But nearly half of recommended interventions were still omitted, study shows
- Hospitals participating in the Get With the Guidelines-Stroke program were more likely to provide guideline-recommended interventions for ischemic stroke patients than non-participating institutions.
- However, only 5.4 interventions out of 10 were implemented in the participating hospitals compared to 4.8 in the non-participating hospitals indicating that stroke care based on guidelines still has room for improvement.
- The study was not able to distinguish patients eligible to receive certain interventions, such as tPA administration, from those who might have been evaluated but deemed ineligible.
Stroke patients treated at hospitals participating in the American Heart Association's Get With The Guidelines (GWTG)-Stroke program were more likely to receive five of 10 key interventions than patients treated at non-participating hospitals, an independent analysis found.
Ischemic stroke patients were more likely to receive tissue plasminogen activator (tPA), education about risk factors, a lipid evaluation, swallowing evaluation, and a neurology evaluation, reported George Howard, DrPH, of the University of Alabama at Birmingham, and co-authors in JAMA Neurology.
But they were not any more likely to receive antithrombotic therapy in 48 hours, an antithrombotic or a statin on discharge, weight loss education, or a rehabilitation assessment.
Overall, patients at a GWTG-Stroke hospital received an average of 5.4 guideline-recommended interventions, while those at other hospitals received 4.8 on average (P<0.001).
"This study was the first to look at care in both GWTG-Stroke hospitals and hospitals not in the program," Howard told MedPage Today. "These data were collected using systems that are completely independent from the GWTG-Stroke systems."
While some areas were better in GWTG-Stroke hospitals, "these data show there is still quite a way to go -- where, for example, less than 10% of patients are receiving tPA and two-thirds of patients still don't receive stroke education on risk factors and warning signs," he added.
GWTG-Stroke has been implemented in more than 2,000 hospitals, which together treat about half of the patients discharged with stroke in the United States. Prior studies have shown that implementing GWTG-Stroke led to improvements in care and better stroke survival.
The quality of care measures in the program include tPA for eligible patients, early use of antithrombotic medication, prophylaxis for deep vein thrombosis, discharge on antithrombotic medications and anticoagulation medications (for atrial fibrillation patients), assessing and managing low-density lipoproteins, weight counseling, smoking cessation education, and screening for dysphagia.
For this study, the researchers looked at a subpopulation of 546 patients from the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study, a longitudinal cohort study of 30,239 participants 45 years and older recruited between 2003 and 2007. Between 2003 and 2015, 207 of these 546 patients (38%) who experienced an ischemic stroke were treated in a hospital currently participating in the GWTG-Stroke program, and 339 people were treated in a non-participating hospital.
GWTG-Stroke hospitals tended to be larger and have graduate medical education programs. Patients treated in GWTG-Stroke hospitals had similar demographics and risk factor profiles as those treated in non-participating hospitals. However, fewer patients in the Stroke Belt (North Carolina, South Carolina, Georgia, Tennessee, Alabama, Mississippi, Arkansas, or Louisiana) were treated in GWTG-Stroke hospitals.
At GWTG-Stroke hospitals:
- 9.2% of patients received tPA (versus 2.4% at non-participating hospitals; adjusted RR 3.74)
- 15.0% received weight loss counseling (versus 17.5%; RR 0.91)
- 33.8% received education about stroke risk factors and warning signs (versus 22.8%; RR 1.54)
- 54.6% had a swallowing evaluation (versus 41.3%; RR 1.25)
- 69.6% received a statin at discharge (versus 62.2%; RR 1.10)
- 76.8% had a lipid profile evaluation (versus 64.0%; RR 1.18)
- 77.8% were assessed for rehabilitation services (versus 76.1%; RR 0.99)
- 86.0% received antithrombotic medication within 48 hours (versus 87.0%; RR 0.99)
- 91.3% were evaluated by a neurologist (versus 79.1%; RR 1.12)
- 92.3% received an antithrombotic at discharge (versus 91.4%; RR 1.01)
"Stroke care is in a multi-year transition," Howard said. "Years ago, care of a stroke patient was passive and many clinicians had the impression there was little to do to help the patient. The care of stroke patients has become increasingly active as more and more clinicians appreciate the positive impact of many of these interventions.
"However, we still have a long way to go to ensure that stroke patients receive the best care."
This study has several limitations, observed Adam Webb, MD, of Emory University Hospital in Atlanta. Participating in GWTG-Stroke is voluntary, so it may be that "the presence of these engaged clinicians and leaders would have been sufficient to improve the quality of stroke care at these hospitals even in the absence of GWTG-Stroke," he wrote in an accompanying editorial.
And the fact that patients received an average of only 5.4 of 10 recommendations at GWTG-Stroke hospitals is concerning. "Some of this gap is undoubtedly explained by the fact that the denominator used in this analysis was all patients with ischemic stroke who were treated and not those patients who might be eligible for a specific intervention," Webb pointed out.
But while some interventions like tPA have limited eligibility, many apply to all patients: "This highlights the overall opportunity for improving the quality of stroke care even in those hospitals that were participating in the GWTG registry."
This study was also limited by its reliance on medical records to determine whether patients received an intervention. "The heterogeneity of medical records from the array of hospitals across the nation made the assessment of care quality for this report more of a challenge," the researchers noted. In some cases, they added, there was insufficient documentation to construct a valid measure of an intervention, such as whether patients received counseling to stop smoking.
Authors reported relationships with Genentech, Penumbra, and Medtronic; two authors also were on Get With The Guidelines committees.
The editorialist reported no conflicts.
- Reviewed by Dori F. Zaleznik, MD Associate Clinical Professor of Medicine (Retired), Harvard Medical School, Boston and Dorothy Caputo, MA, BSN, RN, Nurse Planner
Source Reference: Howard G, et al "Participation in Get With the Guidelines –Stroke and its association with quality of care for stroke" JAMA Neurology 2018: DOI:10.1001/jamaneurol.2018.2101.
Source Reference: Webb A, "The power of clinical registries and quality improvement collaboratives: Get With the Guidelines–Stroke" JAMA Neurology 2018. DOI:10.1001/jamaneurol.2018.1853.
Read the original article on Medpage Today: Stroke Care Better at GWTG Hospitals