A Physical Activity and Diet Just-in-Time Adaptive Intervention to Reduce Blood Pressure: The myBPmyLife Study Rationale and Design.

BACKGROUND: Smartphone applications and wearable devices are promising mobile health interventions for hypertension self-management. However, most mobile health interventions fail to use contextual data, potentially diminishing their impact. The myBPmyLife Study is a just-in-time adaptive intervention designed to promote personalized self-management for patients with hypertension. METHODS AND RESULTS: The study is a 6-month prospective, randomized-controlled, remotely administered trial. Participants were recruited from the University of Michigan Health in Ann Arbor, Michigan or the Hamilton Community Health Network, a federally qualified health center network in Flint, Michigan. Participants were randomized to a mobile application with a just-in-time adaptive intervention promoting physical activity and lower-sodium food choices as well as weekly goal setting or usual care. The mobile study application encourages goal attainment through a central visualization displaying participants' progress toward their goals for physical activity and lower-sodium food choices. Participants in both groups are followed for up for 6 months with a primary end point of change in systolic blood pressure. Exploratory analyses will examine the impact of notifications on step count and self-reported lower-sodium food choices. The study launched on December 9, 2021, with 484 participants enrolled as of March 31, 2023. Enrollment of participants was completed on July 3, 2023. After 6 months of follow-up, it is expected that results will be available in the spring of 2024. CONCLUSIONS: The myBPmyLife study is an innovative mobile health trial designed to evaluate the effects of a just-in-time adaptive intervention focused on improving physical activity and dietary sodium intake on blood pressure in diverse patients with hypertension. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT05154929.

National- and State-Level Trends in Medicare Hospice Beneficiaries for Stroke During 2013 to 2019 in the United States.

BACKGROUND: Stroke is the fifth leading cause of death in the United States, one of the leading contributors to Medicare cost, including through Medicare hospice benefits, and the rate of stroke mortality has been increasing since 2013. We hypothesized that hospice utilization among Medicare beneficiaries with stroke has increased over time and that the increase is associated with trends in stroke death rate. METHODS: Using Medicare Part A claims data and Centers for Disease Control mortality data at a national and state level from 2013 to 2019, we report the proportion and count of Medicare hospice beneficiaries with stroke as well as the stroke death rate (per 100 000) in Medicare-eligible individuals aged ≥65 years. RESULTS: From 2013 to 2019, the number of Medicare hospice beneficiaries with stroke as their primary diagnosis increased 104.1% from 78 812 to 160 884. The number of stroke deaths in the United States in individuals aged ≥65 years also increased from 109 602 in 2013 to 129 193 in 2019 (17.9% increase). In 2013, stroke was the sixth most common primary diagnosis for Medicare hospice, while in 2019 it was the third most common, surpassed only by cancer and dementia. The correlation between the change from 2013 to 2019 in state-level Medicare hospice for stroke and stroke death rate for Medicare-eligible adults was significant (Spearman ρ=0.5; P<0.001). In a mixed-effects model, the variance in the state-level proportion of Medicare hospice for stroke explained by the state-level stroke death rate was 48.2%. CONCLUSIONS: From 2013 to 2019, the number of Medicare hospice beneficiaries with a primary diagnosis of stroke more than doubled and stroke jumped from the sixth most common indication for hospice to the third most common. While increases in stroke mortality in the Medicare-eligible population accounts for some of the increase of Medicare hospice beneficiaries, over half the variance remains unexplained and requires additional research.

Patient Travel Distance to Neurologist Visits.

