Abstract
Background
In an effort to improve stroke quality of care and patient outcomes, quality of care metrics are monitored to assess utilization of evidence-based stroke care processes as part of the Paul Coverdell National Acute Stroke Program (PCNASP). We aimed to assess temporal trends in defect-free care (DFC) received by stroke patients in the PCNASP between 2008 and 2018.
Methods
Quality of care data for 10 performance measures were available for 849,793 patients aged ≥18 years who were admitted to a participating hospital with a clinical diagnosis of stroke between 2008 and 2018. A patient who receives care according to all performance measures for which they are eligible, receives “defect-free care” (DFC) (eg, appropriate medications, assessments, and education). Generalized estimating equations were used to examine the factors associated with receipt of DFC.
Results
DFC among ischemic stroke patients increased from 38.0% in 2008 to 80.8% in 2018 (P < .0001), with the largest improvement seen in receipt of stroke education (relative percent change, RPC = 64%). Similarly, DFC for hemorrhagic stroke and transient ischemic attack patients increased from 46.7% to 82.6% (RPC = 76.9%) and 39.9% to 85.0% (RPC = 113.0%) (P < .001), respectively. Among ischemic stroke patients, the adjusted odds for receiving DFC were lower for women, patients aged 18 to 54 years, Medicaid or Medicare participants, and patients with atrial fibrillation (P < .05).
Conclusions
From 2008 to 2018, receipt of DFC by ischemic stroke patients significantly increased in the PCNASP; however certain subgroups were less likely to receive this level of care. Targeted quality improvement initiatives could result in even further improvements among all stroke patients and help reduce disparities in care
As stroke continues to be a prominent cause of serious long-term disability and mortality in the United States, in 2001, the Centers for Disease Control and Prevention (CDC) implemented state-based registries to measure stroke care in an effort to improve the quality of care received.1 The Paul Coverdell National Acute Stroke Program (PCNASP) has funded state health departments since 2004 to improve the quality of stroke care within hospitals, and more recently, within a stroke system of care (ie, networks of care from the onset of stroke symptoms through post-hospital discharge). To quantify, monitor, and assess the quality of acute stroke care received, the CDC in collaboration with the American Heart Association (AHA) and the Joint Commission,2 developed 10 evidence-based performance measures.3–6 A patient who received care according to all performance measures for which they are eligible, received “defect-free care” (DFC) which was associated with significantly better patient outcomes than when only some of the evidence-based interventions (ie, measures) are implemented.5,7
To our knowledge only 2 studies have examined DFC using PCNASP data.5,8 George et al described trends in receipt of DFC using data from 7 Coverdell participating states from 2005 to 2009.5 They found adherence to 9 of the 10 performance measures for ischemic stroke (IS) patients and DFC for patients with an IS, hemorrhagic stroke (HS) (intracerebral hemorrhage or subarachnoid hemorrhage), or transient ischemic attack (TIA) significantly improved over the 4-year time period.5 The objective of the current study was to assess changes in the proportion of patients who received DFC by stroke type between 2008 and 2018. Further, we aimed to determine if specific patient or hospital characteristics were associated with a greater likelihood of receipt of DFC among patients with an IS, HS, or TIA.
Methods
The design and data collection methods of the PCNASP have been published previously.9 PCNASP includes patients ≥18 years with a final clinical diagnosis of IS, HS, TIA, or stroke type unspecified. Hospital characteristics and resources are state collected and reported annually. There are 10 performance measures for ischemic stroke, 6 measures for TIA, and 5 measures for HS. Performance measures were bundled creating three categories of DFC for each stroke subtype (Table 1).5 Patients were classified as having received DFC if they received care according to all measures for which they were eligible.
Table 1.
