Background: Over 6,000 Veterans are admitted with an acute ischemic stroke annually within the VA Healthcare System. Nearly 25% of all strokes are recurrent events and constitute a leading cause of disability and death within our Veteran population, especially among the 75% of Veterans with stroke and hypertension. Current VA/DoD and American Heart Association/American Stroke Association (AHA/ASA) guidelines stress the importance of delivering guideline concordant management of hypertension, given the strong association between goal blood pressure and decreased morbidity and mortality, especially during the six-month post- stroke period, when most stroke and non-stroke related hospitalizations and deaths occur. Previous Quality Enhancement Research Initiative (QUERI) work has shown that many Veterans 6-months after their stroke do not have their blood pressure optimally controlled. Most Veterans receive their post-stroke risk hypertension care within VA Primary Care and Patient Aligned Care Teams (PACTs). Work performed during the current Health Services Research and Development (HSR&D) Career Development Award (CDA) period has identified several areas for intervention that can assist outpatient providers in Primary Care/PACT to better manage hypertension using existing VA infrastructure, and has led to the development of a bundled, evidence-based, `Post Stroke Hypertension Improvement Intervention.' Therefore, focusing on prevention of future strokes by implementing an intervention to effectively treat hypertension among Veterans with stroke is necessary to improve outcomes in this population. Objective: To: (1) evaluate the feasibility and acceptability of a pilot intervention, implemented at a single VAMC providing suboptimal blood pressure management to post-stroke Veterans, during the `high-risk,' 6- month period post-stroke, such that a more refined intervention can be developed and further informed by key stakeholders, end users, and strategic partners; and (2) collect metrics related to hypertension control at the intervention and four control sites. Methods: A pilot will be initiated at the Michael E. DeBakey VAMC. The Consolidated Framework for Implementation Research (CFIR) conceptual framework and Systems Redesign strategies will be used to evaluate the implementation of the intervention. The feasibility and acceptability of the implementation strategy will be assessed via qualitative interviews with end users of the intervention. Blood pressure will be measured at baseline, 3-months, and 6-months. The distributions and central tendencies of baseline demographic and patient-, provider-, and facility-level characteristics for continuous variables will be examined graphically and by summary statistics. Categorical variables will be examined by calculating frequency distributions. We will match, based on patient volume and mean facility-level blood pressure, our intervention and control sites. Hypothesis: We believe that we can: (1) determine the feasibility and acceptability of a pilot intervention designed to improve post-stroke hypertension control 6-months after discharge; and (2) collect metrics related to hypertension control among Veterans participating in the intervention and four control sites to estimate effect size for a future, larger trial. Conclusion: Interventions that improve management of hypertension among Veterans with ischemic stroke are necessary to prevent recurrent strokes; implementation science strategies can assess the uptake and sustainability of this intervention.

Public Health Relevance

Acute ischemic stroke is a leading cause of death and disability among Veterans receiving inpatient and outpatient care in Veterans Health Administration (VHA) facilities. Hypertension is the single most important modifiable stroke risk factor; however, many Veterans do not obtain `goal' blood pressure (i.e., ? 140/90 mmHg) 6-months after discharge, placing them at increased risk of recurrent strokes. Effective interventions to improve hypertension control have not been developed for post-stroke Veterans. By engaging key stakeholders in the care of Veterans with stroke, we have developed a `Post-Stroke Hypertension Improvement Intervention,' to be implemented at a VA Medical Center providing suboptimal blood pressure management. Ultimately, I will add value to the VA by improving control of post-stroke hypertension by implementing a feasible, acceptable, and well-informed intervention that can be further refined used in various VA settings.

National Institute of Health (NIH)
Veterans Affairs (VA)
Veterans Administration (I21)
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HSR-1 Medical Care and Clinical Management (HSR1)
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VA Connecticut Healthcare System
West Haven
United States
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