National Quality of Care and Outcomes for In‐Hospital Ischemic Stroke: Severe Strokes, Frequent Comorbidities, and Room for Improvement

1University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO
2University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO
3VA Boston Healthcare System, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA
4Duke University Medical Center, Durham, NC
5Duke University Medical Center, Durham, NC
6Michigan State University, East Lansing, MI
7Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
8Massachusetts General Hospital, Boston, MA
9Ronald Reagan–UCLA Medical Center, Los Angeles, CA

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 518

Background:

In‐hospital strokes have distinctive risk factors compared with community‐onset strokes. Analysis of in‐hospital stroke quality of care and outcomes has never been performed at the national level.

Methods:

We conducted a retrospective cohort study of the American Heart Association's Get With The Guidelines (GWTG) Stroke Database from January 2006 to April 2012, using data from 1280 sites that reported at least 1 in‐hospital stroke. Patient characteristics, comorbid illnesses, medications, quality‐of‐care measures, and outcomes were analyzed for the 21,349 in‐hospital ischemic strokes compared with 928,885 community‐onset ischemic strokes.

Results:

Compared with patients with community‐onset stroke, in‐hospital stroke patients had more thromboembolic risk factors such as atrial fibrillation, prosthetic heart valves, carotid stenosis, or congestive heart failure (P < 0.0001), but were less likely to have had a prior stroke, hypertension, or smoke (P < 0.0001). Prior to hospitalization, patients with an in‐hospital stroke used more antiplatelet, anticoagulant, antihypertensive, and lipid‐lowering agents (P < 0.0001). In‐hospital stroke patients experienced more severe strokes (median NIHSS, 9.0 vs. 4.0; P < 0.0001) and remained in the hospital longer (median LOS, 6.0 days vs. 4.0 days; P < 0.0001). Using the GWTG‐Stroke quality‐of‐care metrics, the likelihood of having defect‐free care was lower for in‐hospital strokes (45.3% vs. 58.9%, P < 0.0001). Eleven percent of in‐hospital strokes were treated with IV thrombolysis (2352 of 21,349). In multivariable analysis of patients treated with intravenous thrombolysis, those with in‐hospital stroke had lower rates of intracranial hemorrhage (OR, 0.80; 95% CI, 0.64–1.00; P = 0.049). In multivariate models, patients with in‐hospital stroke were less likely to be discharged home (OR ,0.37; 95% CI, 0.35–0.39, P < 0.001) or able to ambulate independently at discharge (OR, 0.42; 95% CI, 0.39–0.45; P < 0.001). Mortality was higher for in‐hospital stroke (OR, 2.72; 95% CI, 2.57–2.88; P < 0.001).

Conclusions:

This is the largest analysis of quality of care and outcomes for in‐hospital ischemic stroke and the only analysis to use national data from a prospective stroke registry. Patients with in‐hospital stroke have more comorbid illness and more severe strokes. Outcomes are worse with greater disability and higher mortality. A substantial proportion of in‐hospital ischemic strokes were treated with intravenous thrombolysis, and these patients did not experience higher complication rates. GTWG‐concordant care occurs less than half the time for in‐hospital stroke patients and less often than for community‐onset stroke patients. This discrepancy in quality of care represents an important opportunity for improvement.

In-Hospital Versus Community-Onset Strokes



In-Hospital Stroke (n = 21,349) Community-Onset Stroke (n = 928,885) P Value
Patient demographics
 Age, median (IQR) 73.0 (62.0–82.0) 73.0 (60.0–82.0) < 0.0001
 Sex (% male) 45.70% 48.20% < 0.0001
 Race (% white) 72.50% 71.30% < 0.0001
Functional status–independent ambulation
 Prior to admission 82.60% 90.00% < 0.0001
 On admission 36.30% 39.20% < 0.0001
 On discharge 31.00% 50.40% < 0.0001
GWTG quality and achievement measures
 Deficit-free care 45.30% 58.90% < 0.0001
Outcomes
 Discharged home 27.70% 49.90% < 0.0001
 In-hospital mortality 13.90% 5.00% < 0.0001

To cite this abstract:

Cumbler E, Wald H, Bhatt D, Cox M, Xian Y, Reeves M, Smith E, Schwamm L, Fonarow G. National Quality of Care and Outcomes for In‐Hospital Ischemic Stroke: Severe Strokes, Frequent Comorbidities, and Room for Improvement. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 518. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/national-quality-of-care-and-outcomes-for-inhospital-ischemic-stroke-severe-strokes-frequent-comorbidities-and-room-for-improvement/. Accessed July 16, 2019.

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