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SDP 12-178 – HSR&D Study

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SDP 12-178
Quality of Care for Veterans with TIA and Minor Stroke
Dawn M. Bravata MD
Richard L. Roudebush VA Medical Center, Indianapolis, IN
Indianapolis, IN
Funding Period: April 2013 - September 2015

BACKGROUND/RATIONALE:
Approximately 10,000 veterans with transient ischemic attack (TIA) or minor stroke are cared for in an Emergency Department (ED) or admitted to a Veterans Health Administration medical center (VAMC) annually. Because patients with TIA and minor stroke have little neurological impairment and yet are at very high risk of recurrent vascular events, they are ideal candidates for risk reduction interventions.

OBJECTIVE(S):
We sought to identify processes of care which can serve as targets for a future intervention study. This project had two primary aims: (1) to identify gaps in care quality received by patients with TIA or minor stroke across 26 processes of care (i.e., carotid artery evaluation, hypertension management, lipid management, brain imaging, cardiac monitoring, antithrombotics, anticoagulation for atrial fibrillation, diabetes management, deep vein thrombosis prophylaxis, nicotine replacement therapy for tobacco use, etc); (2) to identify facilitators and barriers to providing excellent quality of care for patients with TIA and minor stroke. The secondary aim was to identify the processes of care, received by patients with TIA or minor stroke, that were associated with a lower risk-adjusted 30-day readmission rate, 30-day mortality rate, 30-day recurrent vascular event rate, and 30-day stroke rate.

METHODS:
This project included three components: an administrative data cohort including all patients with a minor stroke or TIA who were cared for in any VHA Emergency Department (ED) or inpatient setting during fiscal year 2011; a chart review cohort that consisted of a sample of TIA and minor stroke patients from large volume VHA hospitals; and interview data from site visits at a sample of VA facilities. Multiple sources of VA electronic health record data were used to develop the electronic quality measures (eQMs); the eQMs were iteratively improved and validated against chart review. A mixed methods approach was used to identify facilitators and barriers of care including quantitative assessments and in-depth qualitative evaluations. Multivariable modeling accounting for clustering of patients within facilities was conducted to evaluate the association between processes and outcomes.

FINDINGS/RESULTS:
Twenty one of the 25 eQMs were considered valid after comparison with chart review. Among the cohort of 8427 patients, performance varied considerably across the 21 EQMs from a low of 2.9% for polysomnography to a high of 87.8% for antithrombotic prescription at discharge; in general performance was highest for EQMs included in the Joint Commission stroke measure set. Performance was higher for minor stroke patients (n=4751) than for TIA patients (n=3676) on nine EQMs (e.g., rehabilitation consultation: 33.3% of TIA versus 62.6% of minor stroke patients, absolute difference of 29.3%, p<0.0001). Performance on 15 EQMs was higher for admitted patients (n=5873) than for patients cared for only in the ED (n=2554) (e.g., carotid artery imaging: 15.9% of ED only versus 67.7% of admitted patients, absolute difference of 51.8%, (p<0.0001).

The site visit data demonstrated: a lack of TIA-specific care protocols, even at sites with stroke protocols; poor coordination of care across settings (e.g., ED to outpatient) and across specialties (e.g., neurology and primary care; a general lack of a sense of time urgency to the evaluation of patients with transient neurologic symptoms; and an interest in having site-specific quality data.

Although several processes of care were associated with outcomes in unadjusted analyses; only carotid imaging (aOR 0.38 [95%CI 0.25-0.57]), lipid measurement (0.60 [0.41-0.90]), antithrombotics by day 2 (0.47 [0.30-0.74]), and neurology consultation (0.50 [0.35-0.71]) were associated with improved 30-day mortality after adjustment for facility and patient characteristics. Carotid imaging was also associated with lower 30-day readmissions (0.77 [0.65-0.92]), and recurrent vascular events (0.72 [0.61-0.85]).

IMPACT:
This project is the first national benchmarking study of TIA and minor stroke care quality. We have identified gaps in care quality, developed tools for efficient performance monitoring, and identified site characteristics that are associated with high quality care. These data are being used to inform the design of an active implementation project.

