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RRP 09-184 – HSR&D Study

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RRP 09-184
Stroke Care Quality within the Veterans Health Administration System
Dawn M. Bravata MD
Richard L. Roudebush VA Medical Center, Indianapolis, IN
Indianapolis, IN
Funding Period: April 2010 - September 2011

BACKGROUND/RATIONALE:
The Department of Veterans Affairs (VA) Office of Quality and Performance (OQP) in partnership with the VA Stroke Quality Enhancement Research Initiative (QUERI) Program conducted the OQP Stroke Special Project. The OQP Stroke Special Project was the first measurement of national VA stroke care quality. Inpatient stroke care quality was measured using 14 quality indicators including: thrombolysis use, dysphagia screening, NIH Stroke Scale (stroke severity) documentation, pressure ulcer risk assessment, fall risk assessment, early ambulation, antithrombotic therapy by hospital day two and at discharge, functional independence measure (FIM) documentation, deep vein thrombosis (DVT) prophylaxis, lipid management, smoking cessation counseling, anticoagulation for atrial fibrillation, and stroke education. Post-stroke care quality (6 processes) was measured across the following domains: hypertension, diabetes, hyperlipidemia, atrial fibrillation, tobacco use, and post-stroke depression.

OBJECTIVE(S):
The overall objective of this project was to examine national VA stroke care quality to identify targets for future implementation projects that will improve VA stroke care quality. The primary aims were to: (1) examine patterns in stroke care across the continuum of care from the inpatient period to the post-stroke period; and (2) identify facility characteristics that were associated with high quality stroke care.

METHODS:
We merged the OQP Stroke Special Project data (chart review on 5000 veterans with ischemic stroke across 132 VA medical centers [VAMC]) with patient-level information from the Functional Status and Outcomes Database (FSOD), vital status data, VA outpatient and inpatient administrative data, Decision Support System (DSS) cost data, Medicare inpatient and outpatient administrative data. We supplemented these patient-level data with facility-level information including: structures of stroke care; complexity; VAMC patient travel time data; wage index; rehabilitation service availability; rural-urban status; and facility level data from VA Chief of Staff Module and VA Primary Care Director Module of the VHA Clinical Practice Organizational Survey. Many of the analyses were conducted at the patient level. Analyses that were conducted at the facility level included hierarchical modeling to account for clustering of patients within facilities.

Key topics of these analyses include: 1) an examination of whether certain processes of inpatient care are associated with each other and hence may serve as "improvement bundles" that can be targeted in future quality improvement activities; 2) examination of potential age disparities in quality of care and outcomes; 3) an assessment of geographic variation in stroke care quality and outcomes including an examination of urban vs. rural differences as well as differences based on Stroke Belt geographic variation; 4) an evaluation of racial differences in inpatient and post-discharge care quality; 5) an assessment of various methods of assessing the quality of stroke care; 6) the development of risk adjustment models for the prediction of post-stroke mortality; and 7) an evaluation of the relationship between quality of care and VA costs.

FINDINGS/RESULTS:
To date, 6 manuscripts have been published or are in press, 5 are under peer-review, and 17 are in preparation. It is not possible to describe the results of all of these analyses; therefore, what follows is a summary of a sample of key findings.

We demonstrated a lack of connection between facility-level inpatient and outpatient stroke care quality (suggesting that stroke care is conducted within silos and that interventions to improve care within a facility but across settings will have to address inpatient care separately from outpatient care).

We conducted a detailed examination of thrombolysis use for stroke across the VA and found several opportunities to improve care: only 11% of eligible patients received thrombolysis, 37% of all patients who received thrombolysis had at least one contraindication to tPA documented, and 17% of patient received the wrong dose. Among the 85 VAMCs that received eligible patients, on average 2.3 patients (range 1-7) were eligible for tPA annually. There were no significant differences in receipt of thrombolytic therapy at the most equipped compared to less equipped VAMCs.