BACKGROUND AND OBJECTIVES: The density of neurologists within a given geographic region varies greatly across the United States. We aimed to measure patient travel distance and travel time to neurologist visits, across neurologic conditions and subspecialties. Our secondary goal was to identify factors associated with long-distance travel for neurologic care. METHODS: We performed a cross-sectional analysis using a 2018 Medicare sample of patients with at least 1 outpatient neurologist visit. Long-distance travel was defined as driving distance ≥50 miles 1-way to the visit. Travel time was measured as driving time in minutes. Multilevel generalized linear mixed models with logistic link function, which accounted for clustering of patients within hospital referral region and allowed modeling of region-specific random effects, were used to determine the association of patient and regional characteristics with long-distance travel. RESULTS: We identified 563,216 Medicare beneficiaries with a neurologist visit in 2018. Of them, 96,213 (17%) traveled long distance for care. The median driving distance and time were 81.3 (interquartile range [IQR]: 59.9-144.2) miles and 90 (IQR: 69-149) minutes for patients with long-distance travel compared with 13.2 (IQR: 6.5-23) miles and 22 (IQR: 14-33) minutes for patients without long-distance travel. Comparing across neurologic conditions, long-distance travel was most common for nervous system cancer care (39.6%), amyotrophic lateral sclerosis [ALS] (32.1%), and MS (22.8%). Many factors were associated with long-distance travel, most notably low neurologist density (first quintile: OR 3.04 [95% CI 2.41-3.83] vs fifth quintile), rural setting (4.89 [4.79-4.99]), long-distance travel to primary care physician visit (3.6 [3.51-3.69]), and visits for ALS and nervous system cancer care (3.41 [3.14-3.69] and 5.27 [4.72-5.89], respectively). Nearly one-third of patients bypassed the nearest neurologist by 20+ miles, and 7.3% of patients crossed state lines for neurologist care. DISCUSSION: We found that nearly 1 in 5 Medicare beneficiaries who saw a neurologist traveled ≥50 miles 1-way for care, and travel burden was most common for lower-prevalence neurologic conditions that required coordinated multidisciplinary care. Important potentially addressable predictors of long-distance travel were low neurologist density and rural location, suggesting interventions to improve access to care such as telemedicine or neurologic subspecialist support to local neurologists. Future work should evaluate differences in clinical outcomes between patients with long-distance travel and those without.

Predictors of referral for long-term EEG monitoring for Medicare beneficiaries with drug-resistant epilepsy.

OBJECTIVE: For people with drug-resistant epilepsy, the use of epilepsy surgery is low despite favorable odds of seizure freedom. To better understand surgery utilization, we explored factors associated with inpatient long-term EEG monitoring (LTM), the first step of the presurgical pathway. METHODS: Using 2001-2018 Medicare files, we identified patients with incident drug-resistant epilepsy using validated criteria of ≥2 distinct antiseizure medication (ASM) prescriptions and ≥1 drug-resistant epilepsy encounter among patients with ≥2 years pre- and ≥1 year post-diagnosis Medicare enrollment. We used multilevel logistic regression to evaluate associations between LTM and patient, provider, and geographic factors. We then analyzed neurologist-diagnosed patients to further evaluate provider/environmental characteristics. RESULTS: Of 12 044 patients with incident drug-resistant epilepsy diagnosis identified, 2% underwent surgery. Most (68%) were diagnosed by a neurologist. In total, 19% underwent LTM near/after drug-resistant epilepsy diagnosis; another 4% only underwent LTM much prior to diagnosis. Patient factors most strongly predicting LTM were age <65 (adjusted odds ratio 1.5 [95% confidence interval 1.3-1.8]), focal epilepsy (1.6 [1.4-1.9]), psychogenic non-epileptic spells diagnosis (1.6 [1.1-2.5]) prior hospitalization (1.7, [1.5-2]), and epilepsy center proximity (1.6 [1.3-1.9]). Additional predictors included female gender, Medicare/Medicaid non-dual eligibility, certain comorbidities, physician specialties, regional neurologist density, and prior LTM. Among neurologist-diagnosed patients, neurologist <10 years from graduation, near an epilepsy center, or epilepsy-specialized increased LTM likelihood (1.5 [1.3-1.9], 2.1 [1.8-2.5], 2.6 [2.1-3.1], respectively). In this model, 37% of variation in LTM completion near/after diagnosis was explained by individual neurologist practice and/or environment rather than measurable patient factors (intraclass correlation coefficient 0.37). SIGNIFICANCE: A small proportion of Medicare beneficiaries with drug-resistant epilepsy completed LTM, a proxy for epilepsy surgery referral. While some patient factors and access measures predicted LTM, non-patient factors explained a sizable proportion of variance in LTM completion. To increase surgery utilization, these data suggest initiatives targeting better support of neurologist referral.

Definitions of Drug-Resistant Epilepsy for Administrative Claims Data Research.

