Stroke Guideline Compliance and Patient Outcomes

Reker DM, Duncan PW, Hoenig HM, Sheedy C, Carlton C, Wu SS, Hayes J, Nelson A. Stroke Guideline Compliance and Patient Outcomes. Paper presented at: VA HSR&D National Meeting; 2006 Feb 17; Arlington, VA.

Objectives:The objectives of this study are to retrospectively review post acute stroke care, quantify whether the care was compliant with published clinical guidelines (AHRQ), and evaluate if guideline compliance is associated with patient outcomes in a large multi-site observational design.Methods:Twenty-three VA sites with acute and subacute rehabilitation units provided care to 520 stroke patients during the period July 1, 2002 through June 30, 2003. This report will detail the preliminary results in the first 446 patients reviewed in 28 units from all 23 sites. Electronic medical records were reviewed using a published and reliable abstraction methodology. Functional gain and discharge location were acquired from the VA Functional Status Outcomes Database. Results:Sixty-seven percent of patients received care in acute rehabilitation units; average age 68.7 (sd = 11.2); 59% white, 24% African American, 17% other; 97% male; 96% admitted from home; and 50% were married. The mean admission and discharge FIM motor scores were 46 and 69. Average guideline compliance was 75% with a patient level range of 41% to 97%. Average guideline compliance for 7 of the 11 domains of the post-acute stroke guideline were: team care 90%, baseline assessment 75%, discharge planning 36%, patient and family education 36%, family involvement in treatment plan 63%, goal setting 77%, and treatment plan 79%. Average length of stay was much longer in the subacute rehabilitation units (29 days) vs. the acute units (22 days). After controlling for age, marital status, unit type (acute vs. subacute), race, baseline FIM motor, and baseline FIM cognition, compliance with stroke guidelines was significantly and positively related to functional gain during the rehabilitation admission and discharge to the community.Implications:In the highest level of VA rehabilitation care, there is unit level variation in average guideline compliant care between 63% and 87%. Ten point incremental increases in guideline compliance were associated with gains of 1.8 FIM motor points and an odds ratio of 1.4 to be discharged to the community. Impacts:The dissemination and adoption of the new VA/DoD clinical stroke guidelines needs to be further promoted throughout the VA in order to provide high quality outcomes for veterans with stroke.