This study, which is also funded by the American Heart Association, will assess whether lifestyle group clinics, care managers and support from community health workers may reduce the risk of a second stroke in socioeconomically disadvantaged minority patients.

1. Systematic Use of STroke Averting
INterventions (SUSTAIN) Trial
‘Stay With the Guidelines’
LA County DHS
Amytis Towfighi, MD (Rancho LA-NRC)
Lillie Hudson, PA, MPH (USC/RLANRC)
Nerses Sanossian, MD (USC)
Tom Anderson, MD (Harbor-UCLA)
Robert Bryg, MD (Olive View-UCLA)
Jeff Guterman, MD (Amb Care Network)
Sandra Gross-Schulman, MD, MPH, RN
UCLA: SOM, Dentistry, Public Health
Barbara Vickrey, MD, MPH, PI (Presenter)
Eric Cheng, MD, MS, Co-PI
William Cunningham, MD, MPH, Co-I
Susan Ettner, PhD, Health Economics
Honghu Liu, PhD, Biostatistics
Brian Mittman, PhD, Implementation
Community
Local AHA - Sylvia Beanes
Healthy African American
Families II/Drew University –
Andrea Jones
Partners In Care Foundation
Watts Labor Community Action
Committee – Phyllis Willis
Also funded by American Heart Association

2. Project Description: Background and Research Questions
Research Question #1:
Does a Chronic Care model-based intervention meaningfully reduce risk of
stroke through improved control of multiple stroke risk factors, compared to
usual care, among socio-economically disadvantaged patients discharged
following ischemic stroke or transient ischemic attack, at 4 Los Angeles
County safety net hospitals?
Research Question #2:
Is such an intervention feasible to implement and sustainable – particularly
with respect to cost - in a safety net healthcare system?
Stroke is the leading cause of disability & 3rd leading cause of death in US
Yet, control of risk factors ((BP, cholesterol, physical activity, diet, aspirin,
smoking cessation) enormously reduces recurrent stroke risk
However, risk factor control to prevent another stroke is poor and worse for
socioeconomically disadvantaged minorities due to multiple barriers:
• 1 in 8 Latino elders in LA public healthcare system have no education
• Substantial transportation barriers in city with no good mass
transit options
• Lack of access to outpatient primary care after discharge
• Wait times for outpatient neurology clinic were ~ 6 months
• Lifestyle changes (activity, diet, smoking) are better addressed
through approaches not offered in traditional physician visits

3. 1st NP/PA call/clinic visit
• Assess medication side
effects, adherence
• Adjust meds per protocol
• Personalized action plan
• Home blood pressure
monitor
SUSTAIN Intervention
+ Usual Care (N = 205)
NP/PA Phone Call
(at 1 week) & Clinic
Visit (at 1 month)
1st
Group Clinic
(at 2 months)
2nd
Group Clinic
(at 5 months)
NP Clinic Visit
(at 7 months)
3rd
Group Clinic
(at 10 months)
One time
delivery of
education
materials +
Usual Care
(N = 205)
TelephoneCoordinationof
Care/Trackingregistry
Randomize Patients in 1:1 ratio (N = 410)
Usual Inpatient Care
1st Group clinic
• NP/PA or dietician/OT led
stroke interactive seminar
• Medication adherence**
• Neuroimaging tool; report
cards
• Q&A period, peer
interaction
• Action plan refined by
patient and NP/PA during
brief one-on-one session
Methods: SUSTAIN Randomized Controlled Trial
Study
outcomes
(both arms)
measured
at 3-, 8-,
and 12-
months

4. Accomplishments/Outcomes
Current Status:
SUSTAIN trial enrollment was completed in summer 2012; trial is
ongoing through follow-up of final study participant in mid-2013
What We Have Learned So Far:
1. It is possible to achieve high rates of recruitment and high levels of
12-month follow-up interviews (~75-80% of eligibles to date)
through in-hospital recruitment and multiple approaches to
identifying ways to contact participants.
2. Care managers (nurse practitioners,
physician assistants) working within/at the
medical centers and using stroke prevention-
specific decision support can effectively
focus on medication management, but
patient load needs to be higher to be
sustainable.
3. Patients who attend the group clinics
endorse their value for lifestyle changes in
diet and physical activity, but participation is
< 50% due mainly to transportation barriers.

5. Scale and Spread
1. Protocols for NP/PA stroke prevention care
management is gearing up for broad implementation
into the Stroke Medical Home at Rancho Los Amigos
National Rehabilitation Center
2. Repatriation of patients hospitalized for acute stroke at
other hospitals into DHS system for outpatient follow-
up is occurring due to protocols established under
SUSTAIN
3. The NP/PA care management component within the
healthcare delivery system of medical centers will be a
component of the subsequent SUCCEED trial (teaming
with community health workers)

6. What is Next
Application submitted to NIH in April 2012 was successful; program
includes funding of a trial building on preliminary SUSTAIN findings:
• “SUCCEED” – Secondary stroke prevention by Uniting
Community and Chronic care model teams Early to End
Disparities
• SUCCEED began September 30, 2012 and is funded through
August 31, 2017.
• Builds on SUSTAIN implementation findings on transportation
and other barriers for lifestyle group clinics and pragmatic need
for higher caseloads for care managers, by incorporating
community health workers (CHW) for:
 Chronic disease self-management
programs delivered in the
community
 Home visits
 Mobile health technology
SUCCEED will have much greater involvement of current community
partners (WLCAC, AHA) plus new partners (Worker Education
Resource Center, Esperanza CHC, Chinatown Service Center, others)
CHW

7. Lessons for Others
1. Protocols for effective in-hospital recruitment in the LA
DHS medical centers
2. Multiple strategies yielding effective retention of study
participants
3. Strategy for teaching about cardiovascular diet in small
group setting and in both English and Spanish
• Reading nutrition labels; use of “props”
• Involvement of family
• Culturally sensitive education
4. Practical algorithms for care managers in stroke
prevention; logic algorithms for programming into
decision support tools
5. Recommendations and standardized training procedure
for blood pressure and lipid measurement for health
services research intervention studies, and for home
blood pressure monitors for stroke patients

8. Added Value from CTSI Funding
Without the CTSI funding, we would not have
been able to recruit the full study sample size
and would have had insufficient power for our
study aims.