Stroke Disparities Program

描述(摘要)：在美国，急性中风是第三大致死原因，也是成人致残的首要原因。不成比例的发病率和死亡率落在服务不足的人群身上。缩小健康差距已成为一项重大的公共卫生挑战，也是2010年健康人倡议的一个主要目标。这项提议的方案目标是确定造成种族差异的生物和社会经济因素，并开发创新的方法来减少缺血性和出血性中风的这些差异。提出了三个研究课题。项目1，解决种族和民族差异的急性卒中干预计划(ASPIRE)，是一项干预性研究，旨在调查在一个主要缺乏服务的社区，实施多水平干预是否可以显著增加接受静脉组织纤溶酶原激活剂(IV TPA)适当治疗的缺血性中风患者的数量。主要的结果衡量标准将是所有接受静脉注射tPA适当治疗的缺血性中风患者的百分比。项目2，通过哥伦比亚特区的协同治疗预防血栓栓子事件的复发(PROTECT DC)是一项随机的II期临床试验，对哥伦比亚特区两家服务不足的医院的缺血性中风患者进行PROTECT DC干预(基于医院的积极二级预防结合导航病例管理)与标准治疗。主要目标是：1)改进保护性DC设计，为INI阶段试验做准备；2)评估干预措施对4个用药目标的影响，这些目标是由次级风险因素控制的客观衡量标准标准化确定的。项目3，基于种族或种族的原发性出血成像的差异(DECHER)是一项纵向、磁共振成像、前瞻性、观察性、队列研究，旨在按种族/民族评估原发性脑出血患者慢性脑微出血的患病率和意义。三个核心将支持这些项目：A)行政管理；B)参与者招募、保留、干预和成果；以及C)生物统计/数据管理。这项申请不仅旨在确定导致中风治疗和结果中种族/民族差异的因素，而且还旨在证明专门为减少这些差异而设计的计划的有效性。 项目1：解决种族和族裔差异的急性卒中干预方案(ASPIRE) 少年派：夏亚美 描述：中风是美国第三大死亡原因，也是成人残疾的主要原因，对服务不足的人群有不成比例的影响，这反映在这些群体中更高的发病率和死亡率上。几项研究表明，黑人比白人更不可能接受静脉注射组织型纤溶酶原激活剂(IV TPA)，这是FDA批准的唯一一种急性缺血性中风治疗方法。需要努力阐明在获得急性中风护理方面造成种族/民族差异的因素，并制定克服这些障碍的方案。该干预项目的具体目标是：a)确定在服务不足的城市人口中急性中风治疗的社会文化和环境障碍；b)调查针对这些障碍实施的多水平干预措施的实施是否能显著增加接受静脉注射组织型纤溶酶原激活剂(IV TPA)适当治疗的缺血性中风患者的数量；以及c)对干预中使用的方法进行计划评估，以确定哪些努力是最有效的。调查人员将协助哥伦比亚特区的6家医院建立一个卒中冠军团队，以实施旨在改善急性卒中护理的教育计划和标准化程序。巴尔的摩的五家医院将作为对照组。该项目的基本设计特点包括：1)以服务不足的人群为重点，以确定社区特有的障碍，然后定制现有的中风教育材料，以提高健康素养，减少寻求治疗的延误；2)实施干预措施，以解决公共、辅助医疗和医院层面的教育、态度和结构性障碍；以及3)为每家医院指派一名专门的研究协调员，他将同时担任中风冠军。这项试验的长期目标是确定系统的、可重复的、有效的方法，以改善服务不足地区的急性中风治疗的交付，这些方法可以在更广泛的领域实施。唯一确定影响服务不足的中风患者预后的方法是阐明与获得治疗相关的复杂问题，而哥伦比亚特区是进行这些调查的理想城市。

DESCRIPTION (abstract): Acute stroke is the third leading cause of death and the leading cause of adult disability in the US. A disproportionate amount of morbidity and mortality falls on underserved populations. Reduction of health disparities has become a significant public health challenge and is a major goal of the Healthy People 2010 initiative. The programmatic goal of this proposal is to identify biological and socioeconomic factors contributing to ethnic disparities and to develop innovative approaches to reduce these disparities for ischemic and hemorrhagic stroke. Three research projects are proposed. Project 1, Acute Stroke Program of Interventions addressing Racial and Ethnic disparities (ASPIRE), is an intervention study designed to investigate whether implementation of a multilevel intervention can significantly increase the number of ischemic stroke patients appropriately treated with intravenous tissue plasminogen activator (IV tPA) in a predominantly underserved community. The primary outcome measure will be the percentage of all ischemic stroke patients appropriately treated with IV tPA. Project 2, Preventing Recurrence of Thromboembolic Events through Coordinated Treatment in the District of Columbia (PROTECT DC) is a randomized phase II clinical trial of the PROTECT DC intervention (hospital-based initiation of aggressive secondary prevention combined with navigator case management) vs. standard management in ischemic stroke patients from two underserved hospitals in the District of Columbia. The primary aims are 1) to refine the PROTECT DC design in preparation for a phase INI trial and, 2) to assess the effect of the intervention on 4 medication goals as defined by normalization of objective measures of secondary risk factor control. Project 