Regional Variation in Recommended Treatments for Ischemic Stroke and TIA

Abstract

Secondary stroke prevention treatments vary in different regions of the US. We determined the degree to which guideline-recommended stroke treatments vary by region for patients treated at hospitals participating in a voluntary national quality improvement program, Get with ehe Guidelines--Stroke. Receipt of 8 guideline-recommended treatments (intravenous tissue-type plasminogen activator, antihypertensives, antithrombotics, anticoagulants for atrial fibrillation, deep vein thrombosis prophylaxis, lipid-lowering medications at discharge, smoking cessation counseling, weight loss education) and defect-free care were compared in 4 US regions among eligible patients with ischemic stroke and transient ischemic attack; there was adjustment for patient demographics, medical history, and hospital characteristics. Among 991 995 admissions (South, 37%; Northeast, 27.6%; Midwest, 19.3%; West, 15.9%). Receipt varied regionally for tissue-type plasminogen activator (58.2%-67.8%), lipid-lowering medications (72.5%-75.7%), antihypertensives (80.1%-83.6%), antithrombotics (95.6%-96.8%), deep vein thrombosis prophylaxis (88.0%-91.4%), weight loss education (49.3%-54.7%), and defect-free care (72.1%-76.5%). In adjusted analyses, patients in the South had lower odds of use of intravenous tissue-type plasminogen activator (OR [95% CI]; 0.82 [0.69-0.97]), antihypertensives (0.82 [0.67-0.99]), and defect-free care (0.83 [0.75-0.92]); but, they were more likely to receive lipid-lowering medications (1.28 [1.05-1.54]) compared with those in the Northeast. Patients in the Midwest had lower odds of intravenous tissue-type plasminogen activator administration (0.82 [0.68-0.99]) and defect-free care (0.81 [0.72-0.92]). Those in the West had lower odds of antihypertensives (0.81 [0.67-0.99]), but had greater odds of receiving lipid-lowering medications (1.26 [1.03-1.53]). Despite relatively high rates of adherence to stroke-related therapies in Get With The Guidelines-Stroke hospitals, regional variations exist, with over one quarter of patients receiving suboptimal care. Systematic improvements may lead to better patient outcomes.