1. Background Using the GWTG-Stroke database and the Centers for Medicare & Medicaid Service files, we analyzed Medicare patients with acute ischemic stroke admitted to GWTG-Stroke hospitals between April 1, 2003 and December 12, 2008. We found concurrent controls at non-GWTG-Stroke hospitals using a matching process based upon average annual ischemic stroke volume, calendar time, hospital teaching status, and hospital region. We defined 4 separate time periods of interest: PRE (18 mos-16 mos prior to joining GWTG-Stroke) RUN-UP (6 mos-1 day prior to GWTG-Stroke) EARLY (day 0-6 months after GWTG-Stroke) SUSTAINED (6 mos-18 mos after GWTG-Stroke). We further combined time periods: PRE+RUN-UP = BEFORE EARLY+SUSTAINED = AFTER. Using site-level Kaplan-Meier estimates and Kruskal-Wallis tests, we analyzed the GWTG-Stroke sites and the non-GWTG-Stroke sites separately in each of the four time periods for the following clinical outcomes: length of stay, discharge home, 30 day mortality, 1 year mortality, 30 day all cause rehospitalization, 30 day stroke rehospitalization, 30 day cardiovascular rehospitalization, 1 year all cause mortality, 1 year stroke mortality, and 1 year cardiovascular mortality. We also analyzed ischemic stroke patients enrolled during the PRE period in both GWTG-Stroke and non-GWTG-Stroke hospitals utilizing a stratified/conditional Cox proportional hazard model with the pair number (1-366) as the stratum; we also analyzed the data using the pre-period hospital level risk rate as an offset in each model. We performed risk adjusted mortality (30 day and 1 year) and discharge to home rates for what we determined to be the most common baseline patient (female, 80 years, white, no medical history, and average-sized hospital). *Outcome Sciences, Inc. is the data collection coordination center for the American Heart Association/American Stroke Association Get With The Guidelines® programs Results Conclusions Limitations P<0.0001 Stroke is a devastating disease, affecting more than 795,000 people in the U.S. each year. The Get With The Guidelines-Stroke (GWTG-Stroke) program was developed by the American Heart Association (AHA) as a quality improvement program for hospitals to improve stroke care infrastructure utilizing a multidisciplinary team approach, and offering data collection, decision support, and data feedback. Participation in the GWTG-Stroke program has also been associated with increased adherence to quality performance measures and increased number of patients with stroke treated over time. Although improvement of these quality of care measures, such as early antithrombotics and smoking cessation, have been seen in patients at GWTG-Stroke hospitals, longer term clinical outcomes, such as mortality, discharge to home, or rehospitalization has not been described. Get With The Guidelines-Stroke Program Participation and Clinical Outcomes for Medicare Beneficiaries Sarah Song MD, MPH 1, Gregg C. Fonarow MD 2, Wendy Pan PhD 3, DaiWai M Olson PhD, RN 4, Adrian F. Hernandez MD, MS 5, Eric D. Peterson MD, MPH 5, Mathew J. Reeves PhD 6, Eric E. Smith MD, MPH 7, Lee H. Schwamm MD 8, Jeffrey L. Saver MD 9 1 Department of Neurology, Rush University Medical Center; 2 Department of Cardiology, University of California-Los Angeles; 3 Department of Biostatistics & Bioinformatics, Duke University; 4 Department of Neurology, Duke University; 5 Department of Cardiology, Duke University; 6Department of Epidemiology and Biostatistics, Michigan State