characteristics, performance measures, and in-hospital outcomes of the first one million stroke and...

Characteristics, Performance Measures, and In-Hospital Outcomes of the First

One Million Stroke and Transient Ischemic Attack Admissions in Get With

The Guidelines-Stroke

Gregg C. Fonarow, MD; Mathew J. Reeves, PhD; Eric E. Smith, MD, MPH; Jeffrey L. Saver MD; Xin Zhao, MS; DaWai Olson, PhD, RN; Adrian

Hernandez, MD, MHS; Eric D. Peterson, MD, MPH; Lee H. Schwamm, MDon behalf of the Get With The Guidelines Steering Committee and Hospitals

Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

DisclosuresGWTG-Stroke is sponsored by the AHA/ASA and is also supported in part by an unrestricted educational grant from Merck/Schering-Plough Pharmaceutical.

The individual author disclosure are listed in the manuscript


• Stroke results in substantial morbidity and mortality.

• While evidence-based guidelines for stroke and TIA care have been developed along with improved diagnostic and treatment modalities, there are gaps, variations, and disparities in how these are applied.

• Furthermore many hospitals may not have the systems, organization, staff, and equipment to effectively diagnose, manage, and treat acute stroke patients.

Background


• The Get With The Guidelines (GWTG)-Stroke Program was developed by the AHA/ASA as a national stroke registry and performance improvement program with the primary goal of improving the quality of care and outcomes for stroke and TIA as well as serve as a scientific resource for new information.

• Although several prior studies have described the quality of care and outcomes for patients hospitalized with stroke and TIA, uncertainty remains about care quality and clinical outcomes for contemporary populations of patients hospitalized with stroke and TIA.

• Furthermore, little is known regarding temporal trends and whether there have been improvement in clinical outcomes among hospitals participating in GWTG-Stroke.

Background


• The objectives of this study were to analyze the characteristics, performance measures, in-hospital outcomes, and temporal trends in the first 1,000,000 acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and TIA admissions from 1,392 hospitals that participated in the GWTG-Stroke Program from 2003 to 2009.

Objectives


• GWTG Stroke is an ongoing, voluntary, observational registry and a continuous performance improvement program for patients hospitalized with stroke or TIA.

• A web-based Patient Management Tool provides decision support at the point-of-care, on-demand reporting and patient education features (Outcome, Cambridge, MA).

• Patient data were abstracted by trained hospital personnel. These included demographics, medical history, initial CT findings, in-hospital treatment and events, discharge treatments, treatment contraindications, counseling, in-hospital mortality, and discharge destination.

Methods


• Trained hospital personnel ascertained consecutive patients admitted with acute ischemic stroke by either prospective clinical identification, retrospective identification using ICD-9 discharge codes, or a combination.

• Methods used for prospective identification varied, but included regular surveillance of ED records, ward census logs, and/or neurological consultations.

• The eligibility of each acute stroke or TIA admission was confirmed at chart review prior to abstraction.

• Performance and quality measures were collected and reported.

• Outcomes included: % of pts with a short length of stay (LOS <4 days); % discharged home, and in-hospital mortality.

Methods


• Characteristics, performance measures, in-hospital outcomes, and temporal trends were evaluated. P-values were based on chi-square rank based group means score statistics for all categorical row variables (equivalent to Wilcoxon test for two levels).

• GEE multivariable logistic regression models were developed to quantify how performance measures, in-hospital mortality, discharge home, and LOS changed on a continuous basis by quarter from 2003 to 2009 and reported as cumulative change over 6 years adjusting for patient and hospital variables.

• Since the makeup of participating hospitals may have changed over time in GWTG-Stroke, we also performed a separate set of analyses for temporal trends among core hospitals which were participating by 2004 and contributed cases in all subsequent quarters of the study.

Statistical Methods


• From April 1st 2003 to August 24th 2009, there were 1,000,000 patients with stroke or TIA entered from 1392 GWTG-Stroke participating hospitals.

