Study Shows Six Readily Available Processes of Care Can Decrease Mortality for Individuals with TIA or Non-Severe Stroke

BACKGROUND:
Studies reporting risk reductions of at least 70% for recurrent events among patients with transient ischemic attack (TIA) or non-severe stroke have emphasized early evaluation and management, but these studies differed in terms of the processes of care that were provided to patients. In addition, the American Heart Association/American Stroke Association stroke prevention guidelines recommend a broad range of processes – from diagnostic processes to secondary prevention interventions. This retrospective cohort study sought to identify specific processes of care that are associated with reduced risk of recurrent stroke or death among patients with TIA or non-severe stroke. Twenty-eight processes of care were examined for 8,076 Veterans who received VA care for non-severe stroke (n=4,213 or 52%) or TIA (n=3,863 or 48%) in an emergency department or inpatient setting from October 2010 through September 2011. Six processes were found to be effective in acute TIA management studies: brain imaging, carotid artery imaging, hypertension medication intensification, high-moderate potency statin, antithrombotics, and anticoagulation for atrial fibrillation. VA patients who received all of the processes for which they were eligible were classified as passing the "without-fail care" rate. Primary outcomes were 90-day and 1-year all-cause mortality and recurrent ischemic stroke.

FINDINGS:

• Without-fail care – including the six readily available processes – was associated with lower odds of death (31% reduction at 1-year) but not recurrent stroke risk. However, among 8,076 TIA or non-severe stroke patients, only 15% received the without-fail care for which they were eligible.
• In sensitivity analyses restricted to >e;65-year-olds, results were virtually identical to the main results.

IMPLICATIONS:

• The six without-fail care processes can be provided routinely across diverse medical centers because they do not require specialized structures of care. Given the strength of the prospective trial evidence, as well as the current findings supporting the association between these processes and improved mortality, healthcare systems should prioritize providing TIA and non-severe stroke patients with the guideline-concordant processes of care for which they are eligible.

LIMITATIONS:

• Without-fail processes were identified a priori, thus it is possible that the without-fail measure did not include processes with the strongest associations with outcomes. The possibility for residual confounding exists in this retrospective cohort study especially because investigators did not have brain imaging results, stroke severity, stroke type, or stroke location.

AUTHOR/FUNDING INFORMATION:
This study was supported by VA HSR&D's Quality Enhancement Research Initiative (QUERI; SDP 12-178). Dr. Sico was supported by an HSR&D Career Development Award. Drs. Bravata, Myers, Reeves, Miech, and Damush, and Mr. Baye and Ms. Ofner are part of the Precision Monitoring to Transform Care (PRISM) QUERI National Program in Indianapolis, IN.

Bravata D, Myers L, Reeves M, Cheng E, Baye F, Ofner S, Miech E, Damush T, Sico J, et al. Processes of Care Associated with Risk of Mortality and Recurrent Stroke among Patients with Transient Ischemic Attack and Non-Severe Ischemic Stroke. JAMA Network Open. July 3, 2019;2(7):e196716.