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Research Highlight

Measuring to Improve Care for Veterans with Cerebrovascular Events

The story of ongoing improvement of acute ischemic stroke care for Veterans over the last decade is one where many projects and strategic partnerships come together to play pivotal roles. These pieces include VHA performance measurement, electronic health record data, chart review projects, national quality reports, a Veterans Affairs Central Office (VACO) directive, funded HSR&D and QUERI projects, and strategic partnerships between HSR&D, QUERI, and VHA operations.

VHA Stroke Performance

In 2009, the Stroke QUERI, in partnership with what was then the national VA Office of Quality and Performance, led the first facilitylevel assessment of VHA stroke care quality.¹ Using administrative data and detailed chart review for patients with ischemic stroke in fiscal year 2007, this large-scale, labor-intensive project assessed inpatient stroke care quality as well as stroke risk factor management in the pre- and post-stroke periods at over 150 VA Medical Centers (VAMCs). This QUERI project led to the first understanding of VHA stroke performance across the system, and found that performance varied considerably across quality measures and across VAMCs, with some of the biggest improvement opportunities in the earliest phases of acute care. ² These results were distributed widely to all VHA facilities, Veterans Integrated Service Networks (VISNs), and Central Office leadership. A stroke quality improvement toolkit and a national VA Stroke Quality Improvement Network (SQUINT) were also launched in support of this initiative.

This new knowledge about VHA stroke performance across the system directly informed the work of the VA Stroke Task Force, a strategic partnership with the national VHA offices of Emergency Medicine and Neurology and other national VHA stakeholders, whose work culminated in the development of the VHA National Acute Ischemic Stroke Directive. Released in late 2011, the directive required every VHA medical center to formally selfdesignate at one of three levels of acute stroke care (Primary Stroke Center, Limited Hours, or Supporting Stroke Facility) and to self-report quarterly via the VA Inpatient Evaluation Center on a core set of facilitylevel stroke quality performance measures. From 2012 to the present, these reports— along with other sources of data, including national measurement of facility-level inpatient stroke care performance via chart review by the VHA External Peer Review Program—have shown steady improvement across VHA in acute stroke care.

In the timespan of only a few years, VHA moved from a system where acute stroke performance was largely unknown to one where facility-level stroke care is now formally organized, measured, and reported—and on an upward trajectory of improvement.

VHA TIA Care

Following the example set with acute stroke care, transient ischemic attack (TIA) represents another clinical area within VHA where timely, high-quality care could directly benefit thousands of Veterans annually. Several non-VHA studies have demonstrated that timely management of vascular risk factors reduces the relative risk of vascular events by a clinically dramatic 70 percent. A QUERI-funded servicedirected project conducted the first national benchmarking evaluation of TIA care across the VHA system nationwide. Electronic quality measures (eQMs) were validated against chart review and used to evaluate TIA care quality across a comprehensive set of processes and outcomes that spanned the care continuum from acute, emergency department care through the inpatient period to the outpatient, primary care setting. Performance varied substantially across elements of care with lowest performance for polysomnography (<5 percent of eligible patients) and highest performance for international normalized ratio (INR) measurement for atrial fibrillation patients receiving anticoagulation (>96 percent of eligible patients).

In an effort to understand how TIA care is being delivered across the VHA system, this study also conducted 72 in-person interviews with multidisciplinary clinical and administrative staff at 14 VAMCs across the country. These interviews revealed that TIA care quality was largely invisible to practitioners because of a lack of access to performance data, with respondents universally welcoming quality performance data about TIA care.

In response to these findings, the PRIS-M QUERI launched the "Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms" (PREVENT) project. PREVENT makes it possible for the first time for participating VAMCs to examine their own facilitylevel TIA quality performance data; offers resources and facilitation to help local VA staff reflect upon and evaluate those data; supports local teams in quality improvement planning and goalsetting; and builds a system-wide quality improvement system for TIA care where staff at one VAMC can connect with and learn from the experience, knowledge, and efforts of VA staff at other VAMCs. As before with acute stroke, this systemic TIA initiative aims to contribute another chapter to a larger story of HSR&D, QUERI, VHA operations, VERC, and VA clinicians around the country working together to measure, organize, and improve care for Veterans.

References

1. Bravata DM, et al. The Quality of VA Inpatient Ischemic Stroke Care, FY2007: Final National and Medical Center Results, VHA Office of Quality and Performance (OQP) Special Study. VHA Office of Quality and Performance and the VA Health Services Research and Development (HSR&D) Quality Enhancement Research Initiative (QUERI); 2009.
2. Arling G, et al. "Estimating and Reporting on the Quality of Inpatient Stroke Care by Veterans Health Administration Medical Centers," Circulation: Cardiovascular Quality and Outcomes 2012; 5:44-51.