Performance measures for stroke and those used in the definition of DFC measures for each stroke subtype
| Stroke performance measure | Measure No. | Definition | Defect free care measure |
||
|---|---|---|---|---|---|
| Ischemic sroke | Hemorrhagic stroke | Transient ischemic attack | |||
| IV Alteplase given when indicated | STK-4 | Patients who arrive at the hospital within 2 hours of time last known well and for whom IV alteplase was initiated at the hospital within 3 hours’ time last known well. | X | ||
| Venous thromboembolism prophylaxis (VTE) | STK-1 | Patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given on day after hospital admission. | X | X | |
| Antithrombotic therapy within 48hrs | STK-5 | Patients administered antithrombotic therapy by the end of hospital day 2. | X | X | |
| Dysphagia screening | STK-7 | Patients were screened in the hospital for dysphagia (ability to swallow) before being given anything by mouth including food, liquid, or medication. | X | X | |
| Discharged on statin medication | STK-6 | Patients who are prescribed statin medication at hospital discharge. | X | X | |
| Discharged on antithrombotic therapy | STK-2 | Patients prescribed antithrombotic therapy at hospital discharge. | X | X | |
| Anticoagulation for atrial fibrillation | STK-3 | Patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge. | X | X | |
| Stroke education | STK-8 | Patients or their caregivers who were given educational materials during the hospital stay addressing the following: activation of the emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors of stroke, and warning signs/symptoms of stroke. | X | X | X |
| Smoking cessation/ advice/ counseling | STK-9 | Patients are counseled or provided advice to quit smoking. | X | X | X |
| Assessed for rehabilitation | STK-10 | Patients who were assessed for or who received rehabilitation services. | X | X | |
IV, intravenous; STK, stroke.
Secular trends in patient and hospital characteristics were assessed using Cochrane-Armitage tests. To account for possible correlations of patients within hospitals, generalized estimating equations (GEE) were used to assess the association between receipt of DFC and risk factors for each stroke subtype. GEE models were adjusted for age, sex, race/ethnicity, insurance status, medical history of hypertension, dyslipidemia, atrial fibrillation (AF), or prior stroke, NIHSS (National Institute of Health Stroke Scale) (for IS patients only), hospital bed size, hospital stroke unit availability, and teaching hospital status. Exploratory analyses, using GEE models adjusted for the same factors, were performed to assess the association between screening for dysphagia and provision of stroke education (ie, 2 measures with the greatest improvement) among IS patients and risk factors. We assessed the relative percent change (RPC) of characteristics and performance measures between 2018 and 2008. Two-sided P-values < .05 were considered significant and analyses were performed using the SAS, Release 9.4 (SAS Institute, Cary, NC). This study was approved by the CDC Institutional Review Board. No extramural funding was used to support this work. The authors are solely responsible for the design and conduct of this study, all study analyses, the drafting and editing of the paper and its final contents.
Results
From 2008 to 2018, 849,793 adults were admitted to PCNASP hospitals with a clinical diagnosis of stroke. Overall, 592,509 (69.7%) patients had an IS, 130,830 (15.4%) had a TIA, and 126,454 (14.9%) had a HS (Table S1). Among all patients, 64.6% were ≥65 years, 51.6% women, 71.8% non-Hispanic whites, 59.6% Medicare beneficiaries, and 73.8% had a history of hypertension prior to stroke. The proportion who were 65 to 74 years, men, a racial/ethnic group other than non-Hispanic white or black, Medicaid beneficiaries, or who were self-insured or had no health insurance increased significantly from 2008 to 2018. Additionally, the proportion of patients with a medical history of dyslipidemia, AF, or recurrent stroke increased.
Among IS patients, DFC significantly improved from 38.0% in 2008 to 80.8% in 2018 (RPC = 112.6%) (Table 2) and adherence to the 10 individual performance measures significantly increased (range RPC from 1.2% to 58.5%, P for trend < .0001 for all measures). Measures with the greatest improvements were provision of stroke education (58.5% in 2008 to 96.0% in 2018, RPC = 64.1%), given intravenous (IV) alteplase when indicated (57.1% in 2008 to 90.5% in 2018, RPC = 58.5%), and discharged on a statin (76.2% in 2008 to 98.2% in 2018, RPC = 28.9%). The percentage of IS patients screened for dysphagia increased by a RPC of 28.4%, despite having the lowest adherence of all the measures (66.6% in 2008 to 85.5% in 2018). Measures with > 90% adherence in 2008 continued to improve, reaching 97% to 99% adherence.
Table 2.