• There were 601,599 (60.2%) ischemic strokes, 108,671 (10.9%) intracerebral hemorrhage s, 34,945 (3.5%) subarachnoid hemorrhages, 26,977 (2.7%) strokes not classified, and 227,788 (22.8%) TIAs.

• Stroke and TIA patients enrolled by year

2003 N= 18,971 (starting April 1st 2003)

2004 N= 41,065 2005 N= 96,139 2006 N= 167,666 2007 N= 220,734 2008 N= 262,785 2009 N= 159,083 (through August 24th, 2009)

Results


Q2 2003 Q3 2003 Q4 2003 Q1 2004 Q2 2004 Q3 2004 Q4 2004 Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006 Q3 2006 Q4 2006 Q1 2007 Q2 2007 Q3 2007 Q4 2007 Q1 2008 Q2 2008 Q3 2008 Q4 2008 Q1 2009 Q2 2009 Q3 2009

New Patients 4,725 3,287 7,926 11,032 9,054 11,706 10,770 14,635 22,519 23,622 29,322 33,997 39,798 43,113 45,031 52,015 55,503 58,207 59,905 62,649 70,316 72,936 72,400 83,349 80,854 87,165

Cumulative 4,725 8,012 15,938 26,970 36,024 47,730 58,500 73,135 95,654 119,276 148,598 182,595 222,393 265,506 310,537 362,552 418,055 476,262 536,167 598,816 669,132 742,068 814,468 897,817 978,671 1,065,83

11,032 14,63533,997 52,015 62,649

83,349 87,16526,970 73,135

182,595

362,552

598,816

897,817

1,065,836

0

250,000

500,000

750,000

1,000,000

Enrollment in GWTG-Stroke by Quarter


Hospital Participation in GWTG-Stroke by State

N=1392


Hospital Characteristics1392 GWTG-Stroke Participating Hospitals

Characteristic N or %

Number of Stroke Discharges 0 - 100 10.0

101 - 300 46.7

301+ 43.2

Number of Beds Median (IQR) 369 (260-553)

Region Northeast 25.9

Midwest 19.0

South 37.7

West 17.3

Hospital Type Academic 60.5

Non Academic 39.5


• Hospitals in every state participate in the GWTG-Stroke Program.

• Of participating hospitals, 39.5% were non-academic institutions.

• Divided by regions, the South has the largest number of participating hospitals (n=500), followed by the Northeast (n=346), the Midwest (n=325), and the West (n=252).

• GWTG-Stroke participating hospitals account for an estimated 32.3% of US acute care hospitals.

• In 2008, there were 156,000 ischemic stroke patients entered into GWTG-Stroke out of 663,000 expected in the US (25%) and 47,937 hemorrhagic stroke patients entered out of 117,000 expected in the US (41%).

Hospital Participation in GWTG-Stroke


Variable Level Total N Overall

Age Median Years (IQR) 1000000 72 (60-82)Gender Female 534467 53.45Race/Ethnicity White 730927 73.33

Black 144140 14.46Asian 22713 2.28Hispanic 53691 5.39

Arrival Mode EMS 557937 58.13Private transport 334961 34.90

Time to Symptom Onset to Arrival

Median Minutes (IQR) 385304 138 (60-384)

NIH Stroke Scale* Median (IQR) 337194 4 (1-10)Medical History

Atrial Fib/Flutter Yes 158909 17.11Stroke/TIA Yes 297843 32.07CAD/Prior MI Yes 257400 27.72Diabetes Mellitus Yes 281544 30.32PVD Yes 45147 4.86Hypertension Yes 723573 77.91Smoker Yes 176354 18.99Dyslipidemia Yes 358403 38.59

Patient Characteristics Total Cohort


Variable Level Ischemic Stroke

Subarachnoid Hemorrhage

Intracerebral Hemorrhage

Stroke, Not Classified

TIA P-value

N (%) 601599 (60.2%)

34945 (3.5%)

108671(10.9%)

26977 (2.7%)

