Gaps in care and outcomes between older and younger ischemic stroke patients are diminishing as hospitals improve adherence to treatments outlined in the American Heart Association/American Stroke Association's Get With the Guidelines–Stroke initiative, according to a new UCLA study.
The study was published online Feb. 8 in Circulation, the Journal of the American Heart Association, in advance of the journal's Feb. 23 print edition.
"The burden of ischemic stroke is disproportionately borne by older patients, who have a greater incidence and prevalence of this common stroke type than younger individuals," said lead study author Dr. Gregg Fonarow, UCLA's Eliot Corday Professor of Cardiovascular Medicine and Science and director of the Ahmanson–UCLA Cardiomyopathy Center. "Prior studies have suggested lower use of guideline-recommended therapy and worse post-stroke outcomes in older patients. We sought to examine age-related differences among stroke patients cared for in hospitals participating in a national performance-improvement program."
Fonarow and his colleagues analyzed more than 500,000 ischemic stroke admissions at 1,256 hospitals participating in the Get With the Guidelines–Stroke initiative, from 2003 to 2009. They examined age-related differences in patient characteristics, adherence to key quality-of-care performance measures, trends, and early clinical outcomes for acute ischemic stroke in patient groups that ranged in age from 50 years old or younger to 90 years old or older.
They found that older stroke patients were more likely than younger patients to have a history of atrial fibrillation or hypertension and were less likely to be African American, Hispanic or recent smokers.
The researchers looked at hospital adherence to seven pre-defined performance measures, including the timely use of intravenous recombinant tissue plasminogen activator (IV tPA), a powerful clot-busting drug shown to reduce ischemic stroke-related disability. These measures were primary targets for stroke quality-improvement efforts in the Get With the Guidelines–Stroke program.
They found that performance on all individual measures was lower in two groups of older patients — those aged 80 to 89 years, and those 90 years and older — compared with younger patients. The researchers also reported that with each 10-year age increase, ischemic stroke patients were, on average, 31 percent less likely to be discharged home and were 27 percent more likely to die in the hospital.
However, the use of guideline-recommended therapies improved substantially in older patients between 2003 to 2009. In patients 90 and older, the use of IV tPA increased more than threefold, from 20.4 percent in 2003 to 62.4 percent in 2009, and the use of lipid-lowering therapy rose dramatically, from 15.6 percent in 2003 to 71.7 percent in 2009. Significant improvements were also noted in the other performance measures.
"While we identified modest age-related differences in individual performance measures, the very good news is that we also noted substantial improvements in performance measures for ischemic stroke from 2003 to 2009 at Get With the Guidelines–Stroke participating hospitals," said Fonarow, immediate past chair of the Get With the Guidelines steering committee. "These include pharmacologic and non-pharmacologic management of stroke in each age group.
"By the end of the study, many of the age-related treatment differences were substantially reduced or eliminated. These findings suggest that Get With the Guidelines–Stroke may have contributed to these very impressive improvements in care," he said.
Fonarow said one limitation of the study is the fact that researchers analyzed the care only at Get With the Guidelines–Stroke hospitals, and the findings may not necessarily apply to other U.S. hospitals.
"The Get With the Guidelines–Stroke program is voluntary, and the hospitals that participate are more likely to be larger teaching hospitals with a strong interest in stroke care and quality improvement," he said. "But expansion of such national hospital-based quality initiatives for performance improvement in ischemic stroke should be considered to help ensure that eligible patients receive optimal care, regardless of their age."
Get With the Guidelines–Stroke is an American Heart Association program supported in part by unrestricted educational grants from Pfizer Inc. and the Merck-Schering Plough Partnership.
Co-authors of the research included Mathew J. Reeves, Ph.D.; Xin Zhao, M.S.; DaiWai M. Olson, Ph.D., R.N.; Eric E. Smith, M.D., M.P.H.; Jeffrey L. Saver, M.D.; and Lee H. Schwamm, M.D.