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Study Suggests Processes of Care to Improve Stroke Outcomes

Many processes of stroke care have been proposed as quality indicators. For most quality indicators, data supported the association between a process of care and a patient outcome, but reports of such associations often lacked adjustment for important clinical characteristics (e.g., stroke severity), or were not evaluated in relation to the overall quality of stroke care. This retrospective cohort study sought to identify processes of stroke care that are associated with improved patient outcomes after adjustment for both patient characteristics and other process measures. Investigators evaluated 1,487 patients admitted to a hospital with a stroke or transient ischemic attack (TIA) at any of three VA or two non-VA hospitals. Seven processes of stroke care were evaluated: 1) fever management, 2) hypoxia management, 3) blood pressure management, 4) neurological evaluation, 5) swallowing evaluation, 6) deep vein thrombosis (DVT) prophylaxis, and 7) early mobilization. Investigators also assessed several patient characteristics (e.g., age, comorbidity, stroke severity). The main outcome was the combined end-point of in-hospital mortality, discharge to hospice, or discharge to a skilled nursing facility.

Findings show that after adjusting for patient characteristics and other processes of care, three processes of care were independently associated with a reduction in the combined outcome: 1) swallowing evaluation, 2) DVT prophylaxis, and 3) treating all episodes of hypoxia with supplemental oxygen. Two of the three processes (swallowing evaluation, DVT prophylaxis) are similar to existing stroke quality measures, but the treatment of hypoxia is not a current performance measure. Thus, authors recommend that organizations that establish national performance measures add treatment of hypoxia to their assessment of stroke care quality, and continue to measure DVT prophylaxis and swallowing assessment among stroke patients. Results also show that the prevalence of the individual processes of care varied from a low of 29% receiving treatment of all episodes of fever – to a high of 92% receiving a neurology evaluation.

PubMed Logo Bravata D, Wells C, Lo A, et al. Processes of care associated with acute stroke outcomes. Archives of Internal Medicine May 10, 2010;170(9):804-810.

This study was partly funded by HSR&D (IIR 01-104), and Dr. Bravata was supported by an HSR&D Advanced Career Development Award. Dr. Bravata is part of VA/HSR&D’s Stroke Quality Enhancement Research Initiative (Stroke-QUERI) and HSR&D’s Center of Excellence on Implementing Evidence-Based Practice in Indianapolis, IN.

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