227788(22.8%)

Demographic

Age Median Years 73 58 71 73 73 <.0001

25th-75th 61-82 48-71 57-81 60-82 60-82

Gender Female 52.45 61.61 49.29 53.14 56.86 <.0001

Race/Ethnicity White 73.42 67.33 67.97 71.52 76.80 <.0001

Black 14.94 13.79 15.63 17.10 12.43

Asian 2.21 3.55 3.96 1.76 1.53

Hispanic 5.09 7.79 6.61 4.69 5.30

Arrival Mode from scene 59.36 68.60 73.67 55.38 46.27 <.0001

Private transport

33.90 15.02 16.52 37.50 48.93

Time to Symptom Onset to Arrival

Median Minutes25th-75th

16562-465

14557-386

11755-327

16063-472

11360-258

<.0001

NIH Stroke Scale*

Median 5 3 9 4 1 <.0001

25th-75th 2-11 0-15 3-19 1-9 0-3

Patient Characteristics by Event Type


Variable Ischemic Stroke




TIA P-value

Total 601599 (60.2%)

34945 (3.5%)

108671 (10.9%)

26977 (2.7%)

227788 (22.8%)

Medical History

Atrial Fib/Flutter 19.02 7.54 16.60 16.52 13.58 <.0001

Stroke/TIA 32.36 12.92 26.50 34.45 36.17 <.0001

CAD/Prior MI 28.99 14.40 22.50 28.55 28.40 <.0001

Carotid Stenosis 4.70 1.49 2.07 5.12 4.62 <.0001Diabetes Mellitus 32.10 17.15 26.16 32.75 28.93 <.0001

PVD 5.31 2.31 3.55 5.10 4.57 <.0001

Hypertension 78.80 65.96 79.58 77.59 76.41 <.0001

Smoker 19.91 34.02 16.46 18.71 15.70 <.0001

Dyslipidemia 39.41 23.48 28.99 33.77 43.43 <.0001

Patient Characteristics by Event Type


• For the 1,000,000 acute stroke (n=772,212) and TIA (n=227,788) admissions entered into the program, the mean age was 70.1 ± 14.9 years and over half (53.5%) were women.

• IS and TIA patients were older, more likely to be men, less likely to be smokers, and more likely to have medical co-morbidities than ICH and SAH patients.

• ICH patients had a relatively high prevalence of vascular risk factors, but not as high as for IS or TIA patients.

• Patients with stroke not classified were most similar to IS patients.

• SAH patients were more likely than IS or TIA patients to be younger, female, non-white and to be cared for in larger academic hospitals.

Patient Characteristics in GWTG-Stroke


Performance Measure IS SAH ICH SNC TIA P-value*

Acute PM

IV rt-PA 2 Hour 59.51 NA NA NA NA .

Early Antithrombotics 95.08 NA NA NA 95.86 <.0001

DVT Prophylaxis 88.80 91.53 86.82 80.79 NA <.0001

Discharge PM

Antithrombotics 95.91 NA NA NA 95.15 <.0001

Anticoag for AF 91.11 NA NA NA 89.11 <.0001

100 or ND 77.46 NA NA NA 72.35 <.0001

Smoking Cessation 89.69 84.00 85.28 82.30 89.43 <.0001

Summary PM

All-or-None Measure 73.29 87.75 85.46 79.89 74.01 <.0001

Composite Measure 89.14 89.54 86.44 81.10 87.50 <.0001

Performance Measures by Event Type


Quality Measures IS SAH ICH SNC TIA P-value*

Door to CT ≤25 Minutes 35.60 23.89 39.81 27.19 20.19 <.0001

Dysphagia Screen 68.30 56.27 69.58 54.36 NA <.0001

Stroke Education† 72.34 64.19 66.24 53.67 66.38 <.0001

Rehabilitation † 95.44 92.22 95.68 86.43 NA <.0001

Quality Measures by Event Type

†Data collected starting 2008


0%

20%

40%

60%

80%

100%

IV rt-PA 2 Hour Early AntiThrom DVT Proph DC Antithrom Anticog for AF LDL100 Smoking All-or-None

Pa

tie

nts

Tre

ate

d .

