Age Disparities in Quality of Care and Clinical Outcomes in US Veterans with Ischemic Stroke

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.

Related HSR&D Project(s)

• RRP 09-184 – Stroke Care Quality within the Veterans Health Administration System

Background This is the first study of age disparities in ischemic stroke care quality and post-stroke outcomes across the Department of Veterans Affairs (VA) system. Methods This was a retrospective study of a national sample of US veterans admitted to VA medical centers for ischemic stroke between 10/1/06 and 9/30/07. The following 14 inpatient stroke quality indicators were assessed: 1) dysphagia screening before oral intake; 2) NIH Stroke Scale (NIHSS) documentation; 3) thrombolysis; 4) deep vein thrombosis (DVT) prophylaxis; 5) early antithrombotic therapy; 6) early ambulation; 7) fall risk assessment; 8) pressure ulcer risk assessment; 9) rehabilitation consultation); 10) antithrombotic therapy at discharge; 11) atrial fibrillation management; 12) lipid management; 13) smoking cessation counseling; and 14) stroke education. Post-stroke outcomes included: risk-adjusted mortality (in-hospital and 6-month post-stroke); hospital readmission (30-day and 6-month); and discharge disposition. Patients were categorized into one of four age categories ( < 65, 65-74, 75-84, and > 85 years). We modeled each quality indicator (defined as pass or fail among eligible patients) using multivariable logistic regression adjusting for: patient race, stroke severity, comorbidity, hospital geography, hospital complexity and hospital volume. Results Among the 3,937 US Veterans with ischemic stroke, 45.8% were < 65 years old, 22.1% were 65-74, 24.3% were 75-84, and 7.9% were > 85. The overall pass rate among the quality indicators was > 70% for 9 of the 14 processes of care. Risk adjusted models demonstrated that patients > 85 years-old were significantly less likely than younger patients to receive certain components of care (atrial fibrillation management, smoking cessation counseling, NIHSS documentation, and early ambulation); conversely, individuals aged > 85 years were more likely than younger patients to have dysphagia screening. Risk adjusted mortality was higher among patients aged > 85 years compared with younger patients: in-hospital mortality: > 85, 10.7%; 75-84, 5.2%; 65-74, 3.3%; and < 65, 1.7%; p < .0001; and 6-month mortality: > 85, 21.0%; 75-84, 13.9%; 65-74, 8.4%; and < 65, 3.2%; p < .0001. The oldest patients also had higher 6-month hospital re-admission rates and higher rate of being discharged to a long-term care facility (data not shown). Conclusions Despite overall relatively good quality of inpatient stroke care within the VA system, the oldest veterans with ischemic stroke ( > 85 years) were less likely to receive 4 components of inpatient stroke care, but were more likely than younger veterans to receive screening for dysphagia. The oldest stroke patients were more likely to die during index hospitalization and at 6-month post-stroke, had higher rates of both readmission and discharge to a long-term care facility. Further work to investigate possible associations between disparities in quality indicators and outcomes post-stroke is needed.