TY - JOUR
T1 - Quality of care for veterans with transient ischemic attack and minor stroke
AU - Bravata, Dawn M.
AU - Myers, Laura J.
AU - Arling, Greg
AU - Miech, Edward J.
AU - Damush, Teresa
AU - Sico, Jason J.
AU - Phipps, Michael S.
AU - Zillich, Alan J.
AU - Yu, Zhangsheng
AU - Reeves, Mathew
AU - Williams, Linda S.
AU - Johanning, Jason
AU - Chaturvedi, Seemant
AU - Baye, Fitsum
AU - Ofner, Susan
AU - Austin, Curt
AU - Ferguson, Jared
AU - Graham, Glenn D.
AU - Rhude, Rachel
AU - Kessler, Chad S.
AU - Higgins, Donald S.
AU - Cheng, Eric
N1 - Funding Information:
tients. This study received human subjects committee approval from the Indiana University School of Medicine Institutional Review Board and from the Richard L. Roudebush VA Medical Center Research and Development Committee. A waiver of informed consent was obtained for the collection of patient-level data. Data were not deidentified.
Funding Information:
Author Affiliations: Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative, Washington, DC (Bravata, Myers, Arling, Miech, Damush, Reeves, Williams, Graham, Cheng); VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana (Bravata, Myers, Miech, Damush, Williams, Austin, Ferguson); Department of Internal Medicine, Indiana University School of Medicine, Indianapolis (Bravata, Myers, Damush, Austin); Department of Neurology, Indiana University School of Medicine, Indianapolis (Bravata, Williams); Regenstrief Institute, Indianapolis, Indiana (Bravata, Miech, Damush, Williams); Purdue University School of Nursing, West Lafayette, Indiana (Arling); Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis (Miech); Clinical Epidemiology Research Center, VA Connecticut Healthcare System, West Haven, Connecticut (Sico); Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut (Sico, Ferguson); Department of Neurology, Yale University School of Medicine, New Haven, Connecticut (Sico); Department of Neurology, University of Maryland School of Medicine, Baltimore (Phipps); Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette, Indiana (Zillich); Department of Biostatistics, Indiana University School of Medicine, Indiana University–Purdue University, Indianapolis (Yu, Baye, Ofner); Department of Epidemiology, Michigan State University, East Lansing (Reeves); VA Nebraska-Western Iowa Health Care System-Omaha Division, Omaha (Johanning); Department of Surgery, University of Nebraska, Omaha (Johanning); Department of Neurology, Miami VA Medical Center, Miami, Florida (Chaturvedi); Department of Neurology, University of Miami School of Medicine, Miami, Florida (Chaturvedi); Specialty Care Services, Department of Veterans Affairs, Washington, DC (Graham, Higgins); Department of Neurology, University of California, San Francisco (UCSF) School of Medicine, San Francisco (Graham); VA Inpatient Evaluation Center, Cincinnati, Ohio (Rhude); Specialty Care Services, VA Central Office, Washington, DC (Kessler); Department of Emergency Medicine, Durham VA Medical Center, Durham, North Carolina (Kessler); Department of Neurology, Stratton VA Medical Center, Albany, New York (Higgins); Department of Neurology, VA Greater Los Angeles Healthcare System, Los Angeles, California (Cheng); Department of Neurology, David Geffen School of Medicine, UCLA (University of California, Los Angeles) (Cheng).
Funding Information:
This work was supported by service directed project 12-178 from the Department of Veterans Affairs (VA) Health Services Research & Development Service (HSR&D), Stroke Quality Enhancement Research Initiative. Dr Sico is supported by VA HSR&D Career Development Award HX001388-01A1. Support for VA and Centers for Medicare & Medicaid Service data was provided by grants SDR 02-237 and 98-004 from the VA Information Resource Center.
Funding Information:
Funding/Support: This work was supported by service directed project 12-178 from the Department of Veterans Affairs (VA) Health Services Research & Development Service (HSR&D), Stroke Quality Enhancement Research Initiative. Dr Sico is supported by VA HSR&D Career Development Award HX001388-01A1. Support for VA and Centers for Medicare & Medicaid Service data was provided by grants SDR 02-237 and 98-004 from the VA Information Resource Center.