We sought to examine whether quality of care or outcomes of care differed by geography, but found no significant differences in short- or long-term post-stroke mortality or quality of care between the patients cared for in Stroke Belt versus non-Stroke Belt VAMCs. Similarly, no systematic age-related disparities in quality of care appear to exist across the VA system. With regard to the primary analysis (focused on 14 inpatient processes and 6 outpatient processes), no consistent racial disparities in stroke care quality were identified. However, in an analysis of the receipt of carotid artery imaging by patient race and hospital status, the unadjusted racial disparity in carotid artery imaging was 7.2% (88.6% whites vs. 81.4% blacks, p<0.001). Nearly 40% of blacks were admitted to one of 13 minority-serving hospitals (the top 10% of VAMCs ranked by the proportion of stroke patients who were black). No racial disparity in carotid artery imaging was detected within non-minority serving hospitals. However, the predicted probability of receiving carotid artery imaging for whites at non-minority-serving hospitals (89.7%) was higher than both whites (78.0%) and blacks (70.5%) at minority-serving hospitals. Therefore, underuse of carotid artery imaging does not appear to be a system-wide problem, but rather occurs at minority-serving VAMCs; facilities which have lower overall imaging rates.

We evaluated blood pressure control among the 3640 stroke survivors in the OQP dataset and found that 33% had uncontrolled blood pressure six months after discharge.

In an assessment of post-stroke rehabilitation care, even when stroke severity and other medical and demographic conditions were adjusted for, presence of a co-located VA inpatient rehabilitation unit was a primary factor driving discharge destination.

The average total inpatient costs for veterans with ischemic stroke were $12,410 (median, $8,114; inter-quartile range, $9,502). Better performance on 4 quality indicators was associated with significantly higher total costs (tPA administration, DVT prophylaxis, dysphagia screening, and rehabilitation assessment), whereas better performance on two quality indicators was associated with significantly lower costs: early ambulation and pressure ulcer risk assessment. For example, patients who received tPA had on average a $8,185 higher cost than patients who did not receive tPA, while patients who received a preventive measure such as pressure ulcer risk assessment had a $1,803 lower cost than those that did not receive this assessment. The other three quality indicators had no association with total costs.

We used these data to contruct the first stroke-specific frailty index, one that effectively predicts post-stroke outcomes. In addition, we found that it is possible to develop prediction models that differentiate between mild and severe stroke.

Reporting of quality data is complicated by estimation error due to small numbers of eligible patients per facility. We applied multilevel modeling and empirical Bayes (EB) estimation to address this issue in performance reporting. We recommended 8 quality indicators for performance reporting: dysphagia screening, NIH Stroke Scale documentation, early ambulation, fall risk assessment, pressure ulcer risk assessment, Functional Independence Measure documentation, lipid management, and deep vein thrombosis prophylaxis. These QIs displayed sufficient variation across facilities, had room for improvement, and identified sites with performance that was significantly above or below the population average. The remaining QIs were not recommended because of too few eligible patients or high pass rates with little variation.

IMPACT:
These data were used by the VA Acute Stroke Taskforce as they made recommendations about acute stroke care; the Acute Stroke Directive was signed November 2011. These data were also the basis of the 12-site INSPIRE service-directed project which is seeking to improve in-patient stroke care quality at high volume VAMCs.

PUBLICATIONS:

Journal Articles

  1. Sico JJ, Myers LJ, Fenton BJ, Concato J, Williams LS, Bravata DM. Association between admission haematocrit and mortality among men with acute ischaemic stroke. Stroke and vascular neurology. 2018 Sep 1; 3(3):160-168.
  2. Sauser K, Bravata DM, Hayward RA, Levine DA. A National Evaluation of Door-to-Imaging Times among Acute Ischemic Stroke Patients within the Veterans Health Administration. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2015 Jun 1; 24(6):1329-32.
  3. Schmid AA, Ofner S, Shorr RI, Williams LS, Bravata DM. Bleeding risk, physical functioning and non-use of anticoagulation among patients with stroke and atrial fibrillation. Qjm : Monthly Journal of The Association of Physicians. 2015 Mar 1; 108(3):189-96.
  4. Jia H, Phipps M, Bravata D, Castro J, Li X, Ordin D, Myers J, Vogel WB, Williams L, Chumbler N. Inpatient stroke care quality for veterans: are there differences between Veterans Affairs medical centers in the stroke belt and other areas? International journal of stroke : official journal of the International Stroke Society. 2015 Jan 1; 10(1):67-72.
  5. Keyhani S, Cheng E, Ofner S, Williams L, Bravata D. The underuse of carotid interventions in veterans with symptomatic carotid stenosis. The American journal of managed care. 2014 Jul 1; 20(7):e250-6.
  6. Yu Z, Liu L, Bravata DM, Williams LS. Joint model of recurrent events and a terminal event with time-varying coefficients. Biometrical journal. Biometrische Zeitschrift. 2014 Mar 1; 56(2):183-97.
  7. Phipps MS, Jia H, Chumbler NR, Li X, Castro JG, Myers J, Williams LS, Bravata DM. Rural-urban differences in inpatient quality of care in US Veterans with ischemic stroke. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2013 Jun 6; 30(1):1-6.
  8. Cheng EM, Bravata DM, El-Saden S, Vassar SD, Ofner S, Williams LS, Keyhani S. Carotid artery stenosis: wide variability in reporting formats--a review of 127 Veterans Affairs medical centers. Radiology. 2013 Jan 1; 266(1):289-94.
  9. Chumbler NR, Jia H, Phipps MS, Li X, Ordin D, Williams LS, Myers LJ, Bravata DM. Postdischarge quality of care: do age disparities exist among Department of Veterans Affairs ischemic stroke patients? Journal of rehabilitation research and development. 2013 Jan 1; 50(2):263-72.
  10. Reeves MJ, Myers LJ, Williams LS, Phipps MS, Bravata DM. Do-not-resuscitate orders, quality of care, and outcomes in veterans with acute ischemic stroke. Neurology. 2012 Nov 6; 79(19):1990-6.
  11. Chumbler NR, Jia H, Phipps MS, Li X, Ordin D, Vogel WB, Castro JG, Myers J, Williams LS, Bravata DM. Does inpatient quality of care differ by age among US veterans with ischemic stroke? Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association. 2012 Nov 1; 21(8):844-51.
  12. Cheng EM, Keyhani S, Ofner S, Williams LS, Hebert PL, Ordin DL, Bravata DM. Lower use of carotid artery imaging at minority-serving hospitals. Neurology. 2012 Jul 10; 79(2):138-44.
  13. Keyhani S, Cheng E, Arling G, Li X, Myers L, Ofner S, Williams LS, Phipps M, Ordin D, Bravata DM. Does the inclusion of stroke severity in a 30-day mortality model change standardized mortality rates at Veterans Affairs hospitals? Circulation. Cardiovascular quality and outcomes. 2012 Jul 10; 5(4):508-13.
  14. Arling G, Reeves M, Ross J, Williams LS, Keyhani S, Chumbler N, Phipps MS, Roumie C, Myers LJ, Salanitro AH, Ordin DL, Myers J, Bravata DM. Estimating and reporting on the quality of inpatient stroke care by Veterans Health Administration Medical Centers. Circulation. Cardiovascular quality and outcomes. 2012 Jan 1; 5(1):44-51.
  15. Keyhani S, Arling G, Williams LS, Ross JS, Ordin DL, Myers J, Tyndall G, Vogel B, Bravata DM. The use and misuse of thrombolytic therapy within the Veterans Health Administration. Medical care. 2012 Jan 1; 50(1):66-73.
  16. Ross JS, Arling G, Ofner S, Roumie CL, Keyhani S, Williams LS, Ordin DL, Bravata DM. Correlation of inpatient and outpatient measures of stroke care quality within veterans health administration hospitals. Stroke. 2011 Aug 1; 42(8):2269-75.
  17. Roumie CL, Ofner S, Ross JS, Arling G, Williams LS, Ordin DL, Bravata DM. Prevalence of inadequate blood pressure control among veterans after acute ischemic stroke hospitalization: a retrospective cohort. Circulation. Cardiovascular quality and outcomes. 2011 Jul 1; 4(4):399-407.
Journal Other

