BACKGROUND/RATIONALE:
The Department of Veterans Affairs (VA) Office of Quality and Performance (OQP) in partnership with the VA Stroke Quality Enhancement Research Initiative (QUERI) Program conducted the OQP Stroke Special Project. The OQP Stroke Special Project was the first measurement of national VA stroke care quality. Inpatient stroke care quality was measured using 14 quality indicators including: thrombolysis use, dysphagia screening, NIH Stroke Scale (stroke severity) documentation, pressure ulcer risk assessment, fall risk assessment, early ambulation, antithrombotic therapy by hospital day two and at discharge, functional independence measure (FIM) documentation, deep vein thrombosis (DVT) prophylaxis, lipid management, smoking cessation counseling, anticoagulation for atrial fibrillation, and stroke education. Post-stroke care quality (6 processes) was measured across the following domains: hypertension, diabetes, hyperlipidemia, atrial fibrillation, tobacco use, and post-stroke depression.

OBJECTIVE(S):
The overall objective of this project was to examine national VA stroke care quality to identify targets for future implementation projects that will improve VA stroke care quality. The primary aims were to: (1) examine patterns in stroke care across the continuum of care from the inpatient period to the post-stroke period; and (2) identify facility characteristics that were associated with high quality stroke care.

METHODS:
We merged the OQP Stroke Special Project data (chart review on 5000 veterans with ischemic stroke across 132 VA medical centers [VAMC]) with patient-level information from the Functional Status and Outcomes Database (FSOD), vital status data, VA outpatient and inpatient administrative data, Decision Support System (DSS) cost data, Medicare inpatient and outpatient administrative data. We supplemented these patient-level data with facility-level information including: structures of stroke care; complexity; VAMC patient travel time data; wage index; rehabilitation service availability; rural-urban status; and facility level data from VA Chief of Staff Module and VA Primary Care Director Module of the VHA Clinical Practice Organizational Survey. Many of the analyses were conducted at the patient level. Analyses that were conducted at the facility level included hierarchical modeling to account for clustering of patients within facilities.

Key topics of these analyses include: 1) an examination of whether certain processes of inpatient care are associated with each other and hence may serve as "improvement bundles" that can be targeted in future quality improvement activities; 2) examination of potential age disparities in quality of care and outcomes; 3) an assessment of geographic variation in stroke care quality and outcomes including an examination of urban vs. rural differences as well as differences based on Stroke Belt geographic variation; 4) an evaluation of racial differences in inpatient and post-discharge care quality; 5) an assessment of various methods of assessing the quality of stroke care; 6) the development of risk adjustment models for the prediction of post-stroke mortality; and 7) an evaluation of the relationship between quality of care and VA costs.

FINDINGS/RESULTS:
To date, 6 manuscripts have been published or are in press, 5 are under peer-review, and 17 are in preparation. It is not possible to describe the results of all of these analyses; therefore, what follows is a summary of a sample of key findings.

We demonstrated a lack of connection between facility-level inpatient and outpatient stroke care quality (suggesting that stroke care is conducted within silos and that interventions to improve care within a facility but across settings will have to address inpatient care separately from outpatient care).

We conducted a detailed examination of thrombolysis use for stroke across the VA and found several opportunities to improve care: only 11% of eligible patients received thrombolysis, 37% of all patients who received thrombolysis had at least one contraindication to tPA documented, and 17% of patient received the wrong dose. Among the 85 VAMCs that received eligible patients, on average 2.3 patients (range 1-7) were eligible for tPA annually. There were no significant differences in receipt of thrombolytic therapy at the most equipped compared to less equipped VAMCs.

We sought to examine whether quality of care or outcomes of care differed by geography, but found no significant differences in short- or long-term post-stroke mortality or quality of care between the patients cared for in Stroke Belt versus non-Stroke Belt VAMCs. Similarly, no systematic age-related disparities in quality of care appear to exist across the VA system. With regard to the primary analysis (focused on 14 inpatient processes and 6 outpatient processes), no consistent racial disparities in stroke care quality were identified. However, in an analysis of the receipt of carotid artery imaging by patient race and hospital status, the unadjusted racial disparity in carotid artery imaging was 7.2% (88.6% whites vs. 81.4% blacks, p<0.001). Nearly 40% of blacks were admitted to one of 13 minority-serving hospitals (the top 10% of VAMCs ranked by the proportion of stroke patients who were black). No racial disparity in carotid artery imaging was detected within non-minority serving hospitals. However, the predicted probability of receiving carotid artery imaging for whites at non-minority-serving hospitals (89.7%) was higher than both whites (78.0%) and blacks (70.5%) at minority-serving hospitals. Therefore, underuse of carotid artery imaging does not appear to be a system-wide problem, but rather occurs at minority-serving VAMCs; facilities which have lower overall imaging rates.

We evaluated blood pressure control among the 3640 stroke survivors in the OQP dataset and found that 33% had uncontrolled blood pressure six months after discharge.

In an assessment of post-stroke rehabilitation care, even when stroke severity and other medical and demographic conditions were adjusted for, presence of a co-located VA inpatient rehabilitation unit was a primary factor driving discharge destination.

The average total inpatient costs for veterans with ischemic stroke were $12,410 (median, $8,114; inter-quartile range, $9,502). Better performance on 4 quality indicators was associated with significantly higher total costs (tPA administration, DVT prophylaxis, dysphagia screening, and rehabilitation assessment), whereas better performance on two quality indicators was associated with significantly lower costs: early ambulation and pressure ulcer risk assessment. For example, patients who received tPA had on average a $8,185 higher cost than patients who did not receive tPA, while patients who received a preventive measure such as pressure ulcer risk assessment had a $1,803 lower cost than those that did not receive this assessment. The other three quality indicators had no association with total costs.

We used these data to contruct the first stroke-specific frailty index, one that effectively predicts post-stroke outcomes. In addition, we found that it is possible to develop prediction models that differentiate between mild and severe stroke.

Reporting of quality data is complicated by estimation error due to small numbers of eligible patients per facility. We applied multilevel modeling and empirical Bayes (EB) estimation to address this issue in performance reporting. We recommended 8 quality indicators for performance reporting: dysphagia screening, NIH Stroke Scale documentation, early ambulation, fall risk assessment, pressure ulcer risk assessment, Functional Independence Measure documentation, lipid management, and deep vein thrombosis prophylaxis. These QIs displayed sufficient variation across facilities, had room for improvement, and identified sites with performance that was significantly above or below the population average. The remaining QIs were not recommended because of too few eligible patients or high pass rates with little variation.

IMPACT:
These data were used by the VA Acute Stroke Taskforce as they made recommendations about acute stroke care; the Acute Stroke Directive was signed November 2011. These data were also the basis of the 12-site INSPIRE service-directed project which is seeking to improve in-patient stroke care quality at high volume VAMCs.

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External Links for this Project

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PUBLICATIONS:

None at this time.

DRA: Other Conditions
DRE: Treatment - Comparative Effectiveness
Keywords: Patient outcomes, Quality assurance, improvement, Stroke
MeSH Terms: none