VA Quality Improvement Intervention Improves Outcomes for Veterans with New Ischemic Stroke Symptoms
BACKGROUND:
Patients with transient ischemic attack (TIA) are at high risk of recurrent vascular events; timely management can reduce that risk by 70%, however, gaps in TIA care quality exist in both private-sector and VA facilities. The Protocol-guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention was developed to improve the quality of VA care for Veterans experiencing TIA. The PREVENT intervention targeted clinical teams (not patients) and included five components: clinical programs, data feedback, professional education, electronic health record tools, and quality improvement support. This non-randomized cluster trial evaluated the PREVENT intervention at six diverse VA medical centers and assessed temporal trends in care quality among 36 matched control sites (six control sites matched to each intervention site on TIA patient volume, facility complexity, and quality of care). The study period extended from 2015 to 2019, including one-year baseline and active implementation periods for each site. The primary effectiveness outcome was the "without-fail" rate, which is an "all-or-none" measure of care quality; in this study, defined as the proportion of Veterans with TIA at a specific facility who received all of the processes of care for which they were eligible from among seven (i.e., brain imaging, carotid artery imaging, neurology consultation). Investigators also examined patients' 90-day recurrent stroke rate, 90-day recurrent vascular event rate, and 90-day mortality rate.
FINDINGS:
- Over the course of a one-year implementation period, the mean without-fail rate improved substantially at the six VA sites utilizing PREVENT (37% to 54%; +17%) and improved only modestly at the 36 matched control sites (39% to 42%; +3%). Investigators observed a net improvement of 14% at PREVENT intervention sites compared with matched controls.
- At PREVENT sites, the observed 90-day all-cause mortality rate decreased from 2.5% to 1.6%; at matched control sites this rate declined similarly from 2.3% to 1.7%. Decreases in the 90-day stroke rate, combined 90-day stroke or death rate, and the recurrent event rate were modestly higher for PREVENT sites than for the matched control sites, but differences were not statistically significant.
LIMITATIONS:
- Because the intervention included multiple components, investigators were unable to isolate and estimate the unique effects of each specific element.
IMPLICATIONS:
- Based on the observed improvements in quality of care, PREVENT was deployed nationwide across the VA healthcare system in 2019.
AUTHOR/FUNDING INFORMATION:
This study was funded by VA HSR&D’s Quality Enhancement Research Initiative (QUERI). Drs. Bravata, Myers, and Perkins are part of the Precision Monitoring to Transform Care (PRISM) QUERI program in Indianapolis, IN.
Bravata D, Myers L, Perkins A, et al. Assessment of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) Program for Improving Quality of Care for Transient Ischemic Attack. JAMA Network Open. September 8, 2020; Epub ahead of print.
