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BACKGROUND/RATIONALE:
Stroke patients cared for in stroke units have better outcomes than patients treated in general wards. Although the benefits of stroke unit care have been demonstrated in numerous studies, the processes of stroke care that are responsible for the observed improvements in patient outcomes have not been identified.
OBJECTIVE(S):
The primary aim of this study is to identify processes of care received by patients hospitalized with acute ischemic stroke or transient ischemic attack (TIA) that are independently associated with patient outcomes, adjusting for both patient characteristics and stroke care quality.
METHODS:
This is a retrospective cohort study of patients admitted to a hospital between 1998 and 2003 with a stroke or transient ischemic attack (TIA) at three Veteran Health Administration (VA) and two non-VA hospitals. Patients were included if they: had an acute ischemic stroke or TIA; had a neurological symptom onset within 2 days of admission; had a neurological deficit on admission; and were >18 years. Patients were excluded if they: were residing in a skilled nursing facility at the time of the stroke symptom onset; were already admitted to the hospital at the time of the stroke symptom onset; were transferred from another acute care facility; or were not admitted to the hospital. The primary outcome was the combined end-point of in-hospital mortality, discharge to hospice, or discharge to a skilled nursing facility. Seven processes of care were evaluated: fever management, hypoxia management, blood pressure management, neurological evalution, swallowing evaluation, deep vein thrombosis (DVT) prophylaxis, and early mobilization.
FINDINGS/RESULTS:
A total of 1487 patients were included in this cohort: 325 (22%) were admitted to one of three VA medical centers, the remaining 116 (78%) were admitted to one of two non-VA hospitals. The combined outcome was observed in 239 (16%). Three processes of care were independently associated with a reduction in the combined outcome after adjusting for the other processes of care and after comprehensive risk adjustment (adjusted OR, 95%CI: speech/swallowing evalution 0.66, 0.45-0.96; and DVT prophylaxis 0.61, 0.38-0.97; and treating all episodes of hypoxia with supplemental oxygen 0.25, 0.09-0.72).
IMPACT:
The challenge within the VA is to provide excellent stroke care across the spectrum of medical centers. The QUEST Project provides key support to this mission by identifying the processes of care that are associated with improved patient outcomes. As part of their ongoing effort to provide excellent stroke care, we recommend that VA medical centers caring for stroke patients and VA administration measuring VA medical care quality should focus upon three components of stroke care: an evaluation of speech/swallowing; DVT prophylaxis; and they treatment of hypoxia.
PUBLICATIONS:
None at this time.
DRA:
Chronic Diseases, Health Services and Systems
DRE:
Quality of Care, Technology Development and Assessment
Keywords:
Adverse events, Quality assessment, Stroke
MeSH Terms:
none
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