3, DiffErenCes in the Imaging of Primary Hemorrhage based on Ethnicity or Race (DECIPHER) is a longitudinal, MR imaging, prospective, observational, cohort study designed to evaluate the prevalence and significance by race/ethnicity of chronic cerebral microbleeds in patients with primary intracerebral hemorrhage. Three cores will support the projects: A) Administration B) Participant Recruitment, Retention, Intervention and Outcomes, and C) Biostatistics / Data Management. This application is designed not only to define factors leading to racial/ethnic disparities in stroke treatment and outcomes, but also to demonstrate the efficacy of programs specifically designed to reduce these disparities. Project 1: Acute Stroke Program of Interventions Addressing Racial and Ethnic Disparities (ASPIRE) PI: Amie Hsia DESCRIPTION: Stroke, the third leading cause of death and the leading cause of adult disability in the United States, has a disproportionate impact on underserved populations that is reflected in higher incidence and mortality rates in these groups. Several studies have suggested that blacks are less likely than whites to receive intravenous tissue plasminogen activator (IV tPA), the only FDA-approved acute ischemic stroke therapy. Efforts are needed to elucidate factors contributing to racial/ethnic disparities in access to acute stroke care and to develop programs to overcome these barriers. The specific aims of this intervention project are: A) to identify previously unrecognized sociocultural and environmental barriers to acute stroke treatment in an underserved, urban population; B) to investigate whether implementation of a multilevel intervention designed to address these barriers can significantly increase the number of ischemic stroke patients appropriately treated with intravenous tissue plasminogen activator (IV tPA); and C) to perform program evaluation of the methods used in the intervention to determine which efforts are the most effective. The investigators will assist each of 6 hospitals in the District of Columbia to develop a team of Stroke Champions to implement educational programs and standardized procedures designed to improve acute stroke care. Five Baltimore hospitals will serve as the control group. Essential design features of this project include: 1) a focus on underserved populations to identify community-specific barriers and then tailor existing stroke education materials to increase health literacy and decrease delays in seeking treatment; 2) implementation of interventions to address educational, attitudinal, and structural barriers at the public, paramedic and hospital levels; and 3) assignment of a dedicated research coordinator to each hospital who will also serve as a Stroke Champion. The long term objective of the trial is to identify systematic, reproducible, effective methods for improving the delivery of acute stroke therapies in underserved areas that can be implemented in a broader arena. The only way to definitively affect outcomes for underserved stroke patients is to elucidate the complex issues related to access to treatment, and the District of Columbia is the ideal city in which to perform these investigations.