2003 2004 2005 2006 2007 2008 2009

Temporal Trends in Acute Stroke and TIA Care 2003-2009Temporal trend P value is <0.0001 for each measure


Measures N 2003 2004 2005 2006 2007 2008 2009 P-value

All-or-None MeasureOverall 657288 43.99 57.60 62.74 69.04 74.88 81.34 84.26 <.0001IS 412832 41.10 55.42 60.72 67.13 73.72 80.34 83.87 <.0001SAH 18190 54.92 65.63 75.91 82.72 87.73 92.57 94.29 <.0001ICH 53047 60.56 69.13 73.15 79.30 84.43 91.69 92.99 <.0001SNC 10585 55.83 69.62 71.29 76.97 81.87 86.06 85.34 <.0001TIA 162634 48.11 59.32 64.04 69.46 73.64 79.22 81.55 <.0001Composite MeasureOverall 2139019 72.30 80.22 82.86 86.07 88.97 91.72 93.08 <.0001IS 563300 73.46 81.25 83.55 86.52 89.50 92.29 93.65 <.0001SAH 20730 60.04 68.66 78.80 85.26 89.54 93.91 95.38 <.0001ICH 62074 63.03 70.85 74.77 80.57 85.49 92.40 93.54 <.0001SNC 13250 58.06 71.51 72.90 78.50 83.18 86.75 86.13 <.0001TIA 219753 74.69 80.86 82.76 85.38 87.43 89.94 90.92 <.0001

Temporal Trends in Acute Stroke and TIA Care 2003-2009Summary Performance Measures


Unadjusted (2003 to 2009) Adjusted (2003 to 2009) *

Outcome Category OR Lower (95% CI)

Upper (95% CI)

P-value

OR Lower (95% CI)

Upper (95% CI)

P-value

All-or-None Overall 7.804 7.054 8.633 <.001 9.390 8.316 10.603 <.001

Measure IS 8.255 7.428 9.175 <.001 10.079 8.880 11.440 <.001

SAH 10.047 8.016 12.592 <.001 16.712 12.260 22.779 <.001

ICH 10.537 8.743 12.698 <.001 15.826 12.513 20.016 <.001

SNC 7.631 5.426 10.732 <.001 8.025 5.350 12.037 <.001

TIA 6.245 5.496 7.097 <.001 7.316 6.278 8.526 <.001

Temporal Trends in Acute Stroke and TIA Care 2003-2009

*Adjusted for age, gender, race, medical history of Afib, stroke/TIA, CAD/prior MI, carotid stenosis, diabetes, PVD, hypertension, dyslipidemia, smoking, arrival mode (EMS vs. other), on/off hour presentation (7 am-6 pm MF vs other), hospital characteristics of region, number of beds, annual stroke volume, academic vs. not. Overall cohort also adjusted for stroke type (IS, SNC, SAH, ICH, TIA).


All-or-None Performance Measure

•In each successive year there were clinically meaningful and statistically significant improvements in all 7 individual PM.

• The absolute improvement from 2003 to 2009 ranged from +4.3% for discharge antithrombotics to +51.0% for smoking cessation (P <.0001 for all comparisons).

• IV tPA use in eligible patients increased from 29.7% to 71.6% (+41.9%), P<0.0001.

• There was substantial and significant improvement in the all-or-none care measure from 2003 to 2009, 44.0% to 84.3% (+40.3%), P<0.0001 overall and for each cerebrovascular event type.

• There was also an increase in composite care from 72.3% to 93.1% (+20.8%), P<0.0001 overall and for each event type.

