Stroke Performance Measures Research Articles

Abstract 3379: Benefiting the Community; The Impact of Joining a Regional Stroke Network

Background: The Cleveland Clinic Health System (CCHS) consists of a large tertiary care center and 10 regional hospitals. It is organized both clinically and administratively into multispecialty organ based Institutes rather than departments. The CCHS re-introduced a regional initiative to standardize stroke care in 2008. Medina Hospital is a 118-bed community hospital in rural North-eastern Ohio, where there is a high stroke burden and previously minimal IV tPA use. Medina Hospital joined the CCHS Stroke Network in November 2009. Hypothesis: We hypothesized that after joining the formally organized stroke CCHS system of care, the proportion of stroke patients receiving IV tPA and the timeliness of administration of acute thrombolytic therapy would both significantly increase. Methods: Data was analyzed from our prospective participation in the Get with the Guidelines-Stroke and the Ohio Coverdell Stroke Registries. Baseline data regarding quality, outcomes and stroke performance measures were reviewed. CCHS initially supported acute stroke care in early 2010 with a telemedicine cart and then introduced 24/7 emergency, on-site, CCHS neurologist, acute stroke call coverage in late 2010. Standardized CCHS stroke care pathways and order sets were also introduced in 2010. The proportion of stroke patients treated with IV tPA in 2010 and 2011 (post- joining CCHS) was compared to 2009 (2-sided Fisher’s exact test), and door-to-needle times were compared from 2010 to 2011 (unpaired t-test). Results: IV tPA treatment utilization increased from 0/69 patients (0%) in 2009 to 9/67 patients (11.8%) in 2010 [exact p=.0033] and 11/46 (19.3%) in the first 7 months of 2011 [exact p=.0001]. Door-to-needle times improved from a mean of 81.4 (95%CI 66.4 to 96.4) minutes in 2010 to 61.7 (95% CI 52.7 to 70.8) minutes in 2011 (p=.0158). Conclusions: Participation in an organized formal collaborative regional hospital stroke treatment network resulted in dramatic improvements from zero IV tPA utilization to greatly exceeding the national benchmark averages for both percentage treatment with IV tPA and door-to-needle time in a rural area where patients previously had minimal access to acute stroke expertise.

Abstract 3635: Mentoring a Stroke Program Coordinator: A Planned, Staged Approach

Background and Issues: Transitions between stroke coordinators can have a deleterious effect upon stroke program development and operations. Typically, a one-month notice of resignation is given. This allows insufficient time to advertise, interview, hire and train or orient new staff. Complicating the issue, the number of experienced stroke coordinators has not kept pace with demand. Hence, extensive training may be required for the replacement if one with experience is not available. Purpose: The purpose of our project was to prepare for a seamless transition between a retiring stroke coordinator and her replacement while maintaining quality and adding neurovascular intervention to the program. Methods: Our facility provides a phased-retirement program that allows gradual transition between full time employment and retirement. In July 2009, a eighty percent stroke coordinator position was split between a coordinator mentee and the experienced coordinator mentor. Over an eighteen-month period, responsibilities were gradually shifted to the replacement with ongoing education, guidance and support from the previous coordinator. For the first six months, orientation and coaching took place on an almost daily basis. Over the following year, progressive periods were planned for independent program management with available backup and support Results: A cerebrovascular intervention program was successfully implemented during the period. Primary Stroke Center Certification was maintained. Compliance with stroke performance measures did not decrease. The Get with the Guidelines Gold Plus Award was received for 2009, 2010 and 2011. Acute stroke treatment rates increased due to program enhancements and improvements during the period. Conclusions: This planned, progressive approach to program leadership transition allowed sufficient training for the replacement coordinator. At the conclusion of the process, the mentee stepped into the full-time position. This seamless transition provided for successful program operations and development.