BACKGROUND AND OBJECTIVE: To assess the accuracy of definitions of drug-resistant epilepsy applied to administrative claims data. METHODS: We randomly sampled 450 patients from a tertiary health system with ≥1 epilepsy/convulsion encounter, ≥2 distinct antiseizure medications (ASMs) from 2014 to 2020, and ≥2 years of electronic medical records (EMR) data. We established a drug-resistant epilepsy diagnosis at a specific visit by reviewing EMR data and using a rubric based on the 2010 International League Against Epilepsy definition. We performed logistic regressions to assess clinically relevant predictors of drug-resistant epilepsy and to inform claims-based definitions. RESULTS: Of 450 patients reviewed, 150 were excluded for insufficient EMR data. Of the 300 patients included, 98 (33%) met criteria for current drug-resistant epilepsy. The strongest predictors of current drug-resistant epilepsy were drug-resistant epilepsy diagnosis code (odds ratio [OR] 16.9, 95% confidence interval [CI] 8.8-32.2), ≥2 ASMs in the prior 2 years (OR 13.0, 95% CI 5.1-33.3), ≥3 nongabapentinoid ASMs (OR 10.3, 95% CI 5.4-19.6), neurosurgery visit (OR 45.2, 95% CI 5.9-344.3), and epilepsy surgery (OR 30.7, 95% CI 7.1-133.3). We created claims-based drug-resistant epilepsy definitions (1) to maximize overall predictiveness (drug-resistant epilepsy diagnosis; sensitivity 0.86, specificity 0.74, area under the receiver operating characteristics curve [AUROC] 0.80), (2) to maximize sensitivity (drug-resistant epilepsy diagnosis or ≥3 ASMs; sensitivity 0.98, specificity 0.47, AUROC 0.72), and (3) to maximize specificity (drug-resistant epilepsy diagnosis and ≥3 nongabapentinoid ASMs; sensitivity 0.42, specificity 0.98, AUROC 0.70). DISCUSSION: Our findings provide validation for several claims-based definitions of drug-resistant epilepsy that can be applied to a variety of research questions.

Trends in Stroke Recurrence in Mexican Americans and Non-Hispanic Whites.

BACKGROUND AND PURPOSE: Stroke incidence and mortality are declining rapidly in developed countries. Little data on ethnic-specific stroke recurrence trends exist. Fourteen-year stroke recurrence trend estimates were evaluated in Mexican Americans and non-Hispanic whites in a population-based study. METHODS: Recurrent stroke was ascertained prospectively in the population-based BASIC (Brain Attack Surveillance in Corpus Christi) project in Texas, between 2000 and 2013. Incident cases were followed forward to determine 1- and 2-year recurrence. Fine & Gray subdistribution hazard models were used to estimate adjusted trends in the absolute recurrence risk and ethnic differences in the secular trends. The ethnic difference in the secular trend was examined using an interaction term between index year and ethnicity in the models adjusted for age, sex, hypertension, diabetes mellitus, smoking, atrial fibrillation, insurance, and cholesterol and relevant interaction terms. RESULTS: From January 1, 2000 to December 31, 2013 (N=3571), the cumulative incidence of 1-year recurrence in Mexican Americans decreased from 9.26% (95% CI, 6.9%-12.43%) in 2000 to 3.42% (95% CI, 2.25%-5.21%) in 2013. Among non-Hispanic whites, the cumulative incidence of 1-year recurrence in non-Hispanic whites decreased from 5.67% (95% CI, 3.74%-8.62%) in 2000 to 3.59% (95% CI, 2.27%-5.68%) in 2013. The significant ethnic disparity in stroke recurrence existed in 2000 (risk difference, 3.59% [95% CI, 0.94%-6.22%]) but was no longer seen by 2013 (risk difference, -0.17% [95% CI, -1.96% to 1.5%]). The competing 1-year mortality risk was stable over time among Mexican Americans, while for non-Hispanic whites it was decreasing over time (difference between 2000 and 2013: -4.67% [95% CI, -8.72% to -0.75%]). CONCLUSIONS: Mexican Americans had significant reductions in stroke recurrence despite a stable death rate, a promising indicator. The ethnic disparity in stroke recurrence present early in the study was gone by 2013.

Impact of early headache neuroimaging on time to malignant brain tumor diagnosis: A retrospective cohort study.