PUBLICATIONS:

Journal Articles

  1. Arling G, Sico JJ, Reeves MJ, Myers L, Baye F, Bravata DM. Modelling care quality for patients after a transient ischaemic attack within the US Veterans Health Administration. BMJ open quality. 2019 Dec 4; 8(4):e000641.
  2. Myers J, Bravata DM, Sico J, Myers L, Chaturvedi S, Cheng E, Baye F, Zillich AJ. The Quality of Medication Optimization Among Patients with Transient Ischemic Attack or Minor Stroke. Journal of the American College of Clinical Pharmacy : JAACP. 2019 Jun 18; https://doi.org/10.1002/jac5.1149.
  3. Homoya BJ, Damush TM, Sico JJ, Miech EJ, Arling GW, Myers LJ, Ferguson JB, Phipps MS, Cheng EM, Bravata DM. Uncertainty as a Key Influence in the Decision To Admit Patients with Transient Ischemic Attack. Journal of general internal medicine. 2019 Sep 1; 34(9):1715-1723.
  4. 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.
  5. Bravata DM, Myers LJ, Arling G, Miech EJ, Damush T, Sico JJ, Phipps MS, Zillich AJ, Yu Z, Reeves M, Williams LS, Johanning J, Chaturvedi S, Baye F, Ofner S, Austin C, Ferguson J, Graham GD, Rhude R, Kessler CS, Higgins DS, Cheng E. Quality of Care for Veterans With Transient Ischemic Attack and Minor Stroke. JAMA neurology. 2018 Apr 1; 75(4):419-427.
  6. Damush TM, Miech EJ, Sico JJ, Phipps MS, Arling G, Ferguson J, Austin C, Myers L, Baye F, Luckhurst C, Keating AB, Moran E, Bravata DM. Barriers and facilitators to provide quality TIA care in the Veterans Healthcare Administration. Neurology. 2017 Dec 12; 89(24):2422-2430.
  7. Bravata DM, Myers LJ, Cheng E, Reeves M, Baye F, Yu Z, Damush T, Miech EJ, Sico J, Phipps M, Zillich A, Johanning J, Chaturvedi S, Austin C, Ferguson J, Maryfield B, Snow K, Ofner S, Graham G, Rhude R, Williams LS, Arling G. Development and Validation of Electronic Quality Measures to Assess Care for Patients With Transient Ischemic Attack and Minor Ischemic Stroke. Circulation. Cardiovascular quality and outcomes. 2017 Sep 1; 10(9).
  8. Chaturvedi S, Ofner S, Baye F, Myers LJ, Phipps M, Sico JJ, Damush T, Miech E, Reeves M, Johanning J, Williams LS, Arling G, Cheng E, Yu Z, Bravata D. Have clinicians adopted the use of brain MRI for patients with TIA and minor stroke? Neurology. 2017 Jan 17; 88(3):237-244.
Journal Other

  1. Bravata DM, Myers L, Reeves M, Cheng EM, Baye F, Ofner S, Miech EJ, Damush TM, Sico JJ, Zillich A, Phipps M, Williams LS, Chaturvedi S, Johanning J, Ferguson J, Yu Z, Arling G. Processes of Care that are Associated With Reduced Risk of Recurrent Vascular Events Among Patients With a Transient Ischemic Attack and Minor Stroke. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2017 Feb 1; 48(1):A162.
  2. Chaturvedi S, Ofner S, Baye F, Phipps M, Sico JJ, Damush TM, Miech EJ, Reeves M, Johanning J, Williams LS, Bravata DM. Have clinicians adopted the use of brain MRI for patients with TIA and minor stroke? [Abstract]. Stroke. 2016 Feb 1; 47(Suppl 1):ATP212.
  3. Damush TM, Miech EJ, Sico JJ, Phipps M, Arling G, Myers L, Ferguson J, Austin CC, Bravata DM. Stroke Nurse Coordinators: Role in Transient Ischemic Attack (TIA) Care in the National Veterans Healthcare Administration. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2016 Feb 1; 47(Suppl 1):ATP402.
  4. Sico JJ, Baye F, Myers L, Concato J, Williams LS, Bravata DM. Cardiac Screening Does Not Improve One-year Mortality Among Patients with Cerebrovascular Disease. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2016 Feb 1; 47(Suppl 1):ATP165.
  5. Sico JJ, Ofner S, Baye F, Concato J, Zillich AJ, Reeves M, Cheng E, Phipps MS, Arling G, Johanning J, Chaturvedi S, Williams LS, Bravata DM. Intensification of Statin Treatment is Associated with Improved Mortality Among Patients with TIA and Ischemic Stroke. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2016 Feb 1; 47(Suppl 1):TP175.
  6. Sico J, Baye F, Myers L, Concato J, Williams LS, Bravata DM. Underutilization of Guideline-Concordant Cardiac Screening among Patients with Cerebrovascular Disease. [Abstract]. Stroke; A Journal of Cerebral Circulation. 2015 Apr 1; 46(4):AWP158.
VA Cyberseminars

