RD Horner, Durham VAMC and Duke University Med Ctr; PW Duncan, Kansas City VAMC and Kansas University Med Ctr; DM Reker, Kansas City VAMC and Kansas University Med Ctr; H Hoenig, Durham VAMC and Duke University Med Ctr; G Samsa, Duke University Med Ctr; BB Hamilton, Duke University Med Ctr; TK Dudley, Durham VAMC

Objectives: The objectives of this study are: 1) to assess variations in the structure and processes of post-stroke rehabilitation care for veterans provided by VA medical cen-ters, 2) to evaluate the rela-tionship between varying structures and processes of stroke care and case-mix adjusted patient outcomes and 3) to measure patient outcomes and provide feedback to VISNs about the structure, processes, and outcomes of care.

Methods: An inception cohort of 288 stroke patients from 11 VA Medical Centers between 1/98 and 3/99 were followed prospectively for 6 months. Data were abstracted from medical records and telephone interview. Primary outcome was the Functional Independence Motor Score (FIM) at 6-months post stroke. Secondary outcomes included Instrumental Activities of Daily Living (IADL), SF-36 physical functioning, mortality, patient satisfaction, and the Stroke Impact Scale (SIS). Process of care in acute and post acute care settings was measured by quantifying compliance with AHCPR post-stroke rehabilitation guidelines using chart review, abstraction criteria, and a weighted method for scoring. Organizational structure variables were collected by survey. Secondary analyses testing the effects of structure on process of care used summary scores in each post acute care setting for 3 aspects of structure of care described in prior work, systemic organization, staffing characteristics, and technology adoption. Linear regression modeling was used for all inferential tests. All outcomes were adjusted for case mix.

Results: Average compliance scores in acute and post acute care settings were 68.2% (sd 14) and 69.5% (sd 14.4), respectively. After case-mix adjustment, level of compliance with post-acute rehabilitation guidelines was significantly associated with FIM motor, IADL, SIS physical domain scores and patient satisfaction. SF-36 physical function scores and mortality were not affected by compliance with post-acute rehabilitation guidelines. Level of compliance with rehabilitation guidelines in acute settings was unrelated to any of the outcome measures. Three summary structure variables, systemic organization, staffing characteristics, and technology adoption, were positively and significantly associated with post acute guideline compliance scores (process). Additionally, those individuals who received inpatient post acute rehabilitation in VA rehabilitation bedservice units, GEM units, or Non-VA private sector acute rehabilitation had significantly higher compliance scores than patients receiving post acute care in nursing homes.

Conclusions: Our results document variability in structure and process of stroke care for veterans. Good process of care, as measured by compliance with post acute stroke care guidelines, affects 3 of 4 6-month functional outcomes. Select structures are associated with greater compliance with post-acute stroke guidelines.

Impact: Stroke is one of the most costly, deadly, and disabling diseases known. Stroke guidelines have been created by AHCPR and by the VA to assist clinicians in providing standards for acute and post acute care. These guidelines, however, have never been evaluated for effects on patient outcomes. Our findings support the use of guidelines as means of assessing quality of care and improving outcomes. These quality indicators are needed to ensure that quality of care is not comprised with new organizational and funding changes involving post-acute stroke care.