BACKGROUND: Neuroimaging for headaches is both common and costly. While the costs are well quantified, little is known about the benefit in terms of diagnosing pathology. Our objective was to determine the role of early neuroimaging in the identification of malignant brain tumors in individuals presenting to healthcare providers with headaches. METHODS: This was a retrospective cohort study using administrative claims data (2001-2014) from a US insurer. Individuals were included if they had an outpatient visit for headaches and excluded for prior headache visits, other neurologic conditions, neuroimaging within the previous year, and cancer. The exposure was early neuroimaging, defined as neuroimaging within 30 days of the first headache visit. A propensity score-matched group that did not undergo early neuroimaging was then created. The primary outcome was frequency of malignant brain tumor diagnoses and median time to diagnosis within the first year after the incident headache visit. The secondary outcome was frequency of incidental findings. RESULTS: 22.2% of 180,623 individuals had early neuroimaging. In the following year, malignant brain tumors were found in 0.28% (0.23-0.34%) of the early neuroimaging group and 0.04% (0.02-0.06%) of the referent group (P<0.001). Median time to diagnosis in the early neuroimaging group was 8 (3-19) days versus 72 (39-189) days for the referent group (P<0.001). Likely incidental findings were discovered in 3.17% (3.00-3.34%) of the early neuroimaging group and 0.66% (0.58-0.74%) of the referent group (P<0.001). CONCLUSIONS: Malignant brain tumors in individuals presenting with an incident headache diagnosis are rare and early neuroimaging leads to a small reduction in the time to diagnosis.

Claims data analyses unable to properly characterize the value of neurologists in epilepsy care.

OBJECTIVE: To determine the association of a neurologist visit with health care use and cost outcomes for patients with incident epilepsy. METHODS: Using health care claims data for individuals insured by United Healthcare from 2001 to 2016, we identified patients with incident epilepsy. The population was defined by an epilepsy/convulsion diagnosis code (ICD codes 345.xx/780.3x, G40.xx/R56.xx), an antiepileptic prescription filled within the succeeding 2 years, and neither criterion met in the 2 preceding years. Cases were defined as patients who had a neurologist encounter for epilepsy within 1 year after an incident diagnosis; a control cohort was constructed with propensity score matching. Primary outcomes were emergency room (ER) visits and hospitalizations for epilepsy. Secondary outcomes included measures of cost (epilepsy related, not epilepsy related, and antiepileptic drugs) and care escalation (including EEG evaluation and epilepsy surgery). RESULTS: After participant identification and propensity score matching, there were 3,400 cases and 3,400 controls. Epilepsy-related ER visits were more likely for cases than controls (year 1: 5.9% vs 2.3%, p < 0.001), as were hospitalizations (year 1: 2.1% vs 0.7%, p < 0.001). Total medical costs for epilepsy care, nonepilepsy care, and antiepileptic drugs were greater for cases (p ≤ 0.001). EEG evaluation and epilepsy surgery occurred more commonly for cases (p ≤ 0.001). CONCLUSIONS: Patients with epilepsy who visited a neurologist had greater subsequent health care use, medical costs, and care escalation than controls. This comparison using administrative claims is plausibly confounded by case disease severity, as suggested by higher nonepilepsy care costs. Linking patient-centered outcomes to claims data may provide the clinical resolution to assess care value within a heterogeneous population.

Recognition and Diagnosis of Obstructive Sleep Apnea in Older Americans.

OBJECTIVES: To estimate the proportion of older Americans at risk for obstructive sleep apnea (OSA) who receive OSA evaluations, diagnosis, and treatment. DESIGN: Cross sectional study. SETTING: National Health and Aging Trends Study (NHATS), Round 3 survey. PARTICIPANTS: Community-dwelling Medicare beneficiaries age 65 and older (N=1,052). MEASUREMENTS: NHATS participants were asked specific questions about sleep disturbances, including items that resembled critical elements of a validated instrument used to assess OSA risk (the STOP-Bang questionnaire). The proportion of older Americans at risk for OSA who received evaluations with home or in-laboratory sleep studies, OSA diagnosis, and OSA treatment was examined, as well as clinical, social, and demographic correlates of OSA. RESULTS: Of 1,052 participants who completed the sleep module, 56% (95% confidence interval (CI)=53-59%) were estimated to be at high risk of OSA. Only 8% (95% CI=5-11%) of the high-risk individuals had been tested for it. Of those tested, 94% (95% CI=87-100%) were diagnosed with OSA. Treatment with positive airway pressure was prescribed for 82% (95% CI=65-99%) of participants with an OSA diagnosis. CONCLUSIONS: Evidence from this nationally representative sample of community-dwelling Medicare beneficiaries suggests that high OSA risk is common but seldom investigated. When investigated, OSA is almost always confirmed and usually treated. These findings suggest a significant gap in OSA assessment for older Americans that could have public health implications.