PY - 2018/4
Y1 - 2018/4
N2 - IMPORTANCE The timely delivery of guideline-concordant care May reduce the risk of recurrent vascular events for patients with transient ischemic attack (TIA) and minor stroke. Although many health care organizations measure stroke care quality, few evaluate performance for patients with TIA or minor stroke, and most include only a limited subset of guideline-recommended processes. OBJECTIVE To assess the quality of guideline-recommended TIA and minor stroke care across the Veterans Health Administration (VHA) system nationwide. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 8201 patients with TIA or minor stroke cared for in any VHA emergency department (ED) or inpatient setting during federal fiscal year 2014 (October 1, 2013, through September 31, 2014). Patients with length of stay longer than 6 days, ventilator use, feeding tube use, coma, intensive care unit stay, inpatient rehabilitation stay before discharge, or receipt of thrombolysis were excluded. Outlier facilities for each process of care were identified by constructing 95% CIs around the facility pass rate and national pass rate sites when the 95% CIs did not overlap. Data analysis occurred from January 16, 2016, through June 30, 2017. MAIN OUTCOMES AND MEASURES Ten elements of care were assessed using validated electronic quality measures. RESULTS In the 8201 patients included in the study (mean [SD] age, 68.8 [11.4] years; 7877 [96.0%] male; 4856 [59.2%] white), performance varied across elements of care: brain imaging by day 2 (6720/7563 [88.9%]; 95% CI, 88.2%-89.6%), antithrombotic use by day 2 (6265/7477 [83.8%]; 95% CI, 83.0%-84.6%), hemoglobin A1c measurement by discharge or within the preceding 120 days (2859/3464 [82.5%]; 95% CI, 81.2%-83.8%), anticoagulation for atrial fibrillation by day 7 after discharge (1003/1222 [82.1%]; 95% CI, 80.0%-84.2%), deep vein thrombosis prophylaxis by day 2 (3253/4346 [74.9%]; 95% CI, 73.6%-76.2%), hypertension control by day 90 after discharge (4292/5979 [71.8%]; 95% CI, 70.7%-72.9%), neurology consultation by day 1 (5521/7823 [70.6%]; 95% CI, 69.6%-71.6%), electrocardiography by day 2 or within 1 day prior (5073/7570 [67.0%]; 95% CI, 65.9%-68.1%), carotid artery imaging by day 2 or within 6 months prior (4923/7685 [64.1%]; 95% CI, 63.0%-65.2%), and moderate- to high-potency statin prescription by day 7 after discharge (3329/7054 [47.2%]; 95% CI, 46.0%-48.4%). Performance varied substantially across facilities (eg, neurology consultation had a facility outlier rate of 53.0%). Performance was higher for admitted patients than for patients cared for only in EDs with the greatest disparity for carotid artery imaging (4478/5927 [75.6%] vs 445/1758 [25.3%]; P < .001). CONCLUSIONS AND RELEVANCE This national study of VHA system quality of care for patients with TIA or minor stroke identified opportunities to improve care quality, particularly for patients who were discharged from the ED. Health care systems should engage in ongoing TIA care performance assessment to complement existing stroke performance measurement.
AB - IMPORTANCE The timely delivery of guideline-concordant care May reduce the risk of recurrent vascular events for patients with transient ischemic attack (TIA) and minor stroke. Although many health care organizations measure stroke care quality, few evaluate performance for patients with TIA or minor stroke, and most include only a limited subset of guideline-recommended processes. OBJECTIVE To assess the quality of guideline-recommended TIA and minor stroke care across the Veterans Health Administration (VHA) system nationwide. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 8201 patients with TIA or minor stroke cared for in any VHA emergency department (ED) or inpatient setting during federal fiscal year 2014 (October 1, 2013, through September 31, 2014). Patients with length of stay longer than 6 days, ventilator use, feeding tube use, coma, intensive care unit stay, inpatient rehabilitation stay before discharge, or receipt of thrombolysis were excluded. Outlier facilities for each process of care were identified by constructing 95% CIs around the facility pass rate and national pass rate sites when the 95% CIs did not overlap. Data analysis occurred from January 16, 2016, through June 30, 2017. MAIN OUTCOMES AND MEASURES Ten elements of care were assessed using validated electronic quality measures. RESULTS In the 8201 patients included in the study (mean [SD] age, 68.8 [11.4] years; 7877 [96.0%] male; 4856 [59.2%] white), performance varied across elements of care: brain imaging by day 2 (6720/7563 [88.9%]; 95% CI, 88.2%-89.6%), antithrombotic use by day 2 (6265/7477 [83.8%]; 95% CI, 83.0%-84.6%), hemoglobin A1c measurement by discharge or within the preceding 120 days (2859/3464 [82.5%]; 95% CI, 81.2%-83.8%), anticoagulation for atrial fibrillation by day 7 after discharge (1003/1222 [82.1%]; 95% CI, 80.0%-84.2%), deep vein thrombosis prophylaxis by day 2 (3253/4346 [74.9%]; 95% CI, 73.6%-76.2%), hypertension control by day 90 after discharge (4292/5979 [71.8%]; 95% CI, 70.7%-72.9%), neurology consultation by day 1 (5521/7823 [70.6%]; 95% CI, 69.6%-71.6%), electrocardiography by day 2 or within 1 day prior (5073/7570 [67.0%]; 95% CI, 65.9%-68.1%), carotid artery imaging by day 2 or within 6 months prior (4923/7685 [64.1%]; 95% CI, 63.0%-65.2%), and moderate- to high-potency statin prescription by day 7 after discharge (3329/7054 [47.2%]; 95% CI, 46.0%-48.4%). Performance varied substantially across facilities (eg, neurology consultation had a facility outlier rate of 53.0%). Performance was higher for admitted patients than for patients cared for only in EDs with the greatest disparity for carotid artery imaging (4478/5927 [75.6%] vs 445/1758 [25.3%]; P < .001). CONCLUSIONS AND RELEVANCE This national study of VHA system quality of care for patients with TIA or minor stroke identified opportunities to improve care quality, particularly for patients who were discharged from the ED. Health care systems should engage in ongoing TIA care performance assessment to complement existing stroke performance measurement.
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U2 - 10.1001/jamaneurol.2017.4648
DO - 10.1001/jamaneurol.2017.4648
M3 - Article
C2 - 29404578
AN - SCOPUS:85045136466
VL - 75
SP - 419
EP - 427
JO - JAMA Neurology
JF - JAMA Neurology
SN - 2168-6149
IS - 4
ER -