  1. Bravata DM. Quality of Care for Veterans with Transient Ischemic Attack (TIA) and Minor Stroke: Identifying Opportunities for Improvement. SQUINT Cyberseminar [Cyberseminar]. PRIS-M QUERI. 2016 Jun 7.
Conference Presentations

  1. Reeves MJ, Myers L, Cheng E, Phipps M, Williams LS, Bravata DM. Thirty-day outcomes among United States Veterans discharged home following an Emergency Department diagnosis of TIA. Presented at: European Stroke Annual Conference; 2016 May 10; Barcelona, Spain.
  2. Chaturvedi S, Ofner S, Baye F, Phipps M, Sico JJ, Damush TM, Miech EJ, Reeves M, Johanning J, Williams LS, Bravata DM. Have clinicians adopted the use of brain MRI for patients with TIA and minor stroke? Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2016 Feb 18; Los Angeles, CA.
  3. Damush TM, Miech EJ, Sico JJ, Phipps M, Arling G, Myers L, Ferguson J, Austin CC, Bravata DM. Stroke Nurse Coordinators: Role of transient ischemic attack (TIA) care in the national Veterans health administration. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2016 Feb 18; Los Angeles, CA.
  4. Sico JJ, Baye F, Myers L, Concato J, Williams LS, Bravata DM. Cardiac screening does not improve one-year mortality among patients with cerebrovascular disease. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2016 Feb 18; Los Angeles, CA.
  5. Sico JJ, Ofner S, Baye F, Concato J, Zillich AJ, Reeves M, Cheng E, Phipps MS, Arling G, Johanning J, Chaturvedi S, Williams LS, Bravata DM. Intensification of Statin Treatment is Associated with Improved Mortality Among Patients with TIA and Ischemic Stroke. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2016 Feb 18; Los Angeles, CA.
  6. Sico JJ, Miech EJ, Keating AB, Damush TM, Bravata DM. The influence of context on gaps in care delivery: post-event hypertension management for Veterans with TIA and minor stroke. Poster session presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2015 Dec 15; Washington, DC.
  7. Bravata DM, Myers L, Cheng E, Arling G, Damush TM, Miech EJ, Sico J, Phipps MJ, Johanning J, Williams LS. The Development and Validation of Clinical Performance Measures. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 9; Philadelphia, PA.
  8. Bravata DM, Myers L, Cheng E, Arling G, Miech EJ, Damush TM, Sico J, Phipps M, Yu Z, Zillich A, Reeves M, Johanning J, Williams LS. Quality of Care for Veterans with Transient Ischemic Attack and Minor Stroke. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2015 Feb 12; Nashville, TN.
  9. Sico J, Baye F, Myers L, Concato J, Williams LS, Bravata DM. Underutilization of Guideline-Concordant Cardiac Screening among Patient with Cerebrovascular Disease. Poster session presented at: American Heart Association / American Stroke Association International Stroke Conference; 2015 Feb 11; Nashville, TN.


DRA: Cardiovascular Disease
DRE: Treatment - Observational
Keywords: QUERI Implementation
MeSH Terms: none

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