Evidence-Based Performance Measures and Outcomes in Patients With Acute Ischemic Stroke

Author Response

How to cite this article: Panda BK, Suryawanshi VR, Attarde G, Borkar N, Iyer S, Shah J. Author Response. Indian J Crit Care Med 2024;28(4):408-409.

10-year Temporal Trends of Intravenous Thrombolysis in Acute Ischemic Stroke: Analysis of the China National Stroke Registry I-Ⅲ

OBJECTIVES

To investigate the 10-year trend in healthcare quality of intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator in acute ischemic stroke (AIS) in China.

MATERIALS AND METHODS

We analyzed 42,188 AIS within 7 days of onset from the China National Stroke Registry (CNSR) Ⅰ-Ⅲ. Primary outcomes were temporal changes in the proportion of patients arriving at the hospital within 3.5 hours (and 2 hours) of onset and receiving IVT within 4.5 hours (and 3 hours), stratified by region and hospital tier. Secondary outcomes included temporal changes in door-to-needle time (DNT), DNT ≤60 min and favorable outcome defined as a 90-day modified Rankin Scale (mRS) of 0-1.

RESULTS

Among patients arriving at the hospital within 3.5 hours of onset, 13.5%, 7.1% and 33.4% patients received IVT within 4.5 hours in CNSR Ⅰ, Ⅱ and Ⅲ, respectively, including a higher proportion from eastern China (37.0%) and tertiary hospitals (36.5%). The median DNT was shorter in CNSR Ⅲ (60.0 min) than those in Ⅱ (95.0 min) and I (94.0 min). The proportion of patients with DNT ≤60 min was greater in Ⅲ (53.4%) than those in Ⅱ (26.7%) and Ⅰ (13.4%). The proportion of favorable outcomes was higher in CNSR Ⅲ (72.8%) than those in Ⅱ (49.6%) and Ⅰ (49.4%). Similar trends were observed for patients arriving at the hospital within 2 hours and receiving IVT within 3 hours of onset.

CONCLUSIONS

The healthcare quality of IVT has improved remarkably in the past decade, notably in eastern China and tertiary hospitals.

Correlation of Quality Metrics of Acute Stroke Care with Clinical Outcomes in an Indian Tertiary-care University Hospital: A Prospective Evidence-based Study

Aim

To characterize the impact of adherence to quality metrics of stroke care on the clinical outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) admissions.

Methods

Consecutive patients with acute stroke were prospectively followed up for their demographic and clinical characteristics, acute stroke management, and associated clinical outcomes at discharge. Stroke quality metrics [adopted from the American Heart Association (AHA)/American Stroke Association's Get with The Guidelines (GWTG)] with a specific interest in an association between acute reperfusion therapies and functional recovery in stroke patients are analyzed and presented. A composite measure of care was considered "0 (non-adherence) to 1 (adherence)." An all-or-none measure of care was calculated to check whether eligible patients received all the quality-of-care interventions. Multivariate Cox regression models were used to study an association between optimal adherence and clinical outcomes.

Results

During the study period, of the total 256 stroke admissions, 200 (78.1%) patients had IS, and the remaining 56 (21.9%) patients had ICH. The median [interquartile range (IQR)] age of total stroke admissions was 57 (36-78) years. Male preponderance was observed (IS: 80% and ICH: 67.9%). The conformity of performance metrics in IS patients was from 69.1% [95% confidence interval (CI), 68.5-69.6] for the use of deep vein thrombosis prophylaxis (DVTp) to 97.8% (95% CI, 96.2-98.6) for the use of statins. In ICH patients, it ranged from 61.7% (95% CI, 60.4-62.5) for the use of DVTp to 89.9% (95% CI, 88.6-89.7) for stroke rehabilitation. The unadjusted odds ratio (OR) of mortality (in-hospital plus the 28th-day postdischarge) was higher in ICH patients vs IS patients (4.42, p = 0.005). Optimal adherence with intravenous recombinant tissue plasminogen activator (IV-rtPA) therapy [hazards ratio (HR) = 0.23], in-hospital acute measures [IS (HR = 0.41) and ICH (HR = 0.63)], and discharge measures [IS (HR = 0.35) and ICH (HR = 0.45)] were associated with reduced hazards of the 28th-day mortality in both cohorts. Compared to ICH, IS patients had significantly improved neurofunctional recovery [modified Rankin score (mRS) ≤ 2, p < 0.01].

Conclusion

Adherence to quality metrics and performance measures was associated with low mortality and favorable clinical outcomes. Also, DVTp as an in-hospital (acute) measure of stroke care needs attention in both cerebrovascular events.

How to cite this article

Panda BK, Suryawanshi VR, Attarde G, Borkar N, Iyer S, Shah J. Correlation of Quality Metrics of Acute Stroke Care with Clinical Outcomes in an Indian Tertiary-care University Hospital: A Prospective Evidence-based Study. Indian J Crit Care Med 2023;27(11):806-815.

