1. 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, MD on behalf of the Get With The Guidelines Steering Committee and Hospitals Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

2. Disclosures GWTG-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 Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

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

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

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

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

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

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

9. From April 1 st 2003 to August 24 th 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 1 st 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 24 th, 2009) Results Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

10. Enrollment in GWTG-Stroke by Quarter Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

11. Hospital Participation in GWTG-Stroke by State N=1392 Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

12. Hospital Characteristics 1392 GWTG-Stroke Participating Hospitals CharacteristicN or % Number of Stroke Discharges0 - 100 10.0 101 - 300 46.7 301+ 43.2 Number of BedsMedian (IQR)369 (260-553) RegionNortheast25.9 Midwest19.0 South37.7 West17.3 Hospital TypeAcademic60.5 Non Academic39.5 Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

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

14. VariableLevelTotal NOverall AgeMedian Years (IQR) 1000000 72 (60-82) GenderFemale 534467 53.45 Race/EthnicityWhite 730927 73.33 Black 144140 14.46 Asian 22713 2.28 Hispanic 53691 5.39 Arrival ModeEMS 557937 58.13 Private 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/FlutterYes 158909 17.11 Stroke/TIAYes 297843 32.07 CAD/Prior MIYes 257400 27.72 Diabetes MellitusYes 281544 30.32 PVDYes 45147 4.86 HypertensionYes 723573 77.91 SmokerYes 176354 18.99 DyslipidemiaYes 358403 38.59 Patient Characteristics Total Cohort Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

15. VariableLevelIschemic Stroke Subarachnoid Hemorrhage Intracerebral Hemorrhage Stroke, Not Classified TIAP-value N (%)601599 (60.2%) 34945 (3.5%) 108671 (10.9%) 26977 (2.7%) 227788 (22.8%) Demographic AgeMedian Years 73 58 71 73 <.0001 25 th -75th 61-82 48-71 57-81 60-82 GenderFemale 52.45 61.61 49.29 53.14 56.86<.0001 Race/EthnicityWhite 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 Modefrom 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 Minutes 25 th -75th 165 62-465 145 57-386 117 55-327 160 63-472 113 60-258 <.0001 NIH Stroke Scale* Median 5 3 9 4 1<.0001 25 th -75th 2-11 0-15 3-19 1-9 0-3 Patient Characteristics by Event Type Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

16. VariableIschemic Stroke Subarachnoid Hemorrhage Intracerebral Hemorrhage Stroke, Not Classified TIAP-value Total601599 (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<.0001 Diabetes 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 Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

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

18. Performance MeasureISSAHICHSNCTIAP-value* Acute PM IV rt-PA 2 Hour 59.51 NA. Early Antithrombotics 95.08NA 95.86<.0001 DVT Prophylaxis 88.80 91.53 86.82 80.79 NA<.0001 Discharge PM Antithrombotics 95.91 NA 95.15<.0001 Anticoag for AF 91.11 NA 89.11<.0001 100 or ND 77.46 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 Measure89.1489.5486.4481.1087.50<.0001 Performance Measures by Event Type Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

19. Quality MeasuresISSAHICHSNCTIAP-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 54.36NA<.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 Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

20. Temporal Trends in Acute Stroke and TIA Care 2003-2009 Temporal trend P value is <0.0001 for each measure Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

21. Measures N2003200420052006200720082009P-value All-or-None Measure Overall 657288 43.99 57.60 62.74 69.04 74.88 81.34 84.26<.0001 IS412832 41.10 55.42 60.72 67.13 73.72 80.34 83.87<.0001 SAH18190 54.92 65.63 75.91 82.72 87.73 92.57 94.29<.0001 ICH53047 60.56 69.13 73.15 79.30 84.43 91.69 92.99<.0001 SNC10585 55.83 69.62 71.29 76.97 81.87 86.06 85.34<.0001 TIA162634 48.11 59.32 64.04 69.46 73.64 79.22 81.55<.0001 Composite Measure Overall2139019 72.30 80.22 82.86 86.07 88.97 91.72 93.08<.0001 IS563300 73.46 81.25 83.55 86.52 89.50 92.29 93.65<.0001 SAH20730 60.04 68.66 78.80 85.26 89.54 93.91 95.38<.0001 ICH62074 63.03 70.85 74.77 80.57 85.49 92.40 93.54<.0001 SNC13250 58.06 71.51 72.90 78.50 83.18 86.75 86.13<.0001 TIA219753 74.69 80.86 82.76 85.38 87.43 89.94 90.92<.0001 Temporal Trends in Acute Stroke and TIA Care 2003-2009 Summary Performance Measures Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

22. Unadjusted (2003 to 2009)Adjusted (2003 to 2009) * OutcomeCategoryORLower (95% CI) Upper (95% CI) P- value ORLower (95% CI) Upper (95% CI) P-value All-or-NoneOverall 7.804 7.054 8.633<.001 9.390 8.31610.603<.001 MeasureIS 8.255 7.428 9.175<.00110.079 8.88011.440<.001 SAH10.047 8.01612.592<.00116.71212.26022.779<.001 ICH10.537 8.74312.698<.00115.82612.51320.016<.001 SNC 7.631 5.42610.732<.001 8.025 5.35012.037<.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). Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22 All-or-None Performance Measure

