Introduction: Many patients with TIA/minor stroke do not achieve goal blood pressure their cerebrovascular event, thereby remaining at high risk for future events. Understanding the influence of contextual factors associated with post-event hypertension management may inform future intervention studies.
Methods: As part of a national, observational study of TIA/minor stroke care across the Veterans Health Administration (VHA), in-person site visits were conducted at participating VHA medical centers in 2014-15. Semi-structured interviews were used to elicit provider perspectives about local practices related to the care of TIA/minor stroke patients. Study team members systematically applied codes transcribed files using qualitative, categorical, and quantitative descriptive codebooks. Investigators used Thematic Content Analysis and mixed-methods matrix displays to analyze coded data, generate, and then validate findings.
Results: Seventy interviews were obtained from staff at 14 sites. Several contextual factors appeared to influence post-event hypertension care delivery for patients after a TIA/minor stroke. Neurologists reported that they perceived no direct responsibility for managing post-event blood pressure and were uncertain whether recommendations regarding blood pressure management were being implemented in primary care. Primary care providers expressed hesitancy about titrating antihypertensive medications post-event, citing concerns about permissive hypertension. Providers also reported that poor blood pressure control was not as salient to patients as symptoms, leading some patients to not adhere to their antihypertensives or not feel a sense of urgency in seeking prompt medical attention. VHA facilities did not have protocols to guide providers in the treatment of post-TIA/minor stroke hypertension, with centers expressing little compulsion to develop them.
Conclusions: Multiple contextual factors at the provider- and system-levels were identified as barriers to achieving post-cerebrovascular event hypertension control; these data have informed the design of a recently funded vascular risk factor intervention.