Does a Community Education Program Help Increase Early Hospital Arrival and Ambulance Use for Patients Who Experience Stroke? -- The CEERIAS Study

This project has results

Results Summary and Professional Abstract

Results Summary

What was the research about?

People having a stroke who go to the emergency room, or ER, early have a better chance of recovery and survival. But some racial and ethnic groups, such as African Americans and Latinos, are more likely to suffer from strokes and less likely to receive prompt care. Many people don’t know they should get to the ER as soon as possible. People may not be sure they are having a stroke. They also may not call 911 for an ambulance, a quick way to get to the ER.

In this study, the research team created a community education program in the South Side of Chicago, where most residents are African American. The program trained people from the community to talk with others about stroke and the importance of getting to the ER early.

To see how well the program worked, the research team compared stroke registry data from before and after the program. Stroke registries track hospital care provided to patients who’ve had a stroke. The team also compared data from the hospital on the South Side of Chicago to hospitals in two communities that didn’t have the program. One community, on the North Side of Chicago, had six hospitals. The other community, in St. Louis, had 14 hospitals.

What were the results?

In the community with the program, among people who’d had a stroke,

The number of people who got to the ER early or used an ambulance didn’t differ before and after the program.
When looking at specific groups of people, more younger people, men, and African Americans got to the ER early after the program than before the program.

When comparing the community with the program to communities that didn’t have the program, the study found no difference in how often people with stroke got to the ER early or used an ambulance.

The number of people who used an ambulance when they thought they were having a stroke increased after the program started.

Who was in the study?

The program went from December 2015 to November 2016. Of the people in the community where the program took place, 72 percent were African American, 26 percent were Hispanic, 11 percent were white, and 1 percent were Asian. In their analysis, the research team looked at stroke registry data from 21,497 patients. Of these, 29 percent were African American, 63 percent were white, and 5 percent were other races; 3 percent were Hispanic. Also, 52 percent were women, and 35 percent were age 65 or younger.

What did the research team do?

In the program, the research team trained 242 people from local churches, schools, and businesses to be community educators. The educators taught people in the community about

Benefits of getting early treatment for stroke
Symptoms of stroke
Who has strokes
Cost of an ambulance

The educators also gave out flyers and pamphlets about strokes to people in the community and at community events.

The research team looked at stroke registry data for the hospitals. The team also looked at ambulance records from the Chicago Fire Department. The team used these records to see how many people with suspected strokes used an ambulance in the community with the program.

What were the limits of the study?

Community educators talked to community members in person only. Results may have differed if educators had reached out to community members in other ways, such as with social media or phone apps.

Future studies could look at a similar program that uses other ways, such as social media and phone apps, to send out health messages.

How can people use the results?

Health educators and communities can use the results when considering ways to help community members get timely care for strokes.

Professional Abstract

Objective

To determine whether an educational community-based stroke preparedness program increases early hospital arrivals and use of emergency medical services (EMS) among patients experiencing stroke symptoms

Study Design

Design Elements	Description
Design	Interrupted time series analysis
Population	Community in the South Side of Chicago; stroke registry data from 21,497 patients receiving care at hospitals in Chicago and St. Louis
Interventions/ Comparators	Stroke preparedness program No stroke preparedness program
Outcomes	Early hospital arrival (defined as arriving at the hospital within 3 hours of experiencing stroke symptoms) by patients with confirmed strokes, EMS usage by patients with confirmed strokes, EMS usage in communities around intervention hospital for patients with suspected strokes
Timeframe	5-year period (January 2013 to December 2017) with 35 months of data collection preintervention and 21 months of data collection postintervention, separated by a 4-month program implementation period

This observational study compared the effectiveness of a community-based educational stroke preparedness program versus no program on increasing early hospital arrival and use of EMS among patients experiencing stroke symptoms.

The research team implemented the stroke preparedness program in a predominantly African-American community with high stroke incidence and low EMS usage, served by one hospital on the South Side of Chicago. The team trained 242 people from businesses, churches, schools, and community advocacy groups to be stroke educators. Training topics included benefits of early treatment for stroke; recognizing stroke symptoms; and helping community members overcome common barriers to getting treatment, such as misperceptions about who is vulnerable to stroke and cost of ambulance services. Educators distributed materials, such as fact sheets and posters, to people in their community, including parishioners, students, and customers, and presented at community events.