Prognosis of Midlife Stroke.

OBJECTIVE: To characterize stroke outcomes in a midlife population-based stroke cohort, and to describe comorbidities, quality of care, and risk of recurrence in this age group. MATERIALS AND METHODS: Ischemic strokes (ISs) were identified from the population-based Brain Attack Surveillance in Corpus Christi Project (2000-2012). Data were from medical records and patient interviews. Ninety-day outcomes (functional, neurologic, cognitive, quality of life [QOL]), prevalence of comorbidities, quality of care, and 1-year recurrence were estimated for those aged 45-64 (midlife) and compared with those aged ≥65 using sex and race-ethnicity adjusted regression models. RESULTS: Of 4858 ISs, 33% occurred in midlife. On average, the midlife group reported some difficulty with function, favorable neurologic and cognitive outcomes, and moderate QOL scores at 90 days. All outcomes except QOL were better in the midlife group. Prevalent comorbidities in midlife were hypertension (74%), diabetes (51%), hyperlipidemia (34%), heart disease (26%), prior stroke/transient ischemic attack (23%), smoking 37%, excess alcohol 10%, and atrial fibrillation 4%. Median body mass index (BMI) was 30 (interquartile range: 26-35). Diabetes, smoking, and alcohol were more prevalent and BMI higher in the midlife group. Quality of stroke care did not differ by age. One-year recurrence in midlife was 8% (95% confidence interval: 6%-9%) and did not differ by age. CONCLUSION: While 90-day outcomes were more favorable than in the elderly, midlife stroke survivors faced some disability and did not experience better QOL despite better outcomes. Additional research should identify targets to optimize secondary stroke prevention and improve outcomes in midlife stroke survivors-an understudied group with great potential disability and economic impact.

A Multicomponent Behavioral Intervention to Reduce Stroke Risk Factor Behaviors: The Stroke Health and Risk Education Cluster-Randomized Controlled Trial.

BACKGROUND AND PURPOSE: The Stroke Health and Risk Education Project was a cluster-randomized, faith-based, culturally sensitive, theory-based multicomponent behavioral intervention trial to reduce key stroke risk factor behaviors in Hispanics/Latinos and European Americans. METHODS: Ten Catholic churches were randomized to intervention or control group. The intervention group received a 1-year multicomponent intervention (with poor adherence) that included self-help materials, tailored newsletters, and motivational interviewing counseling calls. Multilevel modeling, accounting for clustering within subject pairs and parishes, was used to test treatment differences in the average change since baseline (ascertained at 6 and 12 months) in dietary sodium, fruit and vegetable intake, and physical activity, measured using standardized questionnaires. A priori, the trial was considered successful if any one of the 3 outcomes was significant at the 0.05/3 level. RESULTS: Of 801 subjects who consented, 760 completed baseline data assessments, and of these, 86% completed at least one outcome assessment. The median age was 53 years; 84% subjects were Hispanic/Latino; and 64% subjects were women. The intervention group had a greater increase in fruit and vegetable intake than the control group (0.25 cups per day [95% confidence interval: 0.08, 0.42], P=0.002), a greater decrease in sodium intake (-123.17 mg/d [-194.76, -51.59], P=0.04), but no difference in change in moderate- or greater-intensity physical activity (-27 metabolic equivalent-minutes per week [-526, 471], P=0.56). CONCLUSIONS: This multicomponent behavioral intervention targeting stroke risk factors in predominantly Hispanics/Latinos was effective in increasing fruit and vegetable intake, reaching its primary end point. The intervention also seemed to lower sodium intake. Church-based health promotions can be successful in primary stroke prevention efforts. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01378780.

Smoking and mortality in stroke survivors: can we eliminate the paradox?