Evidence-Based Quality Indicators for Stroke Rehabilitation

Previous stroke performance measures consider aspects of postacute treatment, but there are only few specific quality indicators or standards for poststroke rehabilitation. The purpose of this study was to develop a set of indicators for measuring the quality of postacute stroke rehabilitation in inpatient and outpatient facilities using a standardized evidence-based approach. Quality indicators were developed between January 2009 and February 2010 by an interdisciplinary board of healthcare professionals from rehabilitation centers cooperating in the Berlin Stroke Alliance. The Berlin Stroke Alliance is a regional network of >40 providers of acute treatment, rehabilitation, and aftercare aiming to improve stroke services within Berlin and Brandenburg. The indicators were developed according to published international recommendations and predefined methodological requirements. The applied standards included a systematic literature review, a rating of published evidence, an external peer review, and the evaluation in a pilot study before implementation. Of an initial list of 33 indicators, 20 indicators were rated as being appropriate. After completion of the pilot phase, we agreed on a set of 18 indicators. The indicators measure processes (9 indicators), outcomes (5 indicators), and structures (4 indicators) in the following domains of stroke rehabilitation: completion of diagnostics; secondary prevention; cognition and affect; speech and swallowing; management of complications; sensorimotor functions and mobility; discharge status; and aftercare. Documentation of evidence-based quality indicators for stroke rehabilitation in clinical routine is feasible and can serve as a first step toward implementing standardized cross-institutional quality assurance programs for stroke rehabilitation.

Improvement in Stroke Performance Measures

> Trust but verify. > > —Ronald Reagan Collecting and monitoring performance measure data are resource-intensive, requiring time and effort by a team that includes health care providers treating the patients and documenting their care, quality personnel monitoring and working to optimize performance rates, and quality abstractors, who extract information from the medical record. Recently, an additional group of people have become involved, informatics personnel, who strive to extract information electronically and improve performance measure adherence rates through improved electronic health record (EHR) functionality such as documentation templates and electronic reminders. Article see p 503 With the increased focus on measuring processes and outcomes of care, performance measurement will become increasingly widespread.1–3 The National Quality Forum (NQF), the nonprofit organization created to help improve the quality of health care,4 continues to endorse new measure sets. The Centers for Medicare and Medicaid Services (CMS) Voluntary Pay for Reporting Initiative, which began in 2005 with the voluntary hospital-based collection of 10 NQF-endorsed measures, continues to expand, with 76 measures planned by 2014.1 In addition to the increased burden of data collection, the stakes for performance are rising—the CMS “Pay for Reporting” program has become “Pay-for-Performance,” with reimbursement linked to adherence rates.5 Stroke, one of costliest conditions for Medicare and a leading cause of disability and mortality,6 has been a focus for performance measurement activities. Eight NQF-endorsed stroke performance measures are currently used as part of the voluntary Joint Commission Primary Stroke Center certification and will be part of the CMS Hospital Inpatient Prospective Payment System program beginning with 2013 stroke hospital discharges.1 In addition, collection of 7 stroke performance measures using certified EHR technology is required if hospitals wish to qualify for incentive payments through the CMS Electronic Health Record Meaningful Use Incentive program.7 Given the increased concentration …

Impact of Systems of Care and Blood Pressure Management on Stroke Outcomes

Stroke is the third leading cause of death in the United States and the leading cause of disability. Stroke patients' outcomes are strongly determined by how long they remain untreated ("time is brain"). The Joint Commission's adoption of stroke performance improvement measures combined with the Centers for Medicare and Medicaid's more recent adoption in October 2009 make a systems approach to improving stroke outcomes a higher priority. As hospitals establish local and regional stroke care systems to meet these performance measures, treatment of emergent high blood pressure (BP) is a major consideration to improve rapid triage and management of acute stroke patients. Intravenous thrombolysis with tissue plasminogen activator (tPA) is a critical quality of care component for acute ischemic stroke (AIS) treatment, but its administration is contingent on BP management. For patients with AIS who are potentially eligible for tPA and patients with intracerebral hemorrhage, timely, controlled BP may improve patient outcomes. Appropriate BP management, however, is still controversial given the heterogeneity of stroke subtypes, the varying attributes of candidate antihypertensive agents, and both local and central hemodynamics. Additionally, organizational delivery system factors may be suboptimal at some hospitals. Under current hospital stroke performance measures, payment mechanisms, and emergency department throughput measures, the impact of BP management may become transparent to patients and payers, and have important consequences for hospital-derived stroke outcomes.

