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.

---

External Links for this Project

---

PUBLICATIONS:

Journal Articles

1. Sico JJ, Concato J, Wells CK, Lo AC, Nadeau SE, Williams LS, Peixoto AJ, Gorman M, Boice JL, Bravata DM. Anemia is associated with poor outcomes in patients with less severe ischemic stroke. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2013 Apr 1; 22(3):271-8. [view]
2. Chumbler NR, Williams LS, Wells CK, Lo AC, Nadeau S, Peixoto AJ, Gorman M, Boice JL, Concato J, Bravata DM. Derivation and validation of a clinical system for predicting pneumonia in acute stroke. Neuroepidemiology. 2011 Jul 28; 34(4):193-9. [view]
3. Phipps MS, Desai RA, Wira C, Bravata DM. Epidemiology and outcomes of fever burden among patients with acute ischemic stroke. Stroke. 2011 Dec 1; 42(12):3357-62. [view]
4. Schmid AA, Wells CK, Concato J, Dallas MI, Lo AC, Nadeau SE, Williams LS, Peixoto AJ, Gorman M, Boice JL, Struve F, McClain V, Bravata DM. Prevalence, predictors, and outcomes of poststroke falls in acute hospital setting. Journal of rehabilitation research and development. 2011 Jan 3; 47(6):553-62. [view]
5. Bravata DM, Wells CK, Lo AC, Nadeau SE, Melillo J, Chodkowski D, Struve F, Williams LS, Peixoto AJ, Gorman M, Goel P, Acompora G, McClain V, Ranjbar N, Tabereaux PB, Boice JL, Jacewicz M, Concato J. Processes of care associated with acute stroke outcomes. Archives of internal medicine. 2010 May 10; 170(9):804-10. [view]
6. Sico JJ, Phipps MS, Concato J, Wells CK, Lo AC, Nadeau SE, Williams LS, Peixoto AJ, Gorman M, Boice JL, Bravata DM. Thrombocytopenia and in-hospital mortality risk among ischemic stroke patients. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2013 Oct 1; 22(7):e99-e102. [view]
7. Sico JJ, Phipps MS, Concato J, Brandt C, Wells CK, Lo AC, Nadeau SE, Williams LS, Gorman M, Boice JL, Bravata DM. Using Radiological Data to Estimate Ischemic Stroke Severity. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2016 Apr 1; 25(4):792-8. [view]

Journal Other

1. Sico JJ, Bravata DM. Anemia Predicts In-Hospital Mortality Among Patients With Mild Stroke Severity. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2010 Feb 22; 41:e395. [view]
2. Bravata DM. Demographic and Clinical Risk Factors for Dysphagia in Acute Stroke Patients. Stroke; A Journal of Cerebral Circulation. 2009 Apr 1; 40(4):e267. [view]
3. Sico J, Phipps MS, Chumbler NR, Bravata DM. Radiographic Surrogates of Ischemic Stroke Severity for Use in Risk Adjusting In-Hospital Mortality. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2010 Feb 22; 41:e221. [view]
4. Phipps MM, Sico JJ, Bravata DM. Thrombocytopenia and the Risk of In-hospital Mortality among Ischemic Stroke Patients. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2011 Mar 1; 42(3):e143. [view]

Conference Presentations

1. Sico J, Bravata DM. Anemia Predicts In-hospital Mortality Among Patients With Mild Stroke Severity. Paper presented at: American Heart Association / American Stroke Association State-of-the-Art Annual Nursing Symposium; 2010 Feb 23; San Antonio, TX. [view]
2. Cheng E, Williams LS, Vassar S, Ekundayo J, Bravata DM. Can Framingham Calculators Identify Persons at High-Risk for Stroke in a Large Healthcare Organization? Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2010 Feb 23; San Antonio, TX. [view]
3. Bravata DM, Chumbler NR, Williams LS. Demographic and clinical risk factors for dysphagia in acute stroke patients. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2009 Feb 1; San Diego, CA. [view]
4. Bravata M, Wells K, Lo, Nadeau, Pelxoto, Boice L, Concato. Quality Evaluation in Stroke and Transient Ischemic Attack. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD. [view]
5. Bravata DM, Schmid AA. The Development Of A Clinically Useful Post-stroke Fall Risk Screen. Paper presented at: American Occupational Therapy Association Annual Conference; 2009 Apr 10; Houston, TX. [view]
6. Phipps MM, Sico JJ, Bravata DM. Thrombocytopenia and the Risk of In-hospital mortality among ischemic stroke patients. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2011 Feb 9; Los Angeles, CA. [view]
7. Bravata DM. What are the Essential Processes of Acute Stroke Care? Results of the Quality Evaluation in Stroke and Transient Ischemic Attack (QUEST) Project. Paper presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2008 May 1; Baltimore, MD. [view]

DRA: Health Systems
DRE: none
Keywords: Adverse events, Quality assessment, Stroke
MeSH Terms: none