Performance Measures in GWTG-Stroke


Variable Level Overall Ischemic Stroke




TIA P-value

Total Admissions

1,000,000 601,599(60.2%)

34,945 (3.5%)

108,671 (10.9%)

26,977(2.7%)

227,788(22.8%)

Discharge StatusDiedDischarge Destination

6.97 5.52 20.42 25.04 5.49 0.26 <.0001

Home 52.54 45.98 41.01 24.21 51.01 85.47 <.0001Skilled Nursing Facility

17.44 20.38 11.39 19.44 20.87 9.19

Rehabilitation 16.58 21.33 15.31 20.73 14.47 2.43Hospice 3.00 3.56 2.31 5.64 3.25 0.32Transfer 2.84 2.68 9.14 4.61 4.19 1.27Left AMA/Other 0.63 0.53 0.43 0.32 0.73 1.06

Ambulatory Independent 53.64 47.52 45.53 28.22 49.39 81.22 <.0001Status With Assistance 25.26 29.85 19.53 27.35 28.11 13.11

Unable 17.86 19.54 28.95 39.80 17.24 3.17Not Documented 3.25 3.09 5.99 4.64 5.26 2.50

Length of Stay Median 4 4 8 5 4 2 <.000125th-75th 2-6 3-7 3-16 3-9 2-6 1-4Mean 5.43 5.78 11.69 8.15 5.31 3.05>4 Days 39.32 45.60 67.03 55.42 40.46 15.65 <.0001

Stroke-Related In-Hospital Outcomes by Cerebrovascular Event Type


Unadjusted Adjusted +Outcome Event Type

(vs. IS)OR Lower

(95% CI)Upper

(95% CI)P-value OR Lower

(95% CI)Upper

(95% CI)P-value

In-Hospital SAH 4.25 4.03 4.52 <.001 5.42 5.13 5.72 <.001Mortality ICH 5.70 5.50 5.91 <.001 5.82 5.62 6.03 <.001

SNC 1.07 0.99 1.16 0.102 1.11 1.02 1.20 0.011TIA 0.04 0.04 0.05 <.001 0.06 0.05 0.06 <.001

Discharge SAH 1.05 1.00 1.10 0.052 0.64 0.61 0.67 <.001Home ICH 0.49 0.48 0.50 <.001 0.42 0.41 0.43 <.001

SNC 1.28 1.23 1.33 <.001 1.29 1.23 1.35 <.001TIA 6.30 6.14 6.47 <.001 6.96 6.77 7.16 <.001

LOS (> 4 days) SAH 2.23 2.04 2.44 <.001 2.57 2.33 2.83 <.001ICH 1.44 1.40 1.48 <.001 1.49 1.44 1.54 <.001SNC 0.84 0.80 0.88 <.001 0.84 0.80 0.89 <.001TIA 0.22 0.21 0.23 <.001 0.23 0.23 0.24 <.001

Clinical Outcomes by Cerebrovascular Event Type


+ Adjusted for patient and hospital characteristics. See manuscript for variables

• SAH and ICH patients had substantially higher in-hospital mortality rates, were less likely to be discharged home, and were more likely to be discharged to a SNF or hospice compared to IS patients.

• As expected, in-hospital mortality was very low in patients hospitalized with TIA (0.3%).

• Adjustment for potential confounding variables and clustering of data within hospitals did little to attenuate the cerebrovascular event type related differences for clinical outcomes.

•The adjusted OR for in-hospital mortality for ICH compared to IS was 5.8; for SAH it was 5.4.

• After adjustment the odds of being hospitalized longer than 4 days remained significantly elevated for SAH and ICH compared to IS.

Clinical Outcomes in GWTG-Stroke


5.81 5.94 5.77 5.71 5.53 5.47 5.16

29.52

26.7925.66 25.26

24.68 24.64 24.96

19.55

21.39

22.7

20.3 20.5319.82 20.01

0.33 0.33 0.31 0.24 0.25 0.27 0.24

6.757.32 7.29 7.09 6.92 6.94 6.77

0

5

10

15

20

25

30

2003 2004 2005 2006 2007 2008 2009

Year

Mo

rta

lity

, % IS

ICH

SAH

TIA

All

Temporal Trends in Mortality 2003-2009


Temporal trend P value for ischemic stroke (P<0.0001), intracerebral hemorrhage (P=0.0036), subarachnoid hemorrhage (P=0.0106), transient ischemic attack (P=0.2091).