BACKGROUND: Many studies have suggested that smoking does not increase mortality in stroke survivors. Index event bias, a sample selection bias, potentially explains this paradoxical finding. Therefore, we compared all-cause, cardiovascular disease (CVD), and cancer mortality by cigarette smoking status among stroke survivors using methods to account for index event bias. METHODS: Among 5797 stroke survivors of 45 years or older who responded to the National Health Interview Survey years 1997-2004, an annual, population-based survey of community-dwelling US adults, linked to the National Death Index, we estimated all-cause, CVD, and cancer mortality by smoking status using Cox proportional regression and propensity score analysis to account for demographic, socioeconomic, and clinical factors. Mean follow-up was 4.5 years. RESULTS: From 1997 to 2004, 18.7% of stroke survivors smoked. There were 1988 deaths in this stroke survivor cohort, with 50% of deaths because of CVD and 15% because of cancer. Current smokers had an increased risk of all-cause mortality (hazard ratio [HR], 1.36; 95% confidence interval [CI], 1.14-1.63) and cancer mortality (HR, 3.83; 95% CI, 2.48-5.91) compared with never smokers, after controlling for demographic, socioeconomic, and clinical factors. Current smokers had an increased risk of CVD mortality controlling for age and sex (HR, 1.29; 95% CI, 1.01-1.64), but this risk did not persist after controlling for socioeconomic and clinical factors (HR, 1.15; 95% CI, .88-1.50). CONCLUSIONS: Stroke survivors who smoke have an increased risk of all-cause mortality, which is largely because of cancer mortality. Socioeconomic and clinical factors explain stroke survivors' higher risk of CVD mortality associated with smoking.

Does preexisting antiplatelet treatment influence postthrombolysis intracranial hemorrhage in community-treated ischemic stroke patients? An observational study.

OBJECTIVES: Intracranial hemorrhage (ICH) after acute stroke thrombolysis is associated with poor outcomes. Previous investigations of the relationship between preexisting antiplatelet use and the safety of intravenous (IV) thrombolysis have been limited by low event rates. The objective of this study was to determine whether preexisting antiplatelet therapy increased the risk of ICH following acute stroke thrombolysis. The primary hypothesis was that antiplatelet use would not be associated with radiographic evidence of ICH after controlling for relevant confounders. METHODS: Consecutive cases of thrombolysis patients treated in the emergency department (ED) were identified using multiple methods. Retrospective data were collected from four hospitals from 1996 to 2004 and 24 other hospitals from 2007 to 2010 as part of a cluster-randomized trial. The same chart abstraction tool was used during both time periods, and data were subjected to numerous quality control checks. Hemorrhages were classified using a prespecified methodology: ICH was defined as presence of hemorrhage in radiographic interpretations of follow-up imaging (primary outcome). Symptomatic ICH (sICH) was defined as radiographic ICH with associated clinical worsening. A multivariable logistic regression model was constructed to adjust for clinical factors previously identified to be related to postthrombolysis ICH. Sensitivity analyses were conducted where the unadjusted and adjusted results from this study were combined with those of previously published external studies on this topic via meta-analytic techniques. RESULTS: There were 830 patients included, with 47% having documented preexisting antiplatelet treatment. The mean (± standard deviation [SD]) age was 69 (± 15) years, and the cohort was 53% male. The unadjusted proportion of patients with any ICH was 15.1% without antiplatelet use and 19.3% with antiplatelet use (absolute risk difference = 4.2%, 95% confidence interval [CI] = -1.2% to 9.6%); for sICH this was 6.1% without antiplatelet use and 9% with antiplatelet use (absolute risk difference = 3.1%, 95% CI = -1% to 6.7%). After adjusting for confounders, antiplatelet use was not significantly associated with radiographic ICH (odds ratio [OR] = 1.1, 95% CI = 0.8 to 1.7) or sICH (OR = 1.3, 95% CI = 0.7 to 2.2). In patients 81 years and older, there was a higher risk of radiographic ICH (absolute risk difference = 11.9%, 95% CI = 0.1% to 23.6%). The meta-analyses combined the findings of this investigation with previous similar work and found increased unadjusted risks of radiographic ICH (absolute risk difference = 4.9%, 95% CI = 0.7% to 9%) and sICH (absolute risk difference = 4%, 95% CI = 2.3% to 5.6%). The meta-analytic adjusted OR of sICH for antiplatelet use was 1.6 (95% CI = 1.1 to 2.4). CONCLUSIONS: The authors did not find that preexisting antiplatelet use was associated with postthrombolysis ICH or sICH in this cohort of community treated patients. Preexisting tobacco use, younger age, and lower severity were associated with lower odds of sICH. The meta-analyses demonstrated small, but statistically significant increases in the absolute risk of radiographic ICH and sICH, along with increased odds of sICH in patients with preexisting antiplatelet use.

Use of BPPV processes in emergency department dizziness presentations: a population-based study.