Temporal trends in performance measures and DFC among patients who had an acute ischemic stroke, Paul Coverdell National Acute Stroke Program (PCNASP) 2008–2018 ( N = 592,509)
| Characteristic | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | RPC (%) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| IV Alteplase given when indicated* | 842 (57.1) | 1,166 (56.7) | 1,616 (72.3) | 1,761 (72.2) | 2,049 (77.7) | 3,503 (84.0) | 4,118 (87.1) | 4,151 (88.3) | 4,663 (92.5) | 5,596 (93.5) | 5,846 (90.5)* | 58.5 |
| Dysphagia screening | 13,069 (66.6) | 18,563 (74.2) | 24,623 (77.8) | 28,941 (79.8) | 30,658 (83.2) | 44,862 (85.1) | 52,191 (85.9) | 51,157 (86.0) | 52,829 (86.0) | 61,600 (85.6) | 62,700 (85.5)* | 28.4 |
| Antithrombotic therapy within 48 h | 16,490 (96.3) | 20,569 (96.1) | 26,137 (94.7) | 29,608 (95.3) | 29,098 (94.6) | 40,816 (96.1) | 46,465 (96.3) | 44,752 (97.1) | 46,026 (97.7) | 50,653 (97.5) | 49,888 (97.5)* | 1.2 |
| Venous thromboembolism prophylaxis | 9,558 (91.8) | 11,942 (93.1) | 22,086 (82.4) | 26,768 (87.8) | 28,042 (90.3) | 45,464 (98.3) | 53,014 (98.6) | 52,489 (98.9) | 54,365 (99.0) | 60,824 (99.1) | 60,990 (98.9)* | 7.7 |
| Discharged on statin medication | 11,220 (76.2) | 9,798 (89.3) | 1,896 (93.2) | 6,443 (93.4) | 7,983 (95.8) | 36,482 (95.4) | 43,209 (96.4) | 42,492 (97.2) | 55,742 (97.3) | 63,928 (97.8) | 64,616 (98.2)* | 28.9 |
| Anticoagulation for atrial fibrillation | 2,862 (89.4) | 3,234 (88.0) | 1,317 (86.4) | 4,075 (89.6) | 5,140 (94.3) | 7,563 (94.5) | 8,966 (96.0) | 8,829 (96.6) | 9,738 (97.4) | 11,175 (97.2) | 11,385 (97.3)* | 8.8 |
| Discharged on antithrombotic therapy | 18,372 (97.1) | 23,648 (97.9) | 8,954 (98.8) | 28,282 (98.4) | 34,221 (98.6) | 49,676 (98.0) | 57,335 (98.4) | 56,093 (98.8) | 59,495 (99.3) | 67,522 (99.4) | 68,400 (99.4)* | 2.4 |
| Assessed for rehabilitation | 18,297 (95.1) | 23,825 (96.9) | 9,307 (97.3) | 28,983 (96.6) | 35,106 (97.0) | 50,499 (98.0) | 58,349 (98.3) | 57,178 (98.8) | 60,516 (99.1) | 68,681 (99.2) | 69,567 (99.2)* | 4.3 |
| Smoking cessation/ advice/ counseling | 3,599 (93.2) | 4,948 (96.7) | 2,098 (97.0) | 6,370 (97.6) | 7,246 (97.3) | 6,755 (98.2) | 7,584 (96.6) | 7,159 (96.6) | 7,345 (96.8) | 8,376 (98.7) | 8,541 (98.6)* | 5.8 |
| Stroke education | 11,251 (58.5) | 18,004 (73.3) | 4,573 (84.0) | 15,159 (87.5) | 19,594 (88.0) | 27,274 (92.7) | 31,609 (94.8) | 30,847 (96.1) | 32,176 (96.2) | 36,796 (96.0) | 38,156 (96.0)* | 64.1 |
| Defect Free Care | 8,006 (38.0) | 14,278 (53.1) | 22,424 (64.7) | 26,450 (66.8) | 27,655 (69.0) | 44,337 (76.9) | 52,625 (79.3) | 52,198 (80.5) | 55,186 (81.0) | 62,829 (81.0) | 63,728 (80.8)* | 112.6 |
IV, intravenous; RPC, relative percent change calculated as (2018–2008)/2008 × 100.
The P value obtained from type 3 analysis in unadjusted Generalized Estimating Equation models, all P < .0001.