  1. Sico JJ, Fenton B, Williams LS, Bravata DM. Predictors of Optimal Post-Stroke Hypertension Control. [Abstract]. Annals of neurology. 2015 Oct 1; 78(S19):S1-S132.
  2. Bravata DM, Brosch J, Sico J, Baye F, Myers L, Roumie CL, Cheng E, Miech EJ, Williams LS, Arling G. Vascular Risk Factor Control in the Year After Ischemic Stroke Versus Myocardial Infarction. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2015 Apr 1; 46(4):A121.
  3. Sico J, Myers L, Concato J, Williams LS, Bravata DM. Predictors of Optimal Post-Stroke Hypertension Control. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2015 Apr 1; 46(4):ATP140.
  4. Damush TM, Anderson JA, Yu Z, Ofner S, Myers L, Schmid AA, Williams LS. Secondary Stroke Prevention Program: Effect on Stroke Specific Quality of Life. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2013 Feb 1; 44(2):AWP366.
  5. Damush TM, Myers L, Anderson JA, Yu Z, Ofner S, Schmid AA, Williams LS. Implementation of a Secondary Prevention Program: Effect on Medication Adherence. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2013 Feb 1; 44(2):ATP415.
  6. Cheng E, Keyhani S, Ofner S, Williams LS, Bravata DM. Standardized Reporting is Needed to Describe Results of Carotid Artery Imaging. [Abstract]. Neurology. 2012 Apr 1; 78(Suppl 1):P01.032.
  7. Haque S, Reeves MJ, Ofner S, Ordin D, Williams LS, Bravata DM. Frailty Independently Predicts Poor Outcomes But Not Quality of Care: An Analysis of VA Ischemic Stroke Patients. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2012 Feb 1; 43(2):A2275.
  8. Chumbler NR, Morey MC, Griffiths P, Quigley P, Haley JA, Rose DK, Sanford J, Hoenig H. The Effects of a Stroke Telerehabilitation In-Home Intervention on Function and Disability: Preliminary Results of a Randomized Clinical Trial. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2011 Mar 1; 42(3):e76.
  9. Reeves M, Myers L, Williams LS, Phipps MS, Bravata DM. Association between Do Not Resuscitate Orders and the Quality of Acute Stroke Care in the Veterans Health Administration (VHA). [Abstract]. Stroke; A Journal of Cerebral Circulation. 2011 Mar 1; 42(3):e343.
  10. Williams LS, Arling G, Li X, Chumbler NR, Schmid AA, Ordin D, Bravata DM. Patient and Facility Characteristics Associated with Discharge to Inpatient Rehabilitation Post-stroke. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2011 Mar 1; 42(3):e337.
  11. Bravata DM, Myers JL, Arling GW, Ordin D, Vogel WB, Williams LS. The Quality of In-hospital Care for Veterans With Ischemic Stroke. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2010 Feb 22; 41:e222.
Conference Presentations