To measure changes in outcomes of patients with confirmed stroke over time, the research team used stroke registry data at the hospital in the neighborhood that had the program 35 months before and 21 months after the program’s 4-month implementation period. The team also looked at changes in outcomes from similar hospitals in the North Side of Chicago and in St. Louis, where the team did not implement the program. To measure the change in EMS usage for suspected strokes over time in the neighborhood with the program, the team looked at EMS records from the Chicago Fire Department.

The program took place from December 2015 to November 2016. Of the people in the South Side Chicago community, 72% were African American, 26% were Hispanic, 11% were white, and 1% were Asian. The registry included 21,497 patients. Of these, 29% were African American, 63% were white, and 5% were other races; 3% were Hispanic. Also, 52% were female, and 35% were age 65 or younger.

Patients and members of community organizations provided input on all aspects of the study, including program and study design.

Results

Overall, the number of early hospital arrivals or EMS usage by patients with a confirmed stroke did not differ significantly before and after the program started. However, in subgroup analyses, the number of early arrivals increased significantly (p<0.05) for patients under age 66 (0.8% per month increase), men (1.2% per month increase), and African Americans (0.9% per month increase).

Comparing the hospitals in communities that did not have the program with the hospital in the community that did have the program, rates of early arrivals or EMS usage by patients with a confirmed stroke did not differ significantly.

EMS usage for suspected stroke increased 2.2-fold (p<0.001) in areas near the hospital in the community after the program started.

Limitations

Stroke educators interacted face-to-face with community members. Results may have differed if educators had used other communication strategies, such as social media or phone apps.

Conclusions and Relevance

Overall, the number of early hospital arrivals or EMS usage within the hospital did not differ for patients with confirmed stroke before and after program implementation. However, the intervention was associated with an increase in early hospital arrivals for younger patients, men, and African Americans with confirmed stroke. EMS usage by patients with suspected stroke doubled in some areas of the community after program implementation.

Future Research Needs

Future studies could examine similar interventions using approaches such as social media and phone apps to disseminate health messages.

Journal Articles

Health Education & Behavior

A Community-Partnered Approach to Inform a Culturally Relevant Health Promotion Intervention for Stroke

More on this Project

This project's final research report is expected to be available by February 2020.

Peer-Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments.

Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:

Reviewers questioned when the researchers dropped one of the two intervention hospitals from the study because of unreliable data. The researchers explained that the second hospital was not removed from analyses until aim 3. They indicated that they had already collected focus group data from patients in that hospital’s catchment area, as well as having trained half of the stroke promoters.
Reviewers had questions about how dropping one of the two intervention hospitals from the study affected the statistical analysis. They worried that the study may have been underpowered with around 20 patients per month seen in the intervention hospital. The researchers said because they used interrupted time series for analysis, the primary unit of analysis was time, or months, not hospitals or patients. Therefore, the statistical power of the work depended on time units rather than the number of hospitals or patients in the study. To improve the power of the study, the researchers chose an extended study period, five years.
Reviewers asked for greater detail on the locations of comparison hospitals and the populations they serve. It was not clear how hospitals on Chicago’s North Side and in St. Louis, Missouri were similar or different from the Chicago South Side hospitals, especially with regards to their patient populations. The researchers added information to the report about the number of comparison hospitals in both locations and their characteristics, especially comparing stroke patients between the target hospital and comparison hospitals. They also added maps showing the locations of the hospitals in both cities and explaining the geography of Chicago.

Conflict of Interest Disclosures

View the COI disclosure form.

Project Details

Principal Investigator

Shyam Prabhakaran, MD, MS

Project Status

Completed; PCORI Public and Professional Abstracts Posted

Project Title

Community Engagement for Early Recognition and Immediate Action in Stroke (CEERIAS)

Board Approval Date

July 2014

Project End Date

May 2019

Organization

Northwestern University at Chicago

Year Awarded

2014

State

Illinois

Year Completed

2019

Project Type

Research Project

Health Conditions

Cardiovascular Diseases

Stroke

Functional Limitations and Disabilities

Intervention Strategies

Patient Navigation
Other Health Services Interventions
Training and Education Interventions

Populations

Low Health Literacy/Numeracy
Low Income
Racial/Ethnic Minorities
Urban

Funding Announcement

Addressing Disparities

Project Budget

$1,461,662

Study Registration Information

HSRP20152035

NCT02301299

Page Last Updated:

September 10, 2019