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Health Services Research & Development

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2011 HSR&D National Meeting Abstract

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2011 National Meeting

1015 — Inpatient Stroke Care Quality for Veterans: Are there Differences between Stroke Belt States and Other Areas?

Castro JG (Rehabilitation Outcomes Research Center (RORC), Gainesville), Jia H (RORC), Chumbler NR (CIEBP, Indianapolis), Li X (CIEBP, Indianapolis), Phipps MS (Yale University School of Medicine), Ordin D (VA Office of Quality and Performance (OQP)), Vogel WB (RORC), Myers J (CIEBP, Indianapolis), Williams LS (CIEBP, Indianapolis), Bravata DM (CIEBP, Indianapolis)

Objectives:
To compare VA medical centers (VAMCs) located within the Stroke Belt (SB) region with non-SB facilities in terms of: ischemic stroke prevalence, post-stroke mortality, and inpatient stroke care quality.

Methods:
This retrospective cohort included veterans who were hospitalized with ischemic stroke at 111 VAMCs (fiscal year 2007). The SB region was defined as 11 southeastern states in the United States (AL, AR, GA, IN, KY, LA, MS, NC, SC, TN, VA). Stroke prevalence was calculated as [(stroke inpatients/VA users) x10,000]. Stroke care quality was assessed across 14 processes. Multivariate logistic regression modeling was used to examine differences between patients in SB versus non-SB facilities, adjusting for patient and facility characteristics and clustering within VAMCs.

Results:
Among 3,909 subjects, 28% received care in SB facilities. Stroke prevalence was 9.3/10,000 VA healthcare users for SB facilities compared with 7.7/10,000 for non-SB VAMCs. No significant differences in the observed 30-day or 12-month mortality rates were identified (30-day: 7.6% SB, 6.2% non-SB, p = 0.11; 12-month: 18.7% SB, 18.6% non-SB, p = 0.98). Veterans in SB facilities were more likely to be younger, black, and married. Before risk adjustment, SB VAMCs were more likely than non-SB VAMCs to complete dysphagia screening (23.6% vs. 16.2%), document stroke severity with the National Institutes of Health Stroke Scale (29.1% vs. 24.5%), provide deep vein thrombosis prophylaxis (78.4% vs. 72.2%), smoking cessation counseling (97.2% vs. 92.4%), and stroke education (20.6% vs. 14.1%), but were less likely to complete assessments for fall risk (75.9% vs. 78.9%), pressure ulcer risk (90.2% vs. 92.1%), or rehabilitation needs (77.4% vs. 80.2%). After adjustment, SB VAMCs were more likely to perform dysphagia screening (OR = 2.0, 95% CI, p < 0.03) and provide smoking cessation counseling (OR = 3.3, 95% CI, p < 0.01).

Implications:
Despite a higher prevalence of ischemic stroke in SB facilities, few differences in inpatient quality of care and no statistically significant differences in 30-day or 12-month post-stroke mortality were observed. SB VAMCs appear to be providing equivalent or, in some cases, better ischemic stroke care than VAMCs elsewhere.

Impacts:
Resources are needed to improve certain processes of stroke care across the VA healthcare system, regardless of geographic location.


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