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Dawn M. Bravata, MD; Carolyn K. Wells, MPH; Albert C. Lo, MD, PhD; Steven E. Nadeau, MD; Jean Melillo, RN; Diane Chodkowski, RN; Frederick Struve, PhD; Linda S. Williams, MD; Aldo J. Peixoto, MD; Mark Gorman, MD; Punit Goel, MD; Gregory Acompora, MD; Vincent McClain, MD; Noshene Ranjbar, MD; Paul B. Tabereaux, MD; John L. Boice, MD; Michael Jacewicz, MD; John Concato, MD

Arch Intern Med. 2010;170(9):804-810.

Background  Many processes of care have been proposed as metrics to evaluate stroke care. We sought to identify processes of stroke care that are associated with improved patient outcomes after adjustment for both patient characteristics and other process measures.

Methods  This retrospective cohort study included patients 18 years or older with an ischemic stroke or transient ischemic attack (TIA) onset no more than 2 days before admission and a neurologic deficit on admission. Patients were excluded if they resided in a skilled nursing facility, were already admitted to the hospital at stroke onset, or were transferred from another acute-care facility. The combined outcome included in-hospital mortality, discharge to hospice, or discharge to a skilled nursing facility. Seven processes of stroke care were evaluated: fever management, hypoxia management, blood pressure management, neurologic evaluation, swallowing evaluation, deep vein thrombosis (DVT) prophylaxis, and early mobilization. Risk adjustment included age, comorbidity (medical history), concomitant medical illness present at admission, preadmission symptom course, prestroke functional status, code status, stroke severity, nonneurologic status, modified APACHE (Acute Physiology and Chronic Health Evaluation) III score, and admission brain imaging findings.

Results  Among 1487 patients, the outcome was observed in 239 (16%). Three processes of care were independently associated with an improvement in the outcome after adjustment: swallowing evaluation (adjusted odds ratio [OR], 0.64; 95% confidence interval [CI], 0.43-0.94); DVT prophylaxis (adjusted OR, 0.60; 95% CI, 0.37-0.96); and treating all episodes of hypoxia with supplemental oxygen (adjusted OR, 0.26; 95% CI, 0.09-0.73).

Conclusion  Outcomes among patients with ischemic stroke or TIA can be improved by attention to swallowing function, DVT prophylaxis, and treatment of hypoxia.

Author Affiliations: Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center of Excellence on Implementing Evidence-Based Practice and the HSR&D Stroke Quality Enhancement Research Initiative, Richard L. Roudebush VA Medical Center (Drs Bravata and Williams), and Departments of Internal Medicine (Dr Bravata) and Neurology (Dr Williams), Indiana University School of Medicine and Regenstrief Institute, Indianapolis; Clinical Epidemiology Research Center (Mss Wells, Melillo, and Chodkowski and Drs Struve, Goel, Acompora, McClain, Ranjbar, and Concato) and Medicine Service (Drs Peixoto and Concato), VA Connecticut Healthcare System, West Haven; Departments of Neurology (Dr Lo) and Internal Medicine (Drs Peixoto and Concato), Yale University School of Medicine, New Haven, Connecticut; Department of Neurology, Warren Alpert School of Medicine, and Departments of Neurosciences, Community Health, and Engineering at Brown University (Dr Lo), and Providence VA Medical Center (Dr Lo), Providence, Rhode Island; Neurology Service, Malcolm Randall VA Medical Center (Dr Nadeau), and Department of Neurology, University of Florida School of Medicine (Dr Nadeau), Gainesville; Department of Neurology, University of Vermont School of Medicine, Burlington (Dr Gorman); Department of Internal Medicine, University of Alabama, Birmingham (Dr Tabereaux); Medicine Service, Boise VA Medical Center, Boise, Idaho (Dr Boice); and Neurology Service, Memphis VA Medical Center, Memphis, Tennessee (Dr Jacewicz).

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