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Inpatient stroke care quality: Are there geographical differences between Stroke Belt and all other areas?

Castro JG, Jia H, Chumbler NR, Li X, Phipps MS, Ordin D, Vogel WB, Myers J, Williams LS, Bravata DM. Inpatient stroke care quality: Are there geographical differences between Stroke Belt and all other areas? Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD.


Little is understood about the geographic variation in the process of stroke care between Stroke Belt and non-Stroke Belt regions. Assess and compare inpatient stroke care quality between VA medical centers (VAMC) inside and outside the 11-state Stroke Belt region. Study participants were diagnosed with ischemic stroke at 111 VAMCs in 2007. The Stroke Belt region was defined as 11 southeastern states (AL, AR, GA, IN, KY, LA, MS, NC, SC, TN, VA). Inpatient stroke care quality was assessed by 14 quality indicators (dysphagia screening, NIH Stroke Scale (NIHSS) completion, tPA given, deep venous thrombosis prophylaxis, antithrombotic therapy, early ambulation, fall risk assessment, pressure ulcer risk assessment, rehabilitation consultation, antithrombotic therapy at discharge, atrial fibrillation management, lipid management, smoking cessation counseling, stroke education). Multivariate regression was fitted to examine differences between patients in facilities inside and outside the Stroke Belt, adjusting for patient and facility characteristics as well as VAMC clustering factors. Among the 3,909 patients, 28% received care in Stroke Belt facilities. Ischemic stroke prevalence was 9.3/10,000 VA healthcare users for Stroke Belt facilities compared to 7.7/10,000 for other areas. Similarly, Stroke Belt VAMCs had more stroke patients than other VAMCs. No significant difference in 30-day or 12-month mortality was found. Stroke Belt facility patients were more likely to be younger, black, married, and diagnosed with pre-stroke carotid stenosis. Before risk adjustment, Stroke Belt VAMCs were more likely to complete dysphagia screening (23.6% vs. 16.2%), NIHSS (29.1% vs. 24.5%), DVT prophylaxis (78.4% vs. 72.2%), smoking cessation counseling (97.2% vs. 92.4%), smoking education (20.6% vs. 14.1%); but were less likely to complete fall risk assessment (75.9 vs. 78.9%), pressure ulcer risk assessment (90.2% vs. 92.1), and rehabilitation consultation (77.4% vs. 80.2%). After risk adjustment, Stroke Belt VAMCs were more likely to perform dysphagia screening (OR = 2.0, p This research helps policy makers and providers understand the status of inpatient stroke care quality in VAMCs located in Stroke Belt states.

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