Table 1.
Representative Gaps in Quality Care Between In-hospital Strokes and Community-Onset Strokes.
| Quality Measure | In-Hospital Stroke | Community- Onset Stroke | P Value | Population | Comparison to Other Studiesa |
|---|---|---|---|---|---|
| Speed of treatment | |||||
| Time to brain imaging28 | 98 minutes | 29 minutes | <.0001 | Single center | Colorado State registry found nonsignificant trend toward longer time to brain imaging for in-hospital stroke (54 vs 43 minutes; P = .13).2 Michigan State registry found no difference in brain imaging within 25 minutes but for both groups the percentage evaluated within this time frame was low with high rates of missing data (3.1% vs 3.5%; P = .27).5 |
| IV tPA given for within the time goals3 | 31.6% | 73.4% | <.0001 | US National Stroke Registry | Michigan State registry and Colorado State registry studies did not attempt to compare treatment rates within time goals.2,5 |
| Evaluation for risk factors and etiology | |||||
| Cerebral vasculature investigated5 | 55.2% | 75.6% | <.01 | State of Michigan Stroke Registry | Results supported by a different single-center study, which found 13% incomplete evaluation of etiology for in-hospital strokes compared to 3% Community-onset strokes (P value not reported).10 |
| Lipids investigated3 | 71.5% | 86.3% | <.0001 | US National Stroke Registry | The Michigan State registry also demonstrated a significantly lower rate of lipid investigation for in-hospital strokes (23.6% vs 38.0%; P = .01).5 Overall performance on this metric was lower in the Michigan registry compared to the national registry, which may reflect a temporal trend toward improving quality adherence. However, the Colorado State registry found the same rate of use of lipid-lowering therapy between in-hospital and community-onset strokes (89.6% adherence in both groups; P = .87).2 |
| Complication prevention | |||||
| DVT prophylaxis3 | 88.8% | 92.2% | <.0001 | US National Stroke Registry | The Michigan State registry demonstrated a similar magnitude, nonsignificant, trend toward lower DVT prophylaxis for in-hospital strokes (55.2% vs 64.2%; P = .28).5 |
| Secondary prevention | |||||
| Early antithrombotics3 | 89.4% | 96.4% | <.0001 | US National Stroke Registry | The Colorado State registry did not demonstrate a difference in antithrombotic therapy by day 2 between in-hospital and community-onset strokes (100% vs 96.2%; P = 1.00).2 |
| Antithrombotics on discharge3 | 96.1% | 97.7% | <.0001 | US National Stroke Registry | While statistically significant due to a large sample size, the absolute difference is small and both the Colorado (97.7% vs 96.2%; P = .77) and Michigan State registries (88.0% vs 94.6%; P = .26) did not find a significant difference for antithrombotics on discharge.2,5 |
| Anticoagulants on discharge for afib/flutter3 | 90.6% | 93.8% | <.0001 | US National Stroke Registry | Michigan State registry found a similar magnitude of absolute difference for this metric but it was not significant (84.0% vs 86.6%; P = .82).5 The Colorado State registry found a higher rate of adherence also not meeting criteria for significance (100% vs 93.4%; P = 1.00).2 |
| Overall quality of care | |||||
| Defect-free care3 | 60.8% | 82.0% | <.0001 | US National Stroke Registry | This contrasts to the findings of the Colorado State registry which found higher rates of defect-free care for in-hospital strokes (52.8% vs 32.2%; P < .0001) driven by higher in-hospital stroke adherence rates of stroke education and assessment for rehabilitation.2 Metrics and methodology used to calculate defect-free care between the Colorado State registry and GWTG national registry differed. IV tPA metrics were not included in the calculation of defect-free care in the Colorado State registry. |
Abbreviations: afib, atrial fibrillation; DVT, deep vein thrombosis; GWTG, Get With The Guidelines; IV, intravenous; tPA, tissue plasminogen activator.
aDirect comparisons of performance on quality metrics between studies is problematic due to differences in power based on sample size, variation in definitions for quality metrics, and temporal trends toward improved adherence on individual quality metrics over time. Michigan Stroke Registry study included strokes from May 2002 to November 2002. The single-center trial included strokes from October 2005 to September 2007. Colorado Stroke Registry study included strokes from August 2005 and April 2009. National Stroke Registry study included strokes from January 2006 to April 2012.