University; 7 Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary; 8 Department of Neurology, Massachusetts General Hospital; 9 Department of Neurology, University of California-Los Angeles Author Disclosure Information: S. Song: Research Grant; Modest; American Heart Association/Pharmaceutical Roundtable – Spina Outcomes Research Center. G.C. Fonarow: None. W. Pan: None. D.M. Olson: None. A.F. Hernandez: None. E.D. Peterson: Research Grant; Modest; BMS/Sanofi, J&J, Lilly, PI of AHA Data Coordinating Center (for GWTG). M.J. Reeves: None. E.E. Smith: None. L.H. Schwamm: Consultant/Advisory Board; Significant; Consultant Stroke Systems MA DPH. Other; Modest; Chair, AHA GWTG (unpaid). J.L. Saver: None. In this study, we found that patients hospitalized with acute ischemic stroke at GWTG-Stroke hospitals had greater improvement of clinical outcomes over time, than similar non-GWTG-Stroke hospitals. GWTG-Stroke hospitals exhibited reduced proportional 30 day and 1 year mortality, and had more discharges home. Encouragingly, both linked and unlinked hospitals improved their stroke outcome over time. The GWTG-Stroke program continues to show benefits of hospital participation in clinical outcomes. Participation in GWTG-Stroke was voluntary and the control hospitals while concurrent were not based on randomization. Despite our best efforts, matching GWTG-Stroke hospitals with non- GWTG-Stroke hospitals was not perfect, and the matched pairs had significant differences on most outcomes in the PRE period Residual measured and unmeasured confounding may have occurred There was a small amount of missing data which happened most frequently in the SUSTAINED period, due to end of CMS data reporting Acknowledgements NIH/NIA RCMAR/CHIME GWTG-Stroke is provided by the American Heart Association/American Stroke Association and is currently supported, in part, by a charitable contribution from Janssen Pharmaceutical Companies of Johnson & Johnson. GWTG-Stroke has been funded in the past through support from Boeringher-Ingelheim, Merck, Bristol- Myers Squib/Sanofi Pharmceutical Partnership, and the AHA Pharmaceutical Roundtable. A total of 173,985 patients, with 88,584 patients at 366 GWTG-Stroke sites, and 85,401 patients at 366 matched non-GWTG-Stroke sites included in the analysis.Patient characteristics were similar in PRE and SUSTAINED periods. In GWTG-Stroke hospitals between the PRE and the SUSTAINED periods, there was significantly Improved median 30-day mortality of 15.08% to 14.63% Improved median 1-year mortality of 28.25% to 27.59% Decreased median 30-day stroke rehospitalization of 4.36% to 4.05% Increased median 30-day cardiovascular disease rehospitalization of 3.03% to 3.08% In non-GWTG-Stroke hospitals between the PRE and the SUSTAINED periods, there was significantly: Decreased median 30-day stroke rehospitalization of 4.55% to 4.27% Increased median 30-day cardiovascular rehospitalization of 2.65% to 2.94% Univariate analysis of the SUSTAINED period found that clinical outcomes were similar, except that GWTG- Stroke hospitals had decreased stroke/TIA rehospitalizations at 1 year than non-GWTG-Stroke hospitals: 15.2% compared to 16.4% (p<0.0002) GWTG-Stroke hospitals had statistically significantly improved outcomes than non-GWTG-Stroke hospitals during the PRE period for the following: discharge home, 30 and 1 year mortality, 30 day cardiovascular rehospitalization, and 1 year stroke rehospitalization Patient Characteristics Comparing Clinical