Bravata DM (Roudebush VAMC; Indiana University School of Medicine), Wells CK
(Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System), Lo A
(VA Connecticut Healthcare System; Yale School of Medicine), Nadeau S
(Malcolm Randall VAMC; University of Florida School of Medicine), Williams LS
(Roudebush VAMC; Indiana University School of Medicine ), Peixoto A
(VA Connecticut Healthcare System; Yale School of Medicine), Boice JL
(Boise VAMC), Concato J
(Clinical Epidemiology Research Center (CERC), VA Connecticut Healthcare System; Yale School of Medicine)
BACKGROUND: Stroke patients cared for in stroke units have better outcomes than patients treated in general wards, however, the processes of stroke care that are responsible for the observed improvements in outcomes have not been identified. OBJECTIVES: The objective was to identify processes of care received by patients with acute ischemic stroke or transient ischemic attack (TIA) that are independently associated with outcomes, adjusting for both patient characteristics and stroke care quality.
METHODS: This retrospective cohort included patients admitted to a hospital (1998-2003) with a stroke or TIA at three Veterans Heath Administration (VA) and two non-VA hospitals with: acute ischemic stroke or TIA; neurological symptom onset within 2 days of admission; neurological deficit on admission; and =18 years. Patients were excluded if they: resided in a skilled nursing facility; were already admitted to the hospital at the time of the stroke onset; transferred from another acute care facility; or were not admitted to the hospital. The 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 evaluation, swallowing evaluation, deep vein thrombosis (DVT) prophylaxis, and early mobilization.
RESULTS: A total of 1487 patients were included: 325 (22%) at one of three VA medical centers, the remaining 1162 (78%) at 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 evaluation 0.66, 0.45-0.96; and DVT prophylaxis 0.61, 0.38-0.97; and treating all episodes of hypoxia with oxygen 0.25, 0.09-0.72).
The challenge within the VA is to provide excellent stroke care across the spectrum of medical centers.
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 care quality should focus upon three components of stroke care: an evaluation of speech/swallowing; DVT prophylaxis; and the treatment of hypoxia.