Disruptions in Hypertension Management Following Stroke and TIA During the COVID-19 Pandemic: A Critical Analysis

Stroke and transient ischemic attack (TIA) patients face an elevated risk of recurrent vascular events and mortality, making the management of hypertension crucial in preventing such occurrences. However, effective hypertension management relies heavily on timely access to follow-up outpatient care. The onset of the COVID-19 pandemic in the United States disrupted healthcare access, leading to a decline in hospital admissions for various conditions, including stroke. Furthermore, primary care visits transitioned from in-person to remote consultations, causing a reduction in preventive care and blood pressure assessments. These shifts in healthcare delivery, exacerbated by the pandemic, likely contributed to a decline in hypertension control rates.

The impact of the pandemic on healthcare access extended to the Veterans Health Administration (VA), the largest integrated healthcare delivery system in the US. The VA experienced decreased emergency admissions for stroke and other vascular conditions, a reduction in in-person primary care visits, and a substantial increase in virtual healthcare delivery, including telephone visits. Surprisingly, despite these changes in care delivery, the overall quality of inpatient stroke and TIA care within the VA system remained stable.

In a new study conducted by Professor Greg Arling from Purdue University School of Nursing and his colleagues Edward Miech, Dr. Laura Myers, Ali Sexson, and Dr. Dawn Bravata from Department of Veterans Affairs Health Services Research and Development, investigated the challenges faced by stroke and TIA patients during the COVID-19 pandemic. Their study focused on hypertension management and its relationship with access to primary care and neurology clinic visits, emphasizing the importance of these visits in monitoring blood pressure.

The research team used the data from the VA Corporate Data Warehouse, encompassing a broad range of information from the VA electronic medical record system. Patients with ischemic stroke or TIA were identified using primary diagnosis codes. The authors included in their study patients discharged during the early months of the COVID-19 pandemic (March-September 2020) and another group of patients from the same period in previous years (2017-2019). They used systolic blood pressure (SBP) as the primary outcome, comorbid conditions, and other quality indicators. The study assessed the presence of outpatient visits, recorded SBP measurements, and mean SBP control (<140 mmHg) in the 90 days post-discharge.

They analyzed a large sample of 14,716 patients, with 11,900 in the pre-COVID-19 period and 2,816 during the COVID-19 period. The researchers observed that patients in the COVID-19 period were more likely to present with a stroke, be admitted to an inpatient unit, and pass a higher percentage of other quality indicators. Notably, patients in the COVID-19 period had a lower mean APACHE score and were less likely to have a history of TIA or atrial fibrillation. However, during the COVID-19 period, patients were significantly less likely to have outpatient visits or recorded SBP measurements. The authors observed only 38% of patients in the COVID-19 period had a recorded SBP measurement in the 90 days post-discharge, compared to 83% in the pre-COVID-19 period. The proportion of patients with an outpatient clinic visit also decreased significantly during the pandemic.

While mean SBP at discharge did not differ between periods, a lower proportion of patients met the SBP goal of <140 mmHg at discharge during the COVID-19 period. In the 90 days post-discharge, patients in the COVID-19 period had a slightly higher mean SBP and a lower proportion of patients met the SBP goal. Monthly trends revealed a significant drop in outpatient clinic visits, recorded SBP measurements, and SBP <140 mmHg during the pandemic, which gradually improved but remained below pre-pandemic levels by September 2020.

The authors’ findings highlight the disruption of hypertension management among stroke and TIA patients during the COVID-19 pandemic. While only a modest decrement in hypertension control was observed in the 90 days post-discharge, it is essential to consider that 62% of patients during the COVID-19 period did not have routine outpatient follow-up visits, making their SBP unknown. Furthermore, patients with a history of hypertension or SBP above goal at discharge were not more likely to receive follow-up care. These findings align with broader patterns seen during the pandemic, where preventive care and primary care visits were delayed or deferred. The study also underscores the importance of blood pressure management for secondary stroke prevention and calls for prioritizing outpatient hypertension care for post-stroke or TIA patients, especially those with poorly controlled blood pressure. The VA Primary Care service has been working to improve hypertension management in the post-pandemic period, including more timely BP monitoring. Moreover, hypertension management is an ongoing target of VA quality measurement overall and for patients after a stroke or TIA.

In conclusion, Professor Greg Arling and his colleagues highlighted the challenges faced by stroke and TIA patients in managing hypertension during the COVID-19 pandemic. While the impact on hypertension control was modest in the short term, the high rate of missing follow-up blood pressure measurements raises concerns about long-term outcomes. Clinicians must prioritize outpatient hypertension care for these patients, especially those with uncontrolled blood pressure. Future investigations should examine whether disruptions in hypertension management persist and explore the potential of telehealth to mitigate these challenges. Ultimately, the study underscores the need for continued vigilance and adaptability in healthcare delivery during crises like the COVID-19 pandemic to ensure the best possible outcomes for stroke and TIA patients.