Among patients with a TIA, DFC significantly improved from 39.9% in 2008 to 85.0% in 2018 (RPC = 113.0%) (Table 3). Measures with the greatest improvements were provision of stroke education, from 50.7% in 2008 to 91.8% in 2018 (RPC = 81.1%), and discharged on statin medication, from 72.2% in 2008 to 93.4% in 2018 (RPC = 29.4%). Similar improvements in DFC were observed among HS patients, from 46.7% in 2008 to 82.6% in 2018 (RPC = 76.9%) (Table 4). Adherence to the 5 performance measures significantly increased from 2008 to 2018. The proportion of HS patients assessed for rehabilitation increased the least with an RPC of 4.5% between 2008 and 2018; whereas, the proportion of patients who received stroke education increased the most with a RPC of 74.9% from 52.9% to 92.5%) between 2008 and 2018 (P < .001 for trend). For both TIA and HS patients, measures with > 86% in 2008 adherence continued to improve, reaching 93% to 98% adherence.
Table 3.
Temporal trends in performance measures and DFC among patients who had a transient ischemic attack (TIA), Paul Coverdell National Acute Stroke Program (PCNASP) 2008–2018 ( N = 130,830)
| Characteristic | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | RPC (%) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Antithrombotic therapy within 48h | 5,616 (96.2) | 6,162 (96.8) | 6,415 (95.5) | 7,144 (96.1) | 6,713 (96.4) | 8,113 (97.2) | 8,443 (95.9) | 7,182 (96.5) | 7,539 (97.2) | 7,734 (98.3) | 6,689 (97.9)* | 1.8 |
| Discharged on statin medication | 4,593 (72.2) | 3,274 (84.6) | 612 (87.9) | 2,230 (88.5) | 2,642 (92.7) | 8,903 (91.1) | 9,385 (89.8) | 8,117 (91.5) | 10,338 (90.5) | 10,951 (92.6) | 9,887 (93.4)* | 29.4 |
| Anticoagulation for atrial fibrillation | 903 (86.0) | 920 (83.8) | 241 (74.6) | 1,042 (81.9) | 1,331 (86.4) | 1,555 (88.5) | 1,798 (92.9) | 1,568 (92.7) | 1,790 (94.4) | 2,056 (94.1) | 1,845 (93.9)* | 9.2 |
| Discharged on antithrombotic therapy | 7,644 (96.0) | 8,765 (96.5) | 2,273 (97.3) | 8,695 (96.8) | 10,372 (97.1) | 12,705 (97.4) | 13,088 (95.5) | 11,083 (95.8) | 11,765 (96.4) | 12,357 (97.8) | 11,017 (97.6)* | 1.7 |
| Smoking cessation/ advice/ counseling | 1,063 (92.6) | 1,385 (95.4) | 372 (94.9) | 1,340 (97.3) | 1,525 (96.3) | 1,646 (96.9) | 1,670 (95.7) | 1,329 (95.4) | 1,399 (96.7) | 1,385 (97.9) | 1,265 (97.2)* | 5.0 |
| Stroke education | 4,084 (50.7) | 5,922 (64.3) | 1,756 (72.4) | 6,881 (80.2) | 8,452 (84.4) | 10,348 (88.1) | 10,900 (88.7) | 9,257 (90.4) | 9,932 (91.4) | 10,408 (91.9) | 9,338 (91.8)* | 81.1 |
| Defect free care | 3,253 (39.9) | 5,384 (57.9) | 6,921 (86.4) | 8,652 (77.7) | 9,084 (79.8) | 10,861 (80.9) | 11,562 (82.0) | 10,120 (84.5) | 10,534 (83.6) | 11,039 (84.7) | 9,914 (85.0)* | 113.0 |
RPC, relative percent change calculated as (2018–2008)/2008 × 100.
The P value obtained from type 3 analysis in unadjusted Generalized Estimating Equation models, all P < .0001.
Table 4.
