Abstract 206: Aiming to Improve Stroke Care Continuity with Primary Care Follow-up Appointments Scheduled Prior to Hospital Discharge

Abstract

Background: Follow-up care can facilitate patient recovery. To improve care continuity the Ohio Coverdell Stroke Program aimed to improve the proportion of hospitalized stroke patients for whom prior to discharge the hospital scheduled a follow-up appointment with primary care. This is not yet standard of care for stroke. Methods: Of 48 Ohio Coverdell Stroke Program participating hospitals, 37 had data entered into the registry for each quarter of the 12 month quality improvement initiative. Admitted stroke patients of any type planned for discharge home were included. Patients younger than 18 years of age, not admitted to the hospital from the emergency department, or admitted and only receiving comfort care were excluded. Patient-level and hospital-level data were examined to determine performance in a 6 month baseline period (quarters 1-2) and a 6 month active improvement phase (quarters 3 and 4). Patients discharged with and without an appointment scheduled were compared to identify targeted areas for continued improvement. Results: There were 4,558 stroke patients discharged home over 12 months from 37 geographically distributed hospitals (62.4% ischemic stroke, 29.0% TIA, 8.5% hemorrhagic stroke). At baseline, 13.4% of patients had an appointment scheduled with a primary care provider prior to discharge home. This increased to 18.7% in quarter 3 and 26.6% in quarter 4, representing a 98.5% improvement from baseline to quarter 4 in the proportion of patients with a primary care follow-up appointment scheduled. Median quarter 4 performance at a hospital level was 10.5% (distributed from 0-80.0% across 37 hospitals). Analysis of patient characteristics showed differences in the proportion of patients with an appointment by age (15.5% for ages>65 years vs. 18.5% of younger patients, p=0.004); race (15.1% white race vs. 22.1% of African Americans, p<0.001); history of prior stroke (19.0% with prior stroke vs. 16.3% with no prior stroke, p=0.031); comorbid diabetes (18.6% with diabetes vs. 16.1% without, p=0.021); dyslipidemia (18.2% with vs. 15.6% without, p=0.013); and obesity (14.4% were obese/overweight vs. 17.7% who were not overweight/obese, p=0.007). No significant patient level differences were found by patient sex, insurance, stroke type, stroke severity, prior myocardial infarction or coronary artery disease, prior TIA, family history of stroke, or comorbid atrial fibrillation, heart failure, or hypertension. Conclusions: Hospital performance with scheduling primary care follow-up appointments improved significantly; however, only 1 in 4 patients had an appointment scheduled prior to discharge. Case study analysis of missed opportunities may help identify barriers and facilitators associated with access, availability, and awareness that can be addressed in future improvement cycles.