Variable (%) 2003 2004 2005 2006 2007 2008 2009 P-value

Discharge Home

Overall 53.81 54.50 55.72 56.44 57.08 56.35 57.07 <.0001

IS 46.76 47.09 48.30 48.35 48.60 48.81 49.61 <.0001

SAH 45.17 50.73 50.24 51.18 52.05 49.97 54.86 0.0010

ICH 33.01 31.74 32.15 33.01 32.37 32.32 31.66 0.1238

SNC 47.64 52.89 52.48 53.40 56.41 53.05 55.53 0.0227

TIA 82.73 86.29 86.06 86.06 85.84 85.03 86.11 0.2978

LOS > 4

Overall 40.11 41.66 40.40 40.42 39.03 38.06 35.55 <.0001

IS 46.51 47.47 46.50 47.14 46.02 43.51 39.71 <.0001

SAH 61.75 61.61 64.73 65.86 66.91 69.28 65.12 <.0001

ICH 51.15 54.20 53.94 55.43 55.13 56.64 51.33 <.0001

SNC 33.28 42.47 42.57 43.07 39.47 39.56 31.15 0.0027

TIA 18.30 18.49 16.88 16.31 15.54 14.27 14.91 <.0001


Temporal Trends in Clinical Outcomes 2003-2009

Unadjusted (2003 to 2009) Adjusted (2003 to 2009) *Outcome Category OR Lower

(95% CI)Upper

(95% CI)P-

valueOR Lower

(95% CI)Upper

(95% CI)P-value

In-Hospital Overall 0.86 0.80 0.92 <.001 0.98 0.92 1.03 0.392Mortality IS 0.81 0.76 0.87 <.001 0.90 0.84 0.96 0.002

SAH 0.84 0.73 0.96 0.013 1.17 1.01 1.36 0.034ICH 0.89 0.81 0.97 0.006 1.09 0.99 1.20 0.088SNC 0.65 0.52 0.81 <.001 0.77 0.61 0.96 0.020TIA 0.59 0.38 0.91 0.017 0.62 0.44 0.87 0.006

Discharge Overall 1.09 1.04 1.13 <.001 0.99 0.95 1.03 0.631Home IS 1.12 1.07 1.16 <.001 1.02 0.97 1.06 0.519

SAH 1.23 1.08 1.39 0.002 0.86 0.74 0.99 0.041ICH 0.97 0.89 1.06 0.468 0.74 0.67 0.82 <.001SNC 1.20 1.04 1.38 0.012 1.10 0.95 1.27 0.210TIA 1.08 0.99 1.18 0.101 1.05 0.95 1.15 0.352

LOS Overall 0.74 0.70 0.79 <.001 0.72 0.69 0.77 <.001(> 4 days) IS 0.72 0.68 0.77 <.001 0.71 0.67 0.76 <.001

SAH 1.26 1.00 1.60 0.055 1.12 0.84 1.50 0.427ICH 1.04 0.94 1.14 0.494 0.97 0.87 1.09 0.625SNC 0.84 0.72 0.99 0.037 0.85 0.72 1.01 0.067TIA 0.58 0.53 0.64 <.001 0.58 0.53 0.64 <.001

Temporal Trends in Clinical Outcomes 2003-2009

* Adjusted for patient and hospital characteristics.Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

Clinical Outcomes by Calendar Year forIschemic Stroke Patients

Outcome2003

(12,549)

2004

(26,252)

2005

(60,414)

2006

(102,282)

2007

(131,891)

2008

(159,825)

2009

(108,386)

P value

Mortality 5.8 5.9 5.8 5.7 5.5 5.5 5.2 <.001

Discharge Home

46.8 47.1 48.3 48.4 48.7 48.9 49.6 <.001

LOS (> 4 days)