Development of Stroke Performance Measures

In the United States and elsewhere, stroke performance measures have been developed to monitor and improve the quality of care. The process by which these measures are developed, implemented, and evaluated is complex, evolving, and not widely understood. We review the methodological development of stroke performance measures in the United States. A literature search identified articles that addressed the development and endorsement of performance measures for stroke care. Emphasis was given to articles specific to acute stroke, but when these were lacking, other cardiovascular diseases were included. Ten process-based performance measures relevant to acute hospital-based stroke care have now been developed and endorsed. These measures include intravenous thrombolysis, deep vein thrombosis prophylaxis, dysphagia screening, stroke education, and discharge-related medications and assessments. There are currently at least 5 major US-based stroke quality improvement programs implementing stroke measures. Data indicate that rapid improvements in the quality of stroke care can be induced by the systematic collection and evaluation of stroke performance measures. However, current stroke measures are relatively limited, addressing only inpatient care and mostly patients with ischemic stroke. Stroke quality improvement is still in its early stages, but data suggest that large-scale improvements in stroke care can result from the implementation of stroke performance measures. Performance measures that address multidisciplinary stroke unit care, outpatient-based care, and patient-oriented outcomes such as functional recovery should be considered. Ongoing challenges relevant to stroke quality improvement include the role of public reporting and the need to link better stroke care to improved patient outcomes.

Race/ethnicity, quality of care, and outcomes in ischemic stroke.

Prior studies suggest differences in stroke care associated with race/ethnicity. We sought to determine whether such differences existed in a population of black, Hispanic, and white patients hospitalized with stroke among hospitals participating in a quality-improvement program. We analyzed in-hospital mortality and 7 stroke performance measures among 397,257 patients admitted with ischemic stroke to 1181 hospitals participating in the Get With The Guidelines-Stroke program 2003 through 2008. Relative to white patients, black and Hispanic patients were younger and more often had diabetes mellitus and hypertension. After adjustment for both patient- and hospital-level variables, black patients had lower odds relative to white patients of receiving intravenous thrombolysis (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.77 to 0.91), deep vein thrombosis prophylaxis (OR, 0.88; 95% CI, 0.83 to 0.92), smoking cessation (OR, 0.85; 95% CI, 0.79 to 0.91), discharge antithrombotics (OR, 0.88; 95% CI, 0.84 to 0.92), anticoagulants for atrial fibrillation (OR, 0.84; 95% CI, 0.75 to 0.94), and lipid therapy (OR, 0.91; 95% CI, 0.88 to 0.96), and of dying in-hospital (OR, 0.90; 95% CI, 0.85 to 0.95). Hispanic patients received similar care as their white counterparts on all 7 measures and had similar in-hospital mortality. Black (OR, 1.31; 95% CI, 1.28 to 1.35) and Hispanic (OR, 1.16; 95% CI, 1.11 to 1.20) patients had higher odds of exceeding the median length of hospital stay relative to whites. During the study, quality of care improved in all 3 race/ethnicity groups. Black patients with stroke received fewer evidence-based care processes than Hispanic or white patients. These differences could lead to increased risk of recurrent stroke. Quality of care improved substantially in the Get With The Guidelines-Stroke Program over time for all 3 racial/ethnic groups.