  1. Sico JJ, Myers L, Concato J, Williams LS, Bravata DM. Predictors of Optimal Post-Stroke Hypertension Control. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2015 Feb 12; Nashville, TN.
  2. Sico JJ, Bravata DM. Adherence to guidelines: Are ischemic stroke patients receiving guideline-concordant cardiac stress testing? Presented at: American Neurological Association Annual Meeting; 2014 Oct 12; Baltimore, MD.
  3. Sico JJ, Myers L, Williams LS, Bravata DM. Adherence to Guidelines: Are Ischemic Stroke Patients Receiving Guideline-Concordant Cardiac Stress Testing? Paper presented at: American Heart Association / American Stroke Association International Stroke Conference; 2013 Feb 8; Honolulu, HI.
  4. Sico JJ, Myers LJ, Ordin D, Williams LS, Bravata DM. The Association between Hematocrit and Mortality among Ischemic Stroke Patients. Paper presented at: American Heart Association Annual Scientific Sessions; 2012 Nov 5; Los Angeles, CA.
  5. Sico JJ, Myers LJ, Ordin D, Williams LS, Bravata DM. Association between Admission Hematocrit and Mortality among Ischemic Stroke Patients. Paper presented at: American Heart Association / American Stroke Association International Stroke Conference; 2012 Feb 2; New Orleans, LA.
  6. Chumbler NR, Jia H, Phipps M, Li X, Ordin D, Myers J, Williams LS, Bravata DM. Post-Acute Outpatient Quality of Care: Do Age Disparities Exist Among VA Ischemic Stroke Patients? Poster session presented at: American Sociological Association Annual Meeting; 2011 Aug 20; Las Vegas, NV.
  7. Cheng E, Keyhani S, Ofner S, Williams LS, Bravata DM. Disparities in Carotid Artery Imaging among Veterans Presenting with Ischemic Stroke. Paper presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2011 May 14; Atlanta, GA.
  8. Keyhani S, Cheng E, Li X, Arling G, Williams LS, Phipps M, Bravata DM. Does inclusion of NIH stroke scale in a 30-day mortality model impact VAMC rankings? Paper presented at: American Heart Association Quality of Care and Outcomes Research Council Annual Scientific Session; 2011 May 13; Washington, DC.
  9. Phipps MS, Arling GW, Li X, Keyhani S, Hanchate AD, Ross JD, Ofner S, Myers L, Bravata DM. Inpatient Quality of Care and Costs Following Acute Ischemic Stroke in the VA: Is there an Association? Poster session presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2011 May 13; Washington, DC.
  10. Bravata DM. The VA Office of Quality and Performance (OQP) Stroke Special Project. Paper presented at: VA HSR&D / QUERI Annual INSPIRE Acute Stroke Collaborative; 2011 Apr 26; Indianapolis, IN.
  11. Castro JG, Jia H, Chumbler NR, Li X, Phipps MS, Ordin D, Vogel WB, Myers J, Williams LS, Bravata DM. Inpatient stroke care quality: Are there geographical differences between Stroke Belt and all other areas? Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD.
  12. Roumie CL, Ofner S, Ross J, Arling G, Williams LS, Ordin D, Bravata DM. Prevalence of Inadequate Blood Pressure Control Among Veterans after Acute Ischemic Stroke Hospitalization: A Retrospective Cohort. Poster session presented at: VA HSR&D National Meeting; 2011 Feb 16; Washington, DC.
  13. Reeves M, Myers L, Williams LS, Ordin D, Bravata DM. Association between Do Not Resuscitate Orders and the Quality of Acute Stroke Care in the Veterans Health Administration. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2011 Feb 9; Los Angeles, CA.
  14. Williams LS, Arling G, Li X, Chumbler NR, Schmid AA, Ordin D, Bravata DM. Patient and Facility Characteristics Associated with Discharge to Inpatient Rehabilitation Post-Stroke. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2011 Feb 9; Los Angeles, CA.
  15. Bravata DM, Williams LS, Ross JS, Arling G, Ofner S, Roumie CL, Keyhani S, Ordin D. Correlation between inpatient and outpatient measures of stroke care quality within Veterans Health Administration Hospitals. Paper presented at: American Heart Association Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Sessions; 2010 May 12; Washington, DC.
  16. Chumbler NR, Jia H, Li X, Phipps M, Ordin DL, Vogel WB, Castro J, Myers JL, Williams LS, Bravata DM. Age Disparities in Quality of Care and Clinical Outcomes in US Veterans with Ischemic Stroke. Poster session presented at: Quality of Care and Outcomes Research in Cardiovascular Disease and Stroke Annual Scientific Forum; 2010 May 12; Washington, DC.
  17. Jia H, Chumbler NR, Li X, Phipps M, Williams LS, Bravata DM, Vogel B, Castro JG. Rural/urban disparities in quality of care in VHA users with ischemic stroke. Poster session presented at: VA HSR&D Rural Health / VA Office of Rural Health Field-Based Meeting; 2010 May 5; Portland, ME.
  18. Bravata DM, Myers JL, Arling GW, Ordin DL, Vogel WB, Williams LS. The Quality of In-hospital Care for Veterans With Ischemic Stroke. Paper presented at: American Heart Association / American Stroke Association International Stroke Conference; 2010 Feb 23; San Antonio, TX.


DRA: Other Conditions
DRE: Treatment - Comparative Effectiveness
Keywords: Patient outcomes, Quality assurance, improvement, Stroke
MeSH Terms: none

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