Temporal trends in performance measures and DFC among patients who had a hemorrhagic stroke, Paul Coverdell National Acute Stroke Program (PCNASP) 2008–2018 (N = 1 26,454)
| Characteristic | 2008 | 2009 | 2010 | 2011 | 2012 | 2013 | 2014 | 2015 | 2016 | 2017 | 2018 | RPC (%) |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Dysphagia screening | 2,168 (69.5) | 2,992 (73.2) | 3,894 (77.3) | 4,224 (77.5) | 4,462 (79.2) | 6,721 (80.4) | 7,904 (82.7) | 7,638 (82.4) | 8,101 (82.0) | 9,628 (82.6) | 9,932 (82.4)* | 18.6 |
| Venous thromboembolism prophylaxis | 2,470 (92.8) | 3,240 (94.9) | 4,612 (84.3) | 5,363 (91.1) | 5,760 (92.6) | 9,256 (98.1) | 10,898 (98.6) | 10,576 (98.8) | 11,373 (98.8) | 12,825 (98.9) | 12,986 (98.9)* | 6.6 |
| Assessed for rehabilitation | 3,028 (94.1) | 3,929 (95.9) | 1,778 (95.7) | 4,449 (94.5) | 5,503 (94.6) | 8,344 (97.2) | 9,388 (97.7) | 9,108 (98.2) | 9,903 (98.0) | 11,315 (98.4) | 11,322 (98.3)* | 4.5 |
| Smoking cessation/ advice/ counseling | 583 (87.4) | 865 (93.8) | 399 (93.9) | 1,019 (95.5) | 1,205 (96.2) | 958 (98.4) | 897 (95.8) | 879 (97.4) | 924 (96.3) | 977 (97.5) | 929 (97.3)* | 11.3 |
| Stroke education | 1,705 (52.9) | 2,726 (66.6) | 663 (74.7) | 1,788 (79.0) | 2,473 (80.8) | 3,540 (88.7) | 3,936 (91.3) | 3,715 (92.3) | 4,009 (91.7) | 4,520 (91.7) | 4,672 (92.5)* | 74.9 |
| Defect Free Care | 1,776 (46.7) | 2,726 (56.9) | 4,417 (69.5) | 4,875 (71.0) | 5,140 (72.0) | 8,438 (80.0) | 10,059 (82.5) | 9,779 (83.0) | 10,575 (82.7) | 12,068 (82.9) | 12,236 (82.6)* | 76.9 |
RPC, relative percent change calculated as (2018–2008)/2008 × 100.
The P value obtained from type 3 analysis in unadjusted Generalized Estimating Equation models, all P < .0001.
In GEE analyses, IS patients who were women, Medicaid or Medicare recipients, or with a history of AF had lower odds of receiving DFC (Table 5). HS patients with a history of dyslipidemia or recurrent stroke, or who were admitted to a hospital with >400 beds had lower odds of receiving DFC. TIA patients who were other race, women, or with a history of AF had significantly lower odds of receiving DFC.
Table 5.
Association between select characteristics and receipt of DFC for patients who had an ischemic stroke, hemorrhagic stroke, or transient ischemic attack, Paul Coverdell National Acute Stroke Program (PCNASP) 2008–2018
| Characteristics | Ischemic stroke |
Hemorrhagic stroke |
Transient ischemic attacks |
|||
|---|---|---|---|---|---|---|
| OR (95% CI) | AOR (95% CI)* | OR (95% CI) | AOR (95% CI)* | OR (95% CI) | AOR (95% CI)* | |
| Age (y) | ||||||
| 18–54 | Reference | Reference | Reference | Reference | Reference | Reference |
| 55–64 | 1.1 (1.08–1.12) | 1.09 (1.06–1.12) | 1.17 (1.12–1.22) | 1.14 (1.07–1.21) | 1.15 (1.10–1.21) | 1.07 (1.02–1.13) |