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

24. VariableLevel OverallIschemic Stroke Subarachnoi d Hemorrhage Intracerebral Hemorrhage Stroke, Not Classified TIAP-value Total Admissions 1,000,000601,599 (60.2%) 34,945 (3.5%) 108,671 (10.9%) 26,977 (2.7%) 227,788 (22.8%) Discharge Status Died Discharge 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<.0001 Skilled 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 2.43 Hospice 3.00 3.56 2.31 5.64 3.25 0.32 Transfer 2.84 2.68 9.14 4.61 4.19 1.27 Left AMA/Other 0.63 0.53 0.43 0.32 0.73 1.06 AmbulatoryIndependent 53.64 47.52 45.53 28.22 49.39 81.22<.0001 StatusWith Assistance 25.26 29.85 19.53 27.35 28.11 13.11 Unable 17.86 19.54 28.95 39.80 17.24 3.17 Not Documented 3.25 3.09 5.99 4.64 5.26 2.50 Length of StayMedian 4 4 8 5 4 2<.0001 25 th -75th 2-6 3-7 3-16 3-9 2-6 1-4 Mean 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 Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

25. UnadjustedAdjusted + OutcomeEvent Type (vs. IS) ORLower (95% CI) Upper (95% CI) P-valueORLower (95% CI) Upper (95% CI) P-value In-HospitalSAH 4.25 4.03 4.52<.001 5.42 5.13 5.72<.001 MortalityICH 5.70 5.50 5.91<.001 5.82 5.62 6.03<.001 SNC 1.07 0.99 1.160.102 1.11 1.02 1.200.011 TIA 0.04 0.05<.001 0.06 0.05 0.06<.001 DischargeSAH 1.05 1.00 1.100.052 0.64 0.61 0.67<.001 HomeICH 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<.001 TIA 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<.001 ICH 1.44 1.40 1.48<.001 1.49 1.44 1.54<.001 SNC 0.84 0.80 0.88<.001 0.84 0.80 0.89<.001 TIA 0.22 0.21 0.23<.001 0.23 0.24<.001 Clinical Outcomes by Cerebrovascular Event Type Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22 + Adjusted for patient and hospital characteristics. See manuscript for variables

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

27. Temporal Trends in Mortality 2003-2009 Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22 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).

28. Variable (%)2003200420052006200720082009P-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 54.860.0010 ICH 33.01 31.74 32.15 33.01 32.37 32.32 31.660.1238 SNC 47.64 52.89 52.48 53.40 56.41 53.05 55.530.0227 TIA 82.73 86.29 86.06 85.84 85.03 86.110.2978 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 31.150.0027 TIA 18.30 18.49 16.88 16.31 15.54 14.27 14.91<.0001 Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22 Temporal Trends in Clinical Outcomes 2003-2009

29. Unadjusted (2003 to 2009)Adjusted (2003 to 2009) * OutcomeCategoryORLower (95% CI) Upper (95% CI) P- value ORLower (95% CI) Upper (95% CI) P-value In-HospitalOverall 0.86 0.80 0.92<.001 0.98 0.92 1.030.392 MortalityIS 0.81 0.76 0.87<.001 0.90 0.84 0.960.002 SAH 0.84 0.73 0.960.013 1.17 1.01 1.360.034 ICH 0.89 0.81 0.970.006 1.09 0.99 1.200.088 SNC 0.65 0.52 0.81<.001 0.77 0.61 0.960.020 TIA 0.59 0.38 0.910.017 0.62 0.44 0.870.006 DischargeOverall 1.09 1.04 1.13<.001 0.99 0.95 1.030.631 HomeIS 1.12 1.07 1.16<.001 1.02 0.97 1.060.519 SAH 1.23 1.08 1.390.002 0.86 0.74 0.990.041 ICH 0.97 0.89 1.060.468 0.74 0.67 0.82<.001 SNC 1.20 1.04 1.380.012 1.10 0.95 1.270.210 TIA 1.08 0.99 1.180.101 1.05 0.95 1.150.352 LOSOverall 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 1.261.00 1.600.055 1.12 0.84 1.500.427 ICH 1.04 0.94 1.140.494 0.97 0.87 1.090.625 SNC 0.84 0.72 0.990.037 0.85 0.72 1.010.067 TIA 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

30. Clinical Outcomes by Calendar Year for Ischemic Stroke Patients Outcome 2003 (12,549) 2004 (26,252) 2005 (60,414) 2006 (102,282) 2007 (131,891) 2008 (159,825) 2009 (108,386) P value Mortality 5.85.95.8 5.75.5 5.2<.001 Discharge Home 46.847.148.348.448.748.949.6<.001 LOS (> 4 days) 46.547.546.547.146.043.539.7<.001 Total Ischemic Stroke Patients N = 601,599 Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

31. UnadjustedAdjusted+ OutcomeOR95 CI P valueOR95. CI95 CIP value Mortality 0.811 0.758 0.868<.001 0.900 0.841 0.9630.002 Discharge Home 1.117 1.072 1.163<.001 1.015 0.971 1.0600.519 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 Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22

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

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

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

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

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