Hospital-based initiative significantly improves stroke patient care and outcomes, study finds
Care and clinical outcomes for acute stroke patients have improved significantly at hospitals participating in an American Heart Association/American Stroke Association quality-improvement program, according to a new academic study that examined the first million patients enrolled.
To better characterize contemporary stroke patients and determine the impact of participation in the Get With the Guidelines–Stroke program, researchers analyzed several aspects of care for these 1 million patients, who were treated at 1,392 hospitals participating in the initiative between 2003 and 2009.
The study is currently available online in Circulation: Cardiovascular Quality and Outcomes, a journal of the American Heart Association.
Each year, more than 795,000 Americans suffer a stroke, and another 200,000 to 500,000 experience a transient ischemic attack, or TIA, which is characterized by stroke-like symptoms and is often considered a warning sign that a true stroke may happen in the future.
"We found that the opportunities to provide guideline-recommended care addressed by the performance measures were substantially met for stroke and TIA patients, with overall composite care improving substantially, from 72 percent in 2003 to 93 percent in 2009," said lead study author Dr. Gregg C. Fonarow, UCLA's Eliot Corday Professor of Cardiovascular Medicine and Science and director of the Ahmanson–UCLA Cardiomyopathy Center. "Stroke and TIA patients receiving all of the care measures for which they were eligible increased from 44 percent in 2003 to 84 percent in 2009."
The hospital-based initiative provides seven performance measures, which include the timely use of intravenous recombinant tissue plasminogen activator (IV tPA), a powerful clot-busting drug shown to reduce ischemic stroke-related disability, anticoagulation therapy, cholesterol-reducing drugs and educational programs such as smoking cessation.
The average age of the 1 million patients studied in the GWTG–Stroke database was 70.1. Of all the strokes analyzed, ischemic strokes, which are caused by a blood clot blocking a blood vessel in the brain, were the most common (60.2 percent), followed by TIAs (22.8 percent), intracerebral hemorrhages (10.9 percent), subarachnoid hemorrhages (3.5 percent) and unclassified strokes (2.7 percent).
In-hospital mortality was highest among patients suffering hemorrhagic strokes, which are caused by blood leaking into the brain tissue.
Hospital participation in the GWTG–Stroke program had the biggest impact on death rates from the most common stroke types, ischemic stroke and TIA. Risk-adjusted odds of in-hospital mortality after ischemic stroke were reduced by 10 percent.
"The study has shown what is of primary importance to those who rely on the nation's hospitals for optimal stroke care. The implementation of Get With the Guidelines–Stroke has resulted in substantial improvement in care at a rapid pace, in a variety of hospital types and in multiple hospitals simultaneously," said study co-author Dr. Lee H. Schwamm, chair of the Get With the Guidelines national steering committee and director of the TeleStroke and Acute Stroke Services at Massachusetts General Hospital.
The initiative also is making a landmark contribution to stroke patients of today and tomorrow, said Dr. Clyde W. Yancy, president of the American Heart Association and medical director at the Baylor Heart and Vascular Institute.
"Not only has quality improved, but lives are being saved and subsequent strokes are being thwarted," Yancy said. "These findings demonstrate the true potential of implementing best practices within a care-delivery system, and the approach taken by the Get With the Guidelines team is a template for the future."
To further facilitate better treatment and outcomes for stroke patients, the American Heart Association/American Stroke Association has launched "Target: Stroke," a program that will arm health care providers with information and tools to improve the use of the clot-busting drug IV rt-PA, the only drug approved by the U.S. Food and Drug Administration for the urgent treatment of ischemic stroke.
"An earlier analysis of Get With the Guidelines–Stroke data found that despite clinical trial evidence of improved outcomes for stroke patients treated early with an intravenous clot buster, only 27.4 percent of patients treated with IV rt-PA had door-to-needle times within 60 minutes," Yancy said. "The goal for 'Target: Stroke' is to achieve a door-to-needle time within 60 minutes or less in at least 50 percent of ischemic stroke patients treated with a clot-busting drug.
"The new initiative builds on this robust database we have from the Get With the Guidelines program to help us identify best practices that enable hospitals to further improve quality of care and outcomes in acute stroke care."
The GWTG–Stroke program is supported in part by an unrestricted educational grant from Merck/Schering-Plough Pharmaceutical.
Additional co-authors include Mathew J. Reeves, Ph.D.; Eric E. Smith, M.D., M.P.H.; Jeffrey L. Saver, M.D.; Xin Zhao, M.S.; DaiWai Olson, Ph.D.; Adrian F Hernandez, M.D. M.H.S.; and Eric D. Peterson, M.D., M.P.H. Author disclosures are available in the manuscript.