Original Research

Quality of Care for Veterans With In-Hospital Stroke

Fed Pract. 2019 August;36(8):365-369

References

1. Go AS, Mozaffarian D, Roger VL, et al; American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2014 update: a report from the American Heart Association. Circulation. 2014;129:e28-e292.

2. Schwamm LH, Ali SF, Reeves MJ, et al. Temporal trends in patient characteristics and treatment with intravenous thrombolysis among acute ischemic stroke patients at Get With the Guidelines—Stroke hospitals. Circ Cardiovasc Qual Outcomes. 2013;6(5):543-549.

3. Reeves MJ, Parker C, Fonarow GC, Smith EE, Schwamm LH. Development of stroke performance measures: definitions, methods, and current measures. Stroke. 2010;41(7):1573-1578.

4. The Joint Commission. Certificate of distinction for primary stroke centers. https://www.jointcommission.org/certificate_of_distinction_for_primary_stroke_centers_/.Published April 30, 2012. Accessed July 9, 2019.

5. US Department of Veterans Affairs. Center highlight: acute ischemic stroke care for veterans. https://www.queri.research.va.gov/center_highlights/stroke.cfm. Updated February 20, 2014. Accessed July 16, 2019.

6. Chumbler NR, Jia H, Phipps MS, et al. Does inpatient quality of care differ by age among US veterans with ischemic stroke? J Stroke Cerebrovasc Dis. 2012;21(8):844-851.

7. Katzan IL, Spertus J, Bettger JP, et al; American Heart Association Stroke Council; Council on Quality of Care and Outcomes Research; Council on Cardiovascular and Stroke Nursing; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Risk adjustment of ischemic stroke outcomes for comparing hospital performance: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014;45(3):918-944.

8. Cumbler E, Wald H, Bhatt DL, et al. Quality of care and outcomes for in-hospital ischemic stroke: findings from the National Get With the Guidelines—Stroke. Stroke. 2014;45(1):231-238.

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14. US Department of Veterans Affairs. Treatment of Acute Ischemic Stroke (AIS). VHA Directive 2011-038. https://www.hsrd.research.va.gov/news/feature/stroke.cfm. Updated January 20, 2014. Accessed July 17, 2019.

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Discussion

Our study found that veterans who develop an IHS received similar quality of care as did those presenting to the ED with stroke symptoms for many QIs, although there were some notable differences. We were pleased to find that overall rates of secondary stroke prevention initiation (antithrombotic and statin therapy), VTE prophylaxis, rehabilitation evaluations, and smoking cessation counseling were high for both groups, in keeping with evidence-based guidelines.¹⁷ This likely reflected the fact that these metrics typically involve care outside of the acute period and are less likely to be influenced by the location of initial stroke evaluation. Furthermore, efforts to improve smoking cessation and VTE prophylaxis are not exclusive to stroke care and have been the target of several nonstroke quality projects in the VHA. Many aspects of acute stroke care did differ, and present opportunities for quality improvement in the future.

In our sample, patients with IHS had higher IV thrombolytic eligibility, which has not typically been reported in other samples.^10,11,18 In these studies, hospitalized patients have been reported to more often have contraindications to tPA, such as recent surgery or lack of stroke symptom recognition due to delirium or medication effects. Interestingly, patients presenting to VHA EDs had extremely low rates of tPA eligibility (2%), which is lower than many reported estimates of tPA eligibility outside of the VHA.^19,20 This may be due to multiple influences, such as geographic barriers, patient perceptions about stroke symptoms, access to emergency medical services (EMS), EMS routing patterns, and social/cultural factors. Although not statistically significant due to small sample size, tPA use also was twice as high in the IHS group.

Given that a significant proportion of patients with IHS in the VHA system may be eligible for acute thrombolysis, our findings highlight the need for acute stroke protocols to ensure that patients with IHS receive the same rapid stroke assessment and access to thrombolytics as do patients evaluated in the ED. Further investigation is needed to determine whether there are unique features of patients with IHS in VHA hospitals, which may make them more eligible for IV thrombolysis.

Dysphagia is associated with increased risks for aspiration pneumonia in stroke patients.²¹ We found that patients with IHS were less likely to receive dysphagia screening compared with that of stroke patients admitted through the ED. This finding is consistent with the fact that care for patients with IHS is less frequently guided by specific stroke care protocols and algorithms that are more often used in EDs.^8,11 Although attention to swallowing function may lead to improved outcomes in stroke, this can be easily overlooked in patients with IHS.²² However, low dysphagia screening also was found in patients admitted through the ED, suggesting that low screening rates cannot be solely explained by differences in where the initial stroke evaluation is occurring. These findings suggest a need for novel approaches to dysphagia screening in VHA stroke patients that can be universally implemented throughout the hospital.

Finally, we also found very low rates of stroke education prior to discharge for both groups. Given the risk of stroke recurrence and the overall poor level of public knowledge about stroke, providing patients with stroke with formal oral and written information on stroke is a critical component of secondary prevention.^23,24 Educational tools, including those that are veteran specific, are now available for use in VHA hospitals and should be incorporated into quality improvement strategies for stroke care in VHA hospitals.

In 2012, the VHA Acute Stroke Treatment Directive was published in an effort to improve stroke care systemwide. Several of the metrics examined in this study are addressed in this directive. The data presented in this study is one of the only samples of stroke quality metrics within the VHA that largely predates the directive and can serve as a baseline comparator for future work examining stroke care after release of the directive. At present, although continuous internal reviews of quality data are ongoing, longitudinal description of stroke care quality since publication of the directive will help to inform future efforts to improve stroke care for veterans.