Abstract WP380: Hospital-Level Variability in Diagnostic Testing and Ischemic Stroke Subtype Documentation

Abstract

Objective: Documentation of ischemic stroke subtype has clinical and research implications. We aimed to assess hospital-level variability in subtype documentation and diagnostic testing patterns in the Get With The Guidelines (GWTG)-Stroke registry. Methods: We identified patients admitted with ischemic stroke to GWTG-Stroke participating hospitals between January 1, 2016 and September 30, 2017. Sites were instructed on use of the TOAST criteria for subtype documentation. We assessed hospital-level variability in TOAST subtype documentation and, among those with subtype documented, the performance of echocardiography, cerebrovascular imaging, and cardiac rhythm monitoring. Results: Among 607,563 patients with ischemic stroke from 1,906 sites, 348,715 (57.4%) had documented ischemic stroke subtype. Considerable hospital-level variability was observed in subtype documentation (Figure A). Patients with subtype documentation were more likely to be inter-facility transfers and treated at higher volume and academic centers, have complete medical history data, and have higher rates on achievement and quality measures. Carotid and intracranial vascular imaging (69.1% and 58.7%, respectively), echocardiography (74.3%), and cardiac rhythm monitoring (76.2%) were performed most frequently in cryptogenic stroke (CS) patients compared to other subtypes (Figure B; p<0.001 for each comparison). Among CS patients, short-term cardiac rhythm monitoring (65.7%) was most common with only 6.1% undergoing extended surface cardiac rhythm monitoring and 4.4% receiving extended implantable cardiac rhythm monitoring. Conclusions: In a large contemporary nationwide dataset of acute ischemic stroke hospitalizations, we observed that stroke subtype is documented in 57.4% of records, raising an important opportunity for quality improvement. Furthermore, diagnostic testing patterns suggest incomplete evaluation is common, even among patients with CS.