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SDP 12-178 – HSR Study

SDP 12-178
Quality of Care for Veterans with TIA and Minor Stroke
Dawn M. Bravata, MD
Richard L. Roudebush VA Medical Center, Indianapolis, IN
Indianapolis, IN
Funding Period: April 2013 - September 2015
Approximately 10,000 veterans with transient ischemic attack (TIA) or minor stroke are cared for in an Emergency Department (ED) or admitted to a Veterans Health Administration medical center (VAMC) annually. Because patients with TIA and minor stroke have little neurological impairment and yet are at very high risk of recurrent vascular events, they are ideal candidates for risk reduction interventions.

We sought to identify processes of care which can serve as targets for a future intervention study. This project had two primary aims: (1) to identify gaps in care quality received by patients with TIA or minor stroke across 26 processes of care (i.e., carotid artery evaluation, hypertension management, lipid management, brain imaging, cardiac monitoring, antithrombotics, anticoagulation for atrial fibrillation, diabetes management, deep vein thrombosis prophylaxis, nicotine replacement therapy for tobacco use, etc); (2) to identify facilitators and barriers to providing excellent quality of care for patients with TIA and minor stroke. The secondary aim was to identify the processes of care, received by patients with TIA or minor stroke, that were associated with a lower risk-adjusted 30-day readmission rate, 30-day mortality rate, 30-day recurrent vascular event rate, and 30-day stroke rate.

This project included three components: an administrative data cohort including all patients with a minor stroke or TIA who were cared for in any VHA Emergency Department (ED) or inpatient setting during fiscal year 2011; a chart review cohort that consisted of a sample of TIA and minor stroke patients from large volume VHA hospitals; and interview data from site visits at a sample of VA facilities. Multiple sources of VA electronic health record data were used to develop the electronic quality measures (eQMs); the eQMs were iteratively improved and validated against chart review. A mixed methods approach was used to identify facilitators and barriers of care including quantitative assessments and in-depth qualitative evaluations. Multivariable modeling accounting for clustering of patients within facilities was conducted to evaluate the association between processes and outcomes.

Twenty one of the 25 eQMs were considered valid after comparison with chart review. Among the cohort of 8427 patients, performance varied considerably across the 21 EQMs from a low of 2.9% for polysomnography to a high of 87.8% for antithrombotic prescription at discharge; in general performance was highest for EQMs included in the Joint Commission stroke measure set. Performance was higher for minor stroke patients (n=4751) than for TIA patients (n=3676) on nine EQMs (e.g., rehabilitation consultation: 33.3% of TIA versus 62.6% of minor stroke patients, absolute difference of 29.3%, p<0.0001). Performance on 15 EQMs was higher for admitted patients (n=5873) than for patients cared for only in the ED (n=2554) (e.g., carotid artery imaging: 15.9% of ED only versus 67.7% of admitted patients, absolute difference of 51.8%, (p<0.0001).

The site visit data demonstrated: a lack of TIA-specific care protocols, even at sites with stroke protocols; poor coordination of care across settings (e.g., ED to outpatient) and across specialties (e.g., neurology and primary care; a general lack of a sense of time urgency to the evaluation of patients with transient neurologic symptoms; and an interest in having site-specific quality data.

Although several processes of care were associated with outcomes in unadjusted analyses; only carotid imaging (aOR 0.38 [95%CI 0.25-0.57]), lipid measurement (0.60 [0.41-0.90]), antithrombotics by day 2 (0.47 [0.30-0.74]), and neurology consultation (0.50 [0.35-0.71]) were associated with improved 30-day mortality after adjustment for facility and patient characteristics. Carotid imaging was also associated with lower 30-day readmissions (0.77 [0.65-0.92]), and recurrent vascular events (0.72 [0.61-0.85]).

This project is the first national benchmarking study of TIA and minor stroke care quality. We have identified gaps in care quality, developed tools for efficient performance monitoring, and identified site characteristics that are associated with high quality care. These data are being used to inform the design of an active implementation project.

External Links for this Project

NIH Reporter

Grant Number: I01HX000751-01A1

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None at this time.

DRA: Cardiovascular Disease
DRE: Treatment - Observational
Keywords: none
MeSH Terms: none

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