JAMA Network Open: Six Readily Available Processes of Care Can Decrease Mortality for Individuals with TIA or Non-Severe Stroke

Apri 1, 2020

Takeaway: VA patients who received all six processes of care for which they were eligible were classified as passing the ‘without-fail care’ rate, which was associated with a 31% reduction in mortality at one year. These processes of care can be provided routinely across diverse medical centers because they do not require specialized structures of care.

This QUERI (Quality Enhancement Research Initiative) study sought to identify specific processes of care that are associated with reduced risk of recurrent stroke or death among patients with transient ischemic attack (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.’ Primary outcomes were 90-day and 1-year all-cause mortality and recurrent ischemic stroke. Findings show:

• 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.

The six without-fail care processes can be provided routinely across diverse medical centers because they do not require specialized structures of care. Healthcare systems should prioritize providing TIA and non-severe stroke patients with the guideline-concordant processes of care for which they are eligible. 

This study led to the development and implementation of the “Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms” (PREVENT) quality improvement program which has been shown to improve quality of care. The PREVENT program was deployed nationwide in 2019.

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.