Outcomes at GWTG-Stroke Hospitals to Non-GWTG-Stroke Hospitals Hospital Characteristics Overall PRE period (N = 58,830) GWTG-Stroke hospital (N = 29,217) Non-GWTG- Stroke hospital (N = 29,613) P-value (Wilcoxon two-sample / Chi- square) Patient age (mean) 79.43 years (SD 7.86) 79.60 years (SD 7.86) 79.27 years (SD 7.85) P < 0.0001 Female %59.98%59.5460.41%P < 0.030 White %84.16%85.45%82.89%P < 0.0001 Comorbidities Hypertension77.90%77.75%78.06%P = 0.358 Acute myocardial infarction 10.44%10.48%10.39%P = 0.703 Stroke8.83%8.59%9.06%P = 0.464 Coronary artery disease 33.90%33.72%34.08%P = 0.357 Diabetes29.24%28.31%30.16%P < 0.0001 Pneumonia8.55%8.43%8.67%P = 0.294 Renal disease7.24%7.06%7.42%P = 0.094 COPD19.17%18.63%19.70%P = 0.001 Dementia4.58%4.24%4.92%P < 0.0001 Carotid stenosis9.16%9.38%8.95%P = 0.069 Peripheral vascular disease 9.77%9.73%9.82%P = 0.705 Overall POST period (N = 57,056) GWTG-Stroke hospital (N = 30,058) Non-GWTG- Stroke hospital (N = 26,998) P-value (Wilcoxon two-sample / Chi- square) Patient age (mean)79.65 (SD 7.99)79.68 (7.97)79.63 (SD 8.02)P<0.339 Female %59.35%58.82%59.95%P<0.006 White %84.38%85.36%83.29%P < 0.0001 Comorbidities Hypertension79.18%79.04%79.34%P = 0.374 Acute myocardial infarction 10.44%10.89%9.95%P=0.0002 Stroke8.98%9.82%8.04%P<0.0001 Coronary artery disease 34.07%34.59%33.49%P=0.006 Diabetes29.75%29.39%30.16%P=0.044 Pneumonia8.96%8.73%9.21%P=0.046 Renal disease13.34%13.22%13.49%P=0.347 COPD19.95%19.86%20.05%P=0.567 Dementia3.88%3.85%3.92%P=0.669 Carotid stenosis11.29%13.57%8.76%P<0.0001 The majority of hospitals analyzed were from the South, followed by the Northeast; 2.73% of hospitals were in rural areas. The overall mean number of beds per hospital was 278.5, and the mean number of ischemic stroke discharges per hospital was 106.7. Clinical Outcomes for GWTG-Stroke Hospitals vs. Non-GWTG-Stroke Hospitals during the PRE period Unadjusted AnalysisAdjusted Analysis Hazard Ratio Confidence Interval Prob ChiSq Hazard Ratio Confidence Interval Prob ChiSq Discharge Home1.0181.002-1.0350.03051.0191.002-1.0370.0291 Death in 30 day from admission1.0821.037-1.1280.00031.0971.050-1.146<.0001 Death in 1 year from discharge1.0691.036-1.104<.00011.0831.047-1.120<.0001 Any Rehospitalization in 30 days after Discharge1.0310.987-1.0760.16861.0280.982-1.0750.2348 Stroke Rehospitalization in 30 days after Discharge0.9810.902-1.0670.65430.9680.887-1.0580.4776 CVD Rehospitalization in 30 days after Discharge1.1681.039-1.3120.00921.1651.031-1.3160.0146 Any Rehospitalization in 1 year after Discharge0.9910.967-1.0160.47300.9970.972-1.0230.8207 Stroke Rehospitalization in 1 year after Discharge0.9400.894-0.9890.01620.9420.894-0.9930.0267 CVD Rehospitalization in 1 year after Discharge1.0050.954-1.0600.83761.0130.959-1.0700.6380 Ratio of Adjusted Hazard Ratios at GWTG- Stroke Hospitals vs. Changes at Non-GWTG- Stroke Hospitals in RUN-UP, EARLY and SUSTAINED periods compared with PRE period RUN-UP vs. PREEARLY vs. PRESUSTAINED vs. PRE Hazard Ratio Confidence Interval Prob ChiSq Hazard Ratio Confidence Interval Prob ChiSq Hazard Ratio Confidence Interval Prob ChiSq Discharge Home 1.0861.059-1.114<.00011.0901.063-1.117<.00011.0971.078-1.117<.0001 Death in 30 day from admission 0.9480.888-1.0110.10530.8940.839-0.9530.00060.9340.892-0.9790.0040 Death in 1 year from discharge 0.9910.944-1.0400.71190.8890.848-0.933<.00010.9180.887-0.950<.0001 Any Rehospitalization in 30 days after Discharge 0.9620.900-1.0290.25681.0060.943-1.0730.86680.9870.941-1.0350.5841 