Data><Death><Decrease disparity><Development and Research><Discrimination><Disparities><Disparity><Effectiveness><Emergency Department><Emergency room><Enrollment><Ethnic Origin><Ethnicity><Event><Foundations><Funding><Geography><Health Care Utilization><Health Services><Health Services Accessibility><Healthcare><Heart failure><Heterogeneity><Hispanic><Home><Hospital Admission><Hospitalization><Hospitals><Hour><Hypertension><Improve Access><Inpatients><Insurance><Insurance Coverage><Insurance Status><Intervention><Intervention Strategies><Investigators><Ischemic Stroke><Language><Lower disparity><Medicaid><Modeling><Myocardial Infarct><Myocardial Infarction><Neighborhoods><Neurologist><Neurology><Nurse Practitioners><Outcome><Outpatient Care><Patient Outcomes Assessments><Patient Reported Measures><Patient Reported Outcomes><Pharmacists><Physicians><Population Heterogeneity><Principal Investigator><Process><Provider><R & D><R&D><Race><Races><Racial Group><Randomization trial><Randomized><Recurrence><Recurrent><Research><Research Personnel><Researchers><Risk><Risk Assessment><Risk Factors><SARS-CoV-2 epidemic><SARS-CoV-2 global health crisis><SARS-CoV-2 global pandemic><SARS-CoV-2 pandemic><SARS-coronavirus-2 epidemic><SARS-coronavirus-2 pandemic><Severe Acute Respiratory Syndrome CoV 2 epidemic><Severe Acute Respiratory Syndrome CoV 2 pandemic><Severe acute respiratory syndrome coronavirus 2 epidemic><Severe acute respiratory syndrome coronavirus 2 pandemic><Social Workers><Social support><Stroke><Survivors><System><Telemedicine><Testing><Transient Ischemic Attack><Uninsured><United States><Vascular Hypertensive Disease><Vascular Hypertensive Disorder><Visit><access to health services><access to services><access to treatment><accessibility to health services><active followup><acute care><adulthood><after stroke><availability of services><bleeding in brain><blood pressure control><blood pressure management><blood pressure reduction><brain attack><cardiac failure><cardiac infarct><care access><cerebral vascular accident><cerebrovascular accident><comparative effectiveness trial><computer based prediction><coronary attack><coronary infarct><coronary infarction><coronavirus disease 2019 crisis><coronavirus disease 2019 epidemic><coronavirus disease 2019 global health crisis><coronavirus disease 2019 global pandemic><coronavirus disease 2019 health crisis><coronavirus disease 2019 pandemic><coronavirus disease 2019 public health crisis><coronavirus disease crisis><coronavirus disease epidemic><coronavirus disease pandemic><coronavirus disease-19 global pandemic><coronavirus disease-19 pandemic><develop therapy><digital health><disparate effect><disparate impact><disparate result><disparities in race><disparity due to race><disparity reduction><diverse populations><enroll><experience><follow up><follow-up><followed up><followup><food insecurity><health care><health care service use><health care service utilization><health literacy><health service access><health services availability><healthcare service use><healthcare service utilization><healthcare utilization><heart attack><heart infarct><heart infarction><hemorrhagic stroke><heterogeneous population><high blood pressure><homes><hospital re-admission><hospital readmission><hyperpiesia><hyperpiesis><hypertensive disease><hypertensive disorder><improved><indexing><inequality due to race><inequitable effect><inequitable impact><inequitable outcome><inequity due to race><interdisciplinary approach><intervention development><intervention effect><interventional strategy><lower BP><lower blood pressure><lowers blood pressure><mini stroke><mini-stroke><mitigate disparity><multidisciplinary><multidisciplinary approach><outcome disparities><outcome inequality><outcome inequity><outpatient treatment><parent grant><population diversity><post intervention><post stroke><poststroke><predictive modeling><primary care provider><primary outcome><programs><providers from primary care><providers of primary care><race based disparity><race based inequality><race based inequity><race disparity><race related disparity><race related inequality><race related inequity><racial><racial background><racial disparity><racial inequality><racial inequity><racial origin><racial population><racial subgroup><racially unequal><racism><randomisation><randomization><randomized trial><randomly assigned><re-admission><re-hospitalization><readmission><reduce BP><reduce blood pressure><reduce disparity><reduction in BP><reduction in blood pressure><reduction in disparity><rehospitalization><research and development><revascularization><risk for stroke><risk of stroke><segregation><service availability><severe acute respiratory syndrome coronavirus 2 global health crisis><severe acute respiratory syndrome coronavirus 2 global pandemic><social><social health determinants><social support network><social vulnerability><standard care><standard treatment><stroke risk><stroke survivor><stroked><strokes><telehealth><telemonitoring><therapy development><treatment access><treatment and outcome><treatment development><unequal effect><unequal impact><unequal outcome><urgent care><vascular>