“Influence of Stroke Subtype on Quality of Care in The Get With The Guidelines-Stroke Program” Eric E. Smith, MD, MPH; Li Liang PhD; Adrian F Hernandez, MD; Mathew J. Reeves, PhD; Chris P. Cannon, MD; Gregg C. Fonarow, MD; Lee H. Schwamm, MD Smith EE. et al. Neurology 2008.

Background Hemorrhagic stroke, comprising intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH), accounts for 10-15% of all stroke and is the most severe form of stroke. Those who survive are at risk for in-hospital medical complications also seen in ischemic stroke, including aspiration pneumonia and deep venous thrombosis (DVT). The hospital stay represents an opportunity to initiate management of risk factors for hemorrhagic stroke, many of which are also risk factors for ischemic stroke and cardiovascular disease. Smith EE. et al. Neurology 2008

Introduction F  Get With The Guidelines-Stroke (GWTG–Stroke) is an ongoing voluntary, continuous quality-improvement initiative that collects patient level data on characteristics, treatments, in-hospital outcomes, and adherence to quality measures in stroke, including ischemic stroke, ICH and SAH.  Duration of participation in GWTG-Stroke has previously been associated with improved processes of care in ischemic stroke.  In contrast, little has been reported regarding provision of care for hemorrhagic stroke. Smith EE. et al. Neurology 2008

Objectives To examine whether the GWTG performance measures would be lower in hemorrhagic stroke compared to IS or TIA and if participation in GWTG-Stroke would be associated with improved provision of care over time for patients with SAH and ICH. Smith EE. Neurology 2008.

Methods Data analyzed from hospitals participating in GWTG and utilizing the web-based patient management tool for data collection (Outcome Sciences Inc, Cambridge, MA) Between 4/1/2003 and 12/30/ hospitals contributed 479, 284 stroke and TIA admissions. The proportions receiving each quality of care measure were calculated by dividing the total number of patients receiving the intervention by the total number of patients eligible for the intervention, excluding ineligible patients or those with contraindications to treatment. Smith EE et al. Neurology 2008

Methods: Quality Measures Applicable to both hemorrhagic and ischemic stroke Process Measures - door to CT time <25 minutes in patients with symptoms <3 hours duration -dysphagia screen prior to oral intake -DVT prophylaxis started by the second hospital day for non-ambulatory patients. 2. Secondary Prevention Measures -lipid lowering therapy at discharge -smoking cessation counseling -dietary/weight management counseling -diabetic treatment at discharge Smith EE. et al. Neurology 2008

Analyzed Care Measures 1999 AHA ICH Guidelines recommend measures to prevent DVT 2007 ICH Guidelines recommend smoking cessation to prevent recurring ICH and acknowledges high prevalence of oral dysphagia without screening recommendations Recent SAH guidelines recommend measures to prevent DVT and that smoking cessation may decrease the incidence of SAH CT scans to ascertain hemorrhagic and ischemic stroke has been recommended for all stroke patients Smith EE et al. Neurology 2008

Results Stroke subtypes were 61.7% IS, 23.8% TIA, 11.1% ICH and 3.5% SAH. Performance on care measures was generally lower in ICH and SAH compared to IS/TIA, including guideline-recommended measures for DVT prevention (for ICH) and smoking cessation (for SAH) An exception was that ICH patients were more likely than IS/TIA to have door-to-CT times <25 minutes and to undergo dysphagia screening Time spent in the GWTG-Stroke program was associated with improvements in many measures of care for ICH and SAH patients, including DVT prevention and smoking cessation therapy. Smith EE et al. Neurology 2008

Limitations The results may not be generalizable to non-GWTG hospitals because hospital participation in GWTG- Stroke is voluntary and therefore limited to hospitals with an interest in stroke quality improvement. The study does not include a control group for comparison. Although a link between process measures during hospitalization and post-discharge stroke outcomes may be valid, the process-outcome relationships for hemorrhagic stroke was not determined because GWTG-stroke does not collect post-discharge mortality. Smith EE et al. Neurology 2008.

Conclusions The GWTG-Stroke program has shown that the program is associated with sustained improvement in quality of care for ischemic stroke. These data show that a web-based data repository with real-time feedback and decision support can also lead to sustained improvements in quality of care for hemorrhagic stroke. This study provides further scientific evidence that there is a need to determine the durability of GWTG- Stroke related improvements, reasons for non- compliance with quality measures, and to evaluate local quality improvement initiatives launched in partnership with the GWTG-Stroke program. Smith EE et al. Neurology 2008

Clinical Implications Widespread application of GWTG is associated with sustained improvement in the quality of care for ischemic stroke, yet updated guidelines for evidence- based ICH and SAH care and oral dysphagia screening are warranted. These results highlight the importance of overall quality of care improvement initiatives targeted to hemorrhagic stroke patients, aimed at improving processes of care as well as prevention of recurrence, are warranted. Smith EE et al. Neurology 2008