Stroke Rehospitalization in 30 days after Discharge 0.9710.840-1.1230.69370.9000.781-1.0370.14551.0140.914-1.1260.7872 CVD Rehospitalization in 30 days after Discharge 0.9500.856-1.0490.51421.0320.834-1.2760.77450.9230.788-1.0810.3200 Any Rehospitalization in 1 year after Discharge 0.9900.953-1.0270.58570.9920.957-1.0290.67890.9870.962-1.0140.3376 Stroke Rehospitalization in 1 year after Discharge 0.9540.880-1.0330.24561.0000.926-1.0810.99211.0020.948-1.0600.9392 CVD Rehospitalization in 1 year after Discharge 0.9790.902-1.0630.61861.0811.000-1.1670.05071.0380.981-1.0980.1966 By using the PRE period hospital level risk rate as an offset in each model, GWTG-Stroke hospitals had comparatively: Increased rates of discharge home in the earliest time comparison (PRE vs. RUN-UP) Decreased 30 day and 1 year mortality in both EARLY and SUSTAINED vs. PRE periods Ratio of Adjusted HRs at GWTG-Stroke Hospitals vs. Changes at Non-GWTG-Stroke Hospitals: AFTER vs. BEFORE Ratio of HRs Confidence Interval Prob ChiSq Discharge Home 1.0751.060-1.091<.0001 Death in 30 day from admission 0.9840.949-1.0210.4002 Death in 1 year from discharge 0.9560.930-0.9820.0013 Any Rehospitalization in 30 days after Discharge 1.0080.971-1.0460.6940 Stroke Rehospitalization in 30 days after Discharge 0.9550.885-1.0310.2355 CVD Rehospitalization in 30 days after Discharge 1.0500.949-1.1610.3442 Any Rehospitalization in 1 year after Discharge 0.9810.960-1.0020.0744 Stroke Rehospitalization in 1 year after Discharge 0.9550.914-0.9980.0414 CVD Rehospitalization in 1 year after Discharge 1.0040.960-1.0490.8599 When time periods were combined into BEFORE and AFTER periods, GWTG- Stroke hospitals had greater improvement over time in: Discharges to home Mortality at 1 year The Most Common Baseline Stroke Patient GWTG-StrokeNon-GWTG-Stroke Time Period Est. RateStd. Err.Est. RateStd. Err. Risk adjusted 30-day Mortality PRE 16.77%1.66%17.76%2.03% RUN-UP 16.36%2.40%15.60%2.27% EARLY 14.42%2.06%16.16%2.64% SUSTAINED 14.71%1.50%15.39%1.90% BEFORE (PRE+RUN-UP) 16.64%1.37%16.25%1.53% AFTER (EARLY+SUSTAINED) 14.61%1.21%15.76%1.55% Risk adjusted 1-year Mortality PRE 27.83%1.71%28.02%2.31% RUN-UP 26.97%2.58%28.62%3.27% EARLY 24.69%2.37%24.49%2.65% SUSTAINED 23.36%1.62%26.92%2.23% BEFORE (PRE+RUN-UP) 27.27%1.43%28.14%1.88% AFTER (EARLY+SUSTAINED) 23.84%1.34%25.40%1.72% Risk adjusted discharge to home rate PRE 24.76%1.35%26.57%1.50% RUN-UP 25.51%1.97%26.01%2.01% EARLY 25.38%1.78%25.62%2.01% SUSTAINED 25.77%1.31%26.41%1.52% BEFORE (PRE+RUN-UP) 25.03%1.11%26.44%1.20% AFTER (EARLY+SUSTAINED) 25.68%1.06%26.18%1.21% We analyzed risk adjusted mortality values and rates of discharge to home for what we deemed to be our most common baseline patient We found that the risk adjusted 30 day mortality rate decreased for GWTG- Stroke patients from 16.77% in the PRE period to 14.71% in the SUSTAINED period; comparatively, non-GWTG-Stroke patients had an improvement of mortality of 17.76% to 15.39% over the same periods. There was a substantially greater degree of improvement in 30 day mortality when looking at BEFORE and AFTER rates, with GWTG-Stroke hospitals offering an improvement of 16.64% to 14.61%, compared to 16.25% to 15.76%. For1 year mortality, BEFORE and AFTER rates revealed greater improvement in the GWTG-Stroke group, with BEFORE at 27.27%, and AFTER at 23.84%; this was in comparison to non-GWTG-Stroke hospitals, who improved from 28.14% in the BEFORE period to 25.40% in the AFTER period. Methods