46.5 47.5 46.5 47.1 46.0 43.5 39.7 <.001

Total Ischemic Stroke Patients N = 601,599


Unadjusted Adjusted+

Outcome OR 95 CI 95 CI P value OR 95. CI 95 CI P value

Mortality 0.811 0.758 0.868 <.001 0.900 0.841 0.963 0.002

Discharge Home

1.117 1.072 1.163 <.001 1.015 0.971 1.060 0.519

LOS (> 4 days)

0.724 0.683 0.768 <.001 0.713 0.672 0.757 <.001

Temporal Trends in Outcomes for Ischemic Stroke

+Adjusted for PATIENT CHARACTERISTICS of age, gender, race, medical history of atrial fibrillation, previous stroke/TIA, coronary artery disease, carotid stenosis, diabetes, peripheral vascular disease, hypertension, dyslipidemia, smoking, arrival mode (EMS vs. other), on/off hour presentation (7 am-6 pm M-F vs. other), and HOSPITAL CHARACTERISTICS of region, number of beds, annual stroke volume, and teaching hospital vs. not.

Odd Ratios for 6 Year Change 2003 to 2009


• There were temporal trends for improvement in clinical outcomes from 2003 to 2009.

• The portion of patients discharged home in 2003 was 53.8% compared to 57.1% in 2009 (P<0.0001) and LOS > 4 days was seen in 40.1% in 2003 compared to 35.6% in 2009.

• After adjustment, the portion of patients with hospital LOS >4 days declined significantly, adjusted OR 0.72, 95% CI 0.69-0.77, P<0.0001.

• In-hospital mortality also declined significantly over time, unadjusted OR 0.87, 95% CI 0.80-92, P<0.001, 2003 to 2009, but after risk adjustment was only significant for ischemic stroke and TIA.

• There was a 10% risk adjusted reduced odds of mortality in patients with IS from 2003 to 2009.

Temporal Trends in Clinical Outcomes


• Data were collected by medical chart review and are dependent upon the accuracy of documentation and abstraction.

• Residual measured and unmeasured confounding variables may have influenced the findings.

• Further study will be needed to determine if these improvements in outcomes are due to improved care (faster in-hospital response times, guideline-adherence, and reduced complications or errors), secular trends, or other reasons.

• These findings may not apply to hospitals that differ in patient characteristics or care patterns from GWTG-Stroke Hospitals.

Limitations


• GWTG-Stroke is the largest registry and performance improvement programs for hospitalized stroke and TIA patients, with data from 1,000,000 admissions including more than 600,000 IS, 100,000 ICH, 30,000 SAH, and 225,000 TIA admissions.

• This study has characterized the demographics, performance measures, and in-hospital clinical outcomes in a very broad cohort of acute stroke and TIA hospitalizations from every state in the country.

• Among GWTG-Stroke participating hospitals there were substantial improvements over time in performance measures, overall and for each cerebrovascular event type.

• Composite care performance increased substantially from 72.3% to 93.1% (+20.8%) from 2003 to 2009.

Conclusions


• Among hospitals participating in GWTG-Stroke, there have been reductions in LOS and mortality at discharge over the past 6 years in the patients with acute ischemic stroke.

• These findings persist after adjustment for patient and hospital characteristics.

• Further research is warranted to determine if these reductions in mortality are due to increased adherence to inpatient care process measures, secular trends, unmeasured confounders, or other reasons.

• Other factors might include increased public education and awareness, increased use of EMS, improvements in in-hospital response times, guideline-adherence, and prevention of complications or medical errors.

Conclusions


• This study demonstrates the ongoing value of GWTG-Stroke as an integrated stroke and TIA national registry providing national surveillance, supporting vigorous efforts to improve evidence-based stroke/TIA care, and fostering innovative research.

Conclusions


characteristics, performance measures, and in-hospital outcomes of the first one million stroke and...

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