OBJECTIVE: A common cause of dizziness, benign paroxysmal positional vertigo (BPPV), is effectively diagnosed and cured with the Dix-Hallpike test (DHT) and the canalith repositioning maneuver (CRM). We aimed to describe the use of these processes in emergency departments (EDs), assess for trends in use over time, and determine provider level variability in use. STUDY DESIGN: Prospective population-based surveillance study. SETTING: Emergency departments in Nueces County, Texas, from January 15, 2008, to January 14, 2011. SUBJECTS AND METHODS: Adult patients discharged from EDs with dizziness, vertigo, or imbalance documented at triage. Clinical information was abstracted from source documents. A hierarchical logistic regression model adjusting for patient and provider characteristics was used to estimate trends in DHT use and provider-level variability. RESULTS: A total of 3522 visits for dizziness were identified. A DHT was documented in 137 visits (3.9%). A CRM was documented in 8 visits (0.2%). Among patients diagnosed with BPPV, a DHT was documented in only 21.8% (34 of 156) and a CRM in 3.9% (6 of 156). In the hierarchical model (c-statistic = 0.93), DHT was less likely to be used over time (odds ratio, 0.97; 95% confidence interval, 0.95-0.99), and the provider level explained 50% (intraclass correlation coefficient, 0.50) of the variance in the probability of DHT use. CONCLUSION: Benign paroxysmal positional vertigo is seldom examined for and, when diagnosed, infrequently treated in this ED population. Use of the DHT is decreasing over time and varies substantially by provider. Implementation research focused on BPPV care may be an opportunity to optimize management in ED dizziness presentations.

Stroke Health and Risk Education (SHARE): design, methods, and theoretical basis.

BACKGROUND: Stroke is a disease with tremendous individual, family, and societal impact across all race/ethnic groups. Mexican Americans, the largest subgroup of Hispanic Americans, are at even higher risk of stroke than European Americans. AIM: To test the effectiveness of a culturally sensitive, church-based, multi-component, motivational enhancement intervention for Mexican Americans and European Americans in reducing stroke risk factors. METHODS: Participants enroll in family or friendship pairs, from the same Catholic church in the Corpus Christi Texas area, and are encouraged to change diet and physical activity behaviors and provide support for behavior change to their partners. Churches are randomized to either the intervention or control group. Goal enrollment for each of the 10 participating churches is 40 participant pairs. The intervention consists of self-help materials (including a motivational short film, cookbook/healthy eating guide, physical activity guide with pedometer, and photonovella), five motivational interviewing calls, two tailored newsletters, parish health promotion activities and environmental changes, and a peer support workshop where participants learn to provide autonomy supportive counseling to their partner. SHARE's three primary outcomes are self-reported sodium intake, fruit and vegetable intake, and level of physical activity. Participants complete questionnaires and have measurements at baseline, six months, and twelve months. Persistence testing is performed at 18 months in the intervention group. The trial is registered with clinicaltrials.gov (NCT01378780).

Guideline-discordant periprocedural interruptions in warfarin therapy.

BACKGROUND: Periprocedural interruptions in warfarin therapy increase thromboembolic risks to patients and are not indicated for all procedures. We sought to determine the frequency and guideline concordance of periprocedural warfarin interruptions to inform a future educational intervention. METHODS AND RESULTS: In October and November of 2009, an anonymous postal survey was sent to all patients followed for more than 1 year by the University of Michigan Anticoagulation service. Patients were asked how many times in the prior year they were requested to interrupt warfarin therapy for a medical or dental procedure or test and the specific indication for the requested interruption in warfarin therapy. A total of 1686 of 2133 (79%) subjects responded. The mean age of respondents was 69 years (SD=14 years). The majority were men (56%) and white (93%). Atrial fibrillation was the most common indication for warfarin therapy (n=966, 57%). At least 1 request to interrupt warfarin therapy in the prior year was given by 819 of 1648 (50%) respondents, including 481 of the 947 (51%) respondents taking warfarin for atrial fibrillation. Forty-eight percent of requests to interrupt warfarin among all respondents and 50% of requests to interrupt warfarin among those taking warfarin, specifically for atrial fibrillation, were for indications not supported by guideline statements. CONCLUSIONS: Periprocedural requests to interrupt warfarin therapy are common and are often discordant with current guidelines. Educational interventions may decrease risk of periprocedural thromboembolic complications.