The Stroke Practice Improvement Network: A Quasiexperimental Trial of a Multifaceted Intervention to Improve Quality

The aim of this project was to determine whether a tailored multifaceted intervention aimed at site-specific barriers is more effective than audit feedback alone for improving adherence to inhospital stroke performance measures (PMs): door to needle time of less than 1 hour for tissue plasminogen activator, dysphagia screening, deep venous thrombosis prophylaxis, and warfarin treatment for atrial fibrillation. Hospitals were paired on baseline adherence to dysphagia screening and quality improvement infrastructure and randomized to receive audit feedback alone (n=7) versus audit feedback plus site-specific interventions (n=6). Data were collected on all admitted patients with stroke seen in the neurology department before and after a 6-month implementation period. The primary end point was the difference in postintervention adherence rates for each PM, except tissue plasminogen activator because of low sample size. Data were collected on 2071 preintervention patients and 1240 postintervention patients. Targeted site-specific interventions, such as standing orders and standardized dysphagia screens, were imperfectly implemented during the 6-month intervention period. For atrial fibrillation, the intervention group had an 11% higher postintervention adherence rate beyond that of the control group (98% v 87%, P < .005). No other statistically significant changes in PM adherence were observed. Implementation of site-specific interventions for quality improvement of specific measures in stroke was difficult to achieve in a 6-month time frame and led to improved adherence for only one of 3 PMs. Studies with a longer intervention period and more sites are required to determine whether tailored interventions can enhance stroke improvement.

PO13-TU-10 Adherence to disease-specific care stroke performance measures in primary stroke center

PO13-TU-10 Adherence to disease-specific care stroke performance measures in primary stroke center

Get With the Guidelines–Stroke Is Associated With Sustained Improvement in Care for Patients Hospitalized With Acute Stroke or Transient Ischemic Attack

Adherence to evidence-based guidelines for treatment of stroke or transient ischemic attack is suboptimal. We sought to establish whether participation in Get With the Guidelines-Stroke was associated with improvements in adherence. This prospective, nonrandomized, national quality improvement program measured adherence to guideline recommendations in 322 847 hospitalized patients discharged with a diagnosis of ischemic stroke or transient ischemic attack. A volunteer sample of 790 US academic and community hospitals participated from 2003 through 2007. The main outcome measures were change in adherence over time to 7 prespecified performance measures and a composite measure (total number of interventions provided in eligible patients divided by total number of care opportunities among eligible patients). Generalized estimating equations were used to identify factors associated with improvement. Participation in Get With the Guidelines-Stroke was associated with improvements in the 7 individual and 1 composite measures from baseline to the fifth year: intravenous thrombolytics (42.09% versus 72.84%), early antithrombotics (91.46% versus 97.04%), deep vein thrombosis prophylaxis (73.79% versus 89.54%), discharge antithrombotics (95.68% versus 98.88%), anticoagulation for atrial fibrillation (95.03% versus 98.39%), lipid treatment for low-density lipoprotein >100 mg/dL (73.63% versus 88.29%), smoking cessation (65.21% versus 93.61%), and composite (83.52% versus 93.97%) (P<0.0001 for all comparisons). Multivariate analysis showed that time in Get With the Guidelines-Stroke was associated with a 1.18-fold yearly increase in the odds of fulfilling care opportunities that was independent of secular trends. Get With the Guidelines-Stroke participation was associated with increased adherence to all stroke performance measures. Markedly improved stroke care was seen in all hospitals regardless of size, geography, and teaching status.

Benchmarks and Determinants of Adherence to Stroke Performance Measures

Develop achievable benchmarks for 9 stroke performance measures (PM) and to identify organizational factors associated with adherence. Adherence rates and achievable benchmarks were determined for 9 PM within a study of patients (n=2294) admitted with acute ischemic stroke at 17 hospitals. Baseline information regarding hospital characteristics and stroke-specific processes of care were collected, and multi-level models were used to test the association of these factors with adherence. Benchmarks were >or=90% for 8 of the 9 PM. After controlling for clustering, only use of standing orders was associated with adherence to PM, including: dysphagia screening, venous thrombosis prophylaxis, consideration of tPA, and provision of educational material. High levels of adherence are achievable for several acute stroke PM. Use of standing orders is associated with adherence to PM requiring immediate action on admission.