Michael Lyerly is an Associate Professor of Neurology and a Vascular Neurologist; Gary Cutter is a Professor of Biostatistics; and Peter King is a Professor of Neurology and Chief of Neurology; all at the University of Alabama at Birmingham. Terri Woodbury is a Vascular Neurology Nurse Practitioner; Jessica Coffing is a Research Analyst; Teresa Damush is a Senior Researcher; and Linda Williams is a Senior Researcher and Neurologist; all at the Richard L. Roudebush VA Medical Center in Indianapolis, Indiana. Teresa Damush is a Research Professor of Medicine; and Linda Williams is a Professor of Neurology; both at Indiana University School of Medicine and the Regenstrief Institute in Indianapolis. Correspondence: Michael Lyerly (mlyerly@uabmc.edu)
Author disclosures The authors report no actual or potential conflicts of interest with regard to this article.
Disclaimer The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Despite the strength of being a multicenter sampling of stroke care in high volume VHA hospitals, our study had several limitations. The IHS sample size was small, which limited our ability to evaluate differences between the groups, to evaluate generalizability, and account for estimation error.13 It is possible that differences existed between the groups that could not be observed in this sample due to small size (type II error) or that patient-specific characteristics not captured by these data could influence these metrics. Assessments of eligibility and passing were based on retrospective chart review and post hoc coding. Our sample assessed only patients who presented to larger VHA hospitals with higher stroke volumes, thus these findings may not be generalizable to smaller VHA hospitals with less systematized stroke care. This sample did not describe the specialty care services that were received by each patient, which may have influenced their stroke care. Finally, this study is an analysis of use of QIs in stroke care and did not examine how these indicators affect outcomes.
Conclusion
Despite reassuring findings for several inpatient ischemic stroke quality metrics, we found several differences in stroke care between patients with IHS compared with those presenting to the ED, emphasizing the need for standardized approaches to stroke care regardless of care setting. Although patients with IHS may be more likely to be eligible for tPA, these patients received dysphagia screening and less often than did ED patients with stroke. Ongoing quality initiatives should continue to place emphasis on improving all quality metrics (particularly dysphagia screening, stroke severity documentation, and stroke education) for patients with stroke at VHA hospitals across all care settings. Future work will be needed to examine how specific patient characteristics and revisions to stroke protocols may affect stroke quality metrics and outcomes between patients with IHS and those presenting to the ED.
Acknowledgments
The authors would like to thank Danielle Sager for her contributions to this project.
