Use of a Registry to Improve Acute Stroke Care --- Seven States, 2005−2009

Use of a Registry to Improve Acute Stroke Care --- Seven States, 2005−2009
Weekly
February 25, 2011 / 60(07);206-210

Each year, an estimated 795,000 persons in the United States experience a stroke. In all, an estimated 7 million U.S. residents have had a stroke, and the cost of cerebrovascular disease in 2007 was estimated at $41 billion (1). During 2004--2009, CDC funded seven state health departments for different periods to implement stroke care improvement registries. As part of the quality-improvement activities conducted by the Paul Coverdell National Acute Stroke Registry (PCNASR), CDC monitors adherence to 10 quality-of-care measures. This report documents the status of adherence to these 10 performance measures of stroke care through these seven state health departments for the period 2005--2009. The number of participating hospitals in the seven states ranged from 112 to 229 per year, with a total of 303 participating hospitals during the 5-year period. Average annual improvement in adherence to stroke care measures ranged from zero in one measure (prescription of antithrombotic at discharge) to 11% (use of intravenous tissue plasminogen activator [IV tPA]); five measures showed average annual improvements of at least 6%. The proportion of patients receiving "defect-free care" (a descriptor that indicates whether patients received all of the quality-of-care measures for which they were eligible) also improved. These results demonstrate the ability of state health departments to collaborate with hospitals to monitor and improve the delivery of high-quality care for acute stroke patients. This role for public health and state health departments in hospital quality improvement for acute stroke care is a viable approach to improving the quality of stroke care in the United States.

PCNASR was established by Congress in 2001. Its goals are to 1) measure, track, and improve the quality of care and access to care for stroke patients from the onset of symptoms through rehabilitation and recovery; 2) decrease rates of premature death and disability from acute stroke; 3) eliminate disparities in care; 4) support the development of systems of stroke care that emphasize quality of care; and 5) improve access to rehabilitation and opportunities for recovery after stroke. PCNASR is funded by CDC through a cooperative agreement with state health departments. It requires state health departments to recruit hospitals that are representative of all hospitals within a state in terms of size, status as an academic teaching hospital, rural or urban setting, geographic location, and racial/ethnic populations served. The state health departments work with participating hospitals to track the care of hospitalized stroke patients to improve the quality of acute stroke care from the onset of stroke through hospital discharge. Specifically, the health departments provide hospitals with an interactive program of quality-improvement activities through conference calls, in-person meetings, and individual hospital site visits. Topics include education on data-driven quality-improvement methodology and overcoming barriers to improving stroke care. The methods for data collection and the types of data collected on patients and hospitals have been described previously (2).

In 2008, CDC, the American Heart Association, and the Joint Commission (an independent organization that accredits and certifies health-care organizations and programs) developed a set of 10 performance measures of acute stroke care (Box) (3). These measures are derived from published care guidelines and clinical trials; eight of the 10 measures are endorsed by the National Quality Forum as important measures of care (4). Nine of the measures were bundled into groups that define defect-free care* (5).

CDC examined 2005--2009 data on all patients aged ≥18 years who were admitted to a participating hospital with any of four clinical diagnoses†: 1) acute hemorrhagic stroke (intracerebral hemorrhage or subarachnoid hemorrhage); 2) ischemic stroke; 3) ill-defined stroke (not classified as hemorrhagic or ischemic); or 4) transient ischemic attack (TIA). In-hospital mortality was calculated for each stroke type as the percentage of patients who died during admission for acute stroke. Cochran-Armitage tests were used to test for a trend in improvement over time.

During the 5-year period, 139,260 patients with one of the four diagnoses were admitted to a participating hospital in the seven states. Overall, 18,921 (13.6%) patients had hemorrhagic stroke; 82,066 (58.9%) had ischemic stroke; 8,236 (5.9%) had ill-defined stroke; and 30,037 (21.6%) had TIA. Median age of patients was 72 years (range: 18−108 years); 53% were female, and 74% were non-Hispanic white.

In-hospital mortality for hemorrhagic stroke (intracerebral or subarachnoid hemorrhage) increased from 21.0% in 2005 to 23.7% in 2009 (p=0.02). However, in-hospital mortality for ischemic stroke decreased significantly, from 6.2% in 2005 to 5.1% in 2009 (p<0.001). The in-hospital mortality for ill-defined stroke declined (but not significantly), from 6.2% to 4.9%, and the in-hospitality mortality rate for TIA ranged from 0.1% to 0.3% with no significant trend.

Adherence to nine of the 10 performance measures increased significantly during 2005--2009 (Table). The one measure that did not show improvement was provision of antithrombotic therapy at discharge, but this measure was at 98% in 2005 and remained at 98% in 2009. The greatest overall improvements during the 5-year period were adherence to the use of thrombolytic therapy (IV tPA) (average annual improvement of 11%), counseling on smoking cessation (9.2%), and lipid testing and/or treatment (7.6%).

Defect-free care improved significantly (p<0.001) for patients in each of the four categories: adherence to measures for patients with TIA showed the greatest average annual improvement (21%, from 28% to 57%), followed by inpatient measures for patients with ischemic stroke (17%, from 37% to 69%), measures for patients with hemorrhagic stroke or ill-defined stroke (17%, from 31% to 57%), and discharge measures for patients with ischemic stroke (8%, from 51% to 72%) (Table).

Reported by
MG George, MD, X Tong, MPH, PW Yoon, ScD, Div for Heart Disease and Stroke Prevention, National Center for Chronic Disease Prevention and Health Promotion, CDC.


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Use of a Registry to Improve Acute Stroke Care --- Seven States, 2005−2009