| 65–74 | 1.14 (1.12–1.16) | 1.19 (1.16–1.23) | 1.30 (1.24–1.35) | 1.32 (1.22–1.44) | 1.16 (1.10–1.21) | 1.01 (0.95–1.07) |
| 75–84 | 1.12 (1.1–1.14) | 1.24 (1.2–1.28) | 1.36 (1.25–1.48) | 1.43 (1.3–1.57) | 1.11 (1.06–1.16) | 1.01 (0.95–1.06) |
| ≥85 | 1.15 (1.13–1.17) | 1.23 (1.2–1.27) | 1.35 (1.28–1.42) | 1.5 (1.36–1.65) | 1.05 (1.00–1.10) | 0.95 (0.89–1.01) |
| Gender | ||||||
| Men | 1.06 (1.04–1.07) | 1.06 (1.04–1.08) | 1.07 (1.03–1.11) | 1.07 (1.03–1.11) | 1.10 (1.07–1.13) | 1.07 (1.04–1.11) |
| Women | Reference | Reference | Reference | Reference | Reference | Reference |
| Race-ethnicity | ||||||
| Non-Hispanic White | Reference | Reference | Reference | Reference | Reference | Reference |
| Non-Hispanic Black | 0.93 (0.92–0.95) | 0.97 (0.95–1.00) | 1.22 (1.14–1.31) | 1.36 (1.29–1.44) | 1.04 (1.00–1.08) | 0.99 (0.94–1.03) |
| Other | 1.14 (1.11–1.16) | 1.02 (0.99–1.05) | 1.27 (1.21–1.33) | 1.26 (1.20–1.33) | 1.04 (0.99–1.09) | 0.88 (0.84–0.93) |
| Insurance | ||||||
| Private | Reference | Reference | Reference | Reference | Reference | Reference |
| Medicaid-Medicare | 0.96 (0.95–0.98) | 0.93 (0.91–0.95) | 1.18 (1.13–1.23) | 1.02 (0.97–1.07) | 1.03 (0.99–1.06) | 1.04 (1.00–1.09) |
| No-insurance/Self-Pay | 0.92 (0.90–0.94) | 1.01 (0.98–1.04) | 1.16 (1.11–1.22) | 1.25 (1.18–1.33) | 0.95 (0.90–1.00) | 1.04 (0.98–1.11) |
| Hypertension | ||||||
| Yes | 1.03 (1.02–1.05) | 1.02 (1.00–1.04) | 1.27 (1.22–1.33) | 1.28 (1.18–1.39) | 1.29 (1.25–1.33) | 1.19 (1.15–1.23) |
| No | Reference | Reference | Reference | Reference | Reference | Reference |
| Dyslipidemia | ||||||
| Yes | 1.12 (1.11–1.14) | 1.06 (1.04–1.07) | 1.07 (1.01–1.13) | 0.94 (0.86–1.04) | 1.5 (1.46–1.54) | 1.41 (1.36–1.45) |
| No | Reference | Reference | Reference | Reference | Reference | Reference |
| Atrial fibrillation | ||||||
| Yes | 1.06 (1.05–1.08) | 0.90 (0.88–0.92) | 1.08 (1.03–1.13) | 0.93 (0.88–0.99) | 0.85 (0.82–0.88) | 0.75 (0.72–0.79) |
| No | Reference | Reference | Reference | Reference | Reference | Reference |
| Prior stroke | ||||||
| Yes | 1.18 (1.16–1.20) | 1.02 (1.00–1.04) | 1.27 (1.15–1.41) | 1.04 (0.92–1.18) | 1.47 (1.42–1.53) | 1.18 (1.13–1.23) |
| No | Reference | Reference | Reference | Reference | Reference | Reference |
| NIHSS score | ||||||
| 0–4 | Reference | Reference | ||||
| 5–9 | 1.31 (1.29–1.34) | 1.38 (1.35–1.41) | ||||
| 10–14 | 1.43 (1.39–1.47) | 1.57 (1.52–1.62) | ||||
| 15–20 | 1.54 (1.49–1.59) | 1.7 (1.65–1.76) | ||||
| 21–42 | 1.56 (1.51–1.61) | 1.66 (1.60–1.73) | ||||
| Hospital bed size | ||||||
| <200 | Reference | Reference | Reference | Reference | Reference | Reference |
| 200–399 | 1.47 (1.44–1.50) | 1.23 (1.19–1.26) | 1.03 (0.95–1.11) | 1.13 (1.04–1.23) | 1.58 (1.52–1.64) | 1.50 (1.44–1.56) |
| 400+ | 1.48 (1.46–1.51) | 1.13 (1.10–1.16) | 1.17 (1.08–1.25) | 1.20 (1.11–1.30) | 1.47 (1.42–1.53) | 1.40 (1.34–1.47) |
| Stroke unit | ||||||
| Yes | 1.22 (1.20–1.23) | 1.02 (1.00–1.04) | 1.33 (1.27–1.38) | 1.31 (1.25–1.37) | 1.07 (1.04–1.10) | 0.94 (0.91–0.97) |
| No | Reference | Reference | Reference | Reference | Reference | Reference |
| Teaching hospital | ||||||
| Yes | 1.24 (1.22–1.25) | 1.02 (1.00–1.04) | 1.11 (1.06–1.16) | 0.95 (0.90–1.00) | 1.17 (1.14–1.21) | 1.11 (1.07–1.15) |
| No | Reference | Reference | Reference | Reference | Reference | Reference |
| Year | ||||||
| 2008 | Reference | Reference | Reference | Reference | Reference | Reference |
| 2009 | 1.85 (1.79–1.92) | 1.52 (1.44–1.62) | 1.51 (1.38–1.64) | 1.60 (1.46–1.76) | 2.07 (1.95–2.20) | 2.09 (1.96–2.22) |
| 2010 | 2.99 (2.89–3.10) | 2.57 (2.43–2.72) | 2.56 (2.35–2.78) | 2.50 (2.28–2.73) | 9.35 (8.65–10.11) | 11.11 (10.22–12.09) |
| 2011 | 3.33 (3.21–3.45) | 3.05 (2.89–3.22) | 2.81 (2.58–3.05) | 2.92 (2.67–3.19) | 5.29 (4.96–5.63) | 5.50 (5.15–5.88) |
| 2012 | 3.68 (3.55–3.81) | 3.19 (3.03–3.37) | 2.94 (2.71–3.19) | 3.09 (2.83–3.38) | 5.95 (5.58–6.35) | 5.98 (5.59–6.39) |
| 2013 | 5.54 (5.35–5.73) | 4.81 (4.56–5.07) | 5.62 (4.31–7.31) | 5.66 (4.36–7.34) | 6.74 (6.33–7.18) | 6.68 (6.25–7.13) |
| 2014 | 6.35 (6.14–6.57) | 5.42 (5.15–5.71) | 3.69 (2.34–5.81) | 3.79 (2.63–5.46) | 7.2 (6.76–7.67) | 7.01 (6.57–7.49) |
| 2015 | 6.97 (6.74–7.21) | 5.59 (5.31–5.89) | 5.67 (5.22–6.15) | 5.94 (5.45–6.48) | 8.37 (7.82–8.96) | 8.26 (7.69–8.87) |
| 2016 | 7.13 (6.89–7.38) | 5.43 (5.16–5.71) | 6.46 (4.35–9.61) | 6.29 (4.74–8.34) | 7.77 (7.28–8.30) | 7.31 (6.83–7.83) |
| 2017 | 7.16 (6.92–7.40) | 5.44 (5.17–5.72) | 6.42 (5.38–7.65) | 6.30 (5.45–7.29) | 8.59 (8.04–9.18) | 8.13 (7.59–8.72) |
| 2018 | 6.98 (6.75–7.21) | 5.32 (5.06–5.60) | 5.75 (5.13–6.44) | 6.06 (5.06–7.27) | 8.67 (8.09–9.28) | 8.25 (7.67–8.88) |
AOR, adjusted odds ratio; NIHSS, National Institutes of Health Stroke Scale.
Adjusted for all variables in the table.
In exploratory analyses, IS patients who were non-Hispanic black, Medicaid or Medicare recipients, or admitted to a teaching hospital had lower odds for being screened for dysphagia (Table S2). IS patients who were ≥75 years, Medicaid or Medicare recipients, had a history of AF, a NIHSS ≥15 or were admitted to a teaching hospital had lower odds of receiving stroke education.
Discussion
From 2008 to 2018, DFC significantly improved among patients with IS, HS, and TIA. For each stroke subtype, significant improvements were observed for all applicable performance measures, particularly provision of stroke education. Adjusted analyses identified disparities in receipt of stroke care for each of the subtypes. IS patients eligible for treatment were less likely to receive DFC if they were 18 to 54 years, women, non-Hispanic black, Medicaid or Medicare recipients, or had a history of AF.
A previous report using PCNASP data from 2005 to 2009, demonstrated improvements in all performance measures and DFC across stroke subtypes during this time period.5 This study, using PCNASP data from 2008 to 2018, demonstrates continued progress in the receipt of DFC for each stroke subtype. Our results are also comparable to the AHA’s Get with the Guidelines-Stroke (GWTG) program which recognizes hospitals’ performance on quality of care measures.10 For participating GWTG hospitals from 2006 to 2013, improvements were observed for 9 measures of IS care examined (stroke education was excluded from the analysis), as well as, DFC.10 Previous evidence suggests that IS patients who receive evidence-based care (especially IV alteplase), as well as DFC, have better outcomes.8,11–14
Improvements in DFC may be attributed to continued improvements in individual performance measures, particularly in the provision of IV alteplase, stroke education, and screening for dysphagia, which could be due to focused quality improvement initiatives for these measures after 2007.11,15 Similar to a previous study, predictors of dysphagia screening included history of AF, increased age, and higher NIHSS; however, contrary to previous evidence, we saw that women and non-Hispanic black patients with IS were less likely to be screened for dysphagia14. While screening has improved over the last decade, it still has the lowest attainment among IS and HS patients. The AHA and American Stroke Association 2018 guidelines recommend dysphagia screening for those patients at risk for aspiration; however, these guidelines do not specify which instruments to choose for evaluation or recommend a specific protocol as many exist and are contingent on hospital policy and staff capacity17,18. Further, omission of screening may stem from varying opinions on which patients to screen (eg, patients with a mild stroke) or lack of resources to screen on nights or weekends.14,16–19
Stroke education for patients and caregivers is a critical component of an ideal transition from hospital to the next site of care and has been shown to reduce the risk of recurrent stroke and decrease health costs for patients.15,20 Similar to previous studies, we observed that women, older stroke patients, and Medicaid or Medicare beneficiaries were less likely to receive education poststroke; whereas, contrary to previous studies, non-Hispanic blacks were more likely to receive stroke education.21–24 Provision of stroke education saw the greatest improvement for each stroke subtype which could be attributed to changes in discharge planning processes or due to increased documentation.20 Despite improvements, there are still challenges to providing effective stroke education, especially when the average length of stay is ≤4 days and stroke patients have disabilities that affect their communication, and retention and understanding of new information.20 Ideally, stroke education should be repetitive and tailored to one’s level of health literacy, utilize multiple types of materials (eg, print and verbal), and inform on preventive measures (ie, signs, symptoms, and self-management) and available community resources.20,25,26
Our study has limitations. PCNASP is a federally-funded quality improvement program led by state health departments and focused on implementing initiatives to improve stroke care. Hospitals are recruited and participation is voluntary, which limits the generalizability of results. All hospitals participated in the quality improvement initiatives through the PCNASP, and there is no control group to compare the magnitude of quality improvement across the years. The data included in this analysis is from 3 different grant cycles resulting in changes in hospital participation over time; however, we controlled for hospital characteristics through GEE models to minimize bias. Missing data could exclude stroke cases from a performance measure which could lead to potentially biased estimates. We could not account for several measures associated with stroke, such as ABCD2 score, as they were not collected within PCNASP. Although CDC recommends including every patient that meets PCNASP inclusion criteria, when that is not feasible states and hospitals may create a sampling plan to reduce burden. Use of endovascular therapy for acute IS, shown to improve clinical outcomes relative to IV alteplase for large vessel occlusion strokes, could not be assessed in this study and might affect our interpretations.27 Nearly all trend and association analyses were statistically significant, and some improvements may be an artifact of the large sample. Further, several measures appear to be “topped out” and may not provide meaningful distinction in improvements of performance (ie, STK-1, STK-2, STK-5, STK-6, STK-9, STK-10, Table 1).28
In conclusion, we found significant improvements in nationally endorsed measures of acute stroke care for each stroke subtype over the last eleven years in the PCNASP. Particularly, improvements in provision of stroke education, IV alteplase when indicated, and screening for dysphagia appeared to drive improvements in the assessment of DFC among IS patients. Improvements in DFC may have also been impacted by the Target: Stroke initiatives from the American Heart Association/American Stroke Association, the expansion in number of hospitals and requirements necessary to be certified by accreditation programs, and recommendations made by the Brain Attack Coalition.29–32 State successes and key strategies employed can offer guidance to others working towards improving their systems of care.15 However, additional efforts are needed to minimize disparities for IS patients, particularly for persons 18 to 54 years, women, non-Hispanic blacks, Medicare or Medicaid beneficiaries, and persons with a history of AF. This study suggests continued quality improvement efforts may further reduce disparities in acute stroke care.
Supplementary Material
Acknowledgments
We would like to thank Robert Merritt, Elin Begley, Erika Odom, Lisa Cooper, Joanna Elmi, Kincaid Lowe, Ashely Marshall, Amena Abbas, Tiffany Chang, Asha Krishnaswamy, Jacquie Dozier, and Mary G. George of the Paul Coverdell National Acute Stroke Program team, as well as, all participating states and partners.
Funding
This work (staff time and PCNASP) was supported by the CDC.
Footnotes
Conflicts of Interest
None reported.
Supplementary materials
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ahj.2020.11.010.
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