Variation in stroke care at the hospital level: A cross-sectional multicenter study

Introduction

Stroke is one of the leading causes of mortality and disability. Improving patient outcomes can be achieved by improving stroke care and adherence to guidelines. Since wide variation in adherence rates for stroke guidelines still exists, we aimed to describe and compare stroke care variability within Belgian hospitals.

Materials and methods

An observational, multicenter study was performed in 29 Belgian hospitals. We retrospectively collected patient characteristics, quality indicators, and time metrics from the last 30 consecutive patients per hospital, diagnosed with ischemic stroke in 2019 with structured questionnaires. Mean adherence ratios (%) ± SD (minimum - maximum) were calculated.

Results

We analyzed 870 patient records from 29 hospitals. Results showed large inter- and intrahospitals variations in adherence for various indicators. Almost all the patients received brain imaging (99.7%) followed by admission at a stroke unit in 82.9% of patients. Of patients not receiving thrombolysis, 92.5% of patients were started on antithrombotic drugs. Indicators with moderate median adherence but large interhospital variability were glycemia monitoring [82.3 ± 16.7% (26.7-100.0%)], performing clinical neurological examination and documentation of stroke severity [63.1 ± 36.8% (0-100%)], and screening for activities of daily living [51.1 ± 40.3% (0.0-100.0%)]. Other indicators lacked adequate adherence: swallowing function screening [37.0 ± 30.4% (0.0-93.3%)], depression screening [20.2 ± 35.8% (0.0-100%)], and timely body temperature measurement [15.1 ± 17.0% (0.0-60%)].

Conclusion

We identified high adherence to guidelines for some indicators, but lower rates with large interhospital variability for other recommendations also based on robust evidence. Improvement strategies should be implemented to improve the latter.

Quality of acute ischemic stroke care at a tertiary Hospital in Ghana

Background

Information on the quality of acute ischemic stroke care provided in lower-to-middle income countries is limited.

Objective

This study was undertaken to examine the quality of acute ischemic stroke care provided at Tamale Teaching Hospital in Ghana.

Methods

The medical records of patients admitted into the medical ward of the hospital between January to October 2021 were reviewed retrospectively. Extent of compliance to 15 stroke performance indicators were determined.

Results

Under the study period, 105 patients were admitted at the hospital with acute ischemic stroke. The mean (±SD) age was 65 ± 12 years; 38.1% were males; 65.7% had National Health Insurance Scheme coverage. Glasgow Coma Scale was the only functional stroke rating scale used by physicians to rate stroke severity. About a quarter of the patients had CT scan performed within 24 h of admission. Less than a quarter of the patients had a last known well time documented. Rate of thrombolytic administration was 0%. Less than a quarter of the patients were prescribed venous thromboembolism prophylaxis on the day of admission or day after. Only 13.8% of patients had documented reasons for not being prescribed venous thromboembolism prophylaxis. Antiplatelet therapy was prescribed to 33.3% of the patients by the end of day 2 of admission. Anticoagulation was prescribed to all patients who had comorbid condition of atrial fibrillation as part of the discharge medications. More than half of the patients were discharged to go home with statin medications. Documented stroke education was provided to 31.4% caretakers or patients. Slightly less than half of the patients were assessed for or received rehabilitation. Less than a quarter had documented dysphagia screening within 24 h of admission. None of the patient had their stroke severity rated with National Institutes of Health Stroke Scale on arrival. No patient obtained carotid imaging assessment by end of day 2.

Conclusion

There were several gaps in the quality of acute ischemic stroke care provided to patients at the Tamale Teaching Hospital. With the exception of discharging patients on statin medications, there was poor adherence to all other stroke performance indicators.

Concurrency of Early-Age Exposure to Chinese Famine and Diabetes Increases Recurrence of Ischemic Stroke

Background and Purpose: Early age exposure to the Chinese Great Leap Forward famine (1959–1961) is associated with the incidence of risk factors for ischemic stroke. This study aims to examine the relationship between early age famine exposure and 12-month stroke recurrence. We sought to explore the interaction between famine exposure status and metabolic phenotypes on stroke recurrence and how the adherence of crucial evidence-based key performance indicators (KPI) would modify this interaction.

Methods: We analyzed data of patients who were born between 1953 and 1964 in the China National Stroke Registry II (CNSR-II). The study population was further divided into five subgroups for comparing 12-month stroke recurrence. A multivariate Cox proportional hazard regression model was used in analyzing the impact of the concurrence of metabolic phenotypes—type 2 diabetes (T2D) or metabolic syndrome (MetS)—and early-age famine exposure on recurrent risk. The influence of the adherence to predefined KPI and concurrency of metabolic phenotype was also evaluated.

Results: Concurrent T2D and early age famine exposure was associated with an increased recurrence risk of ischemic stroke with 12 months [adjusted hazard ratio (HR): 1.63, 95% confidence interval (CI) 1.28–2.07]. Optimal adherence to KPI was not associated with significantly reduced risk of 12-month stroke recurrence (adjusted HR: 0.80, 95% CI: 0.51–1.26).

Conclusions: Concurrency of early-age famine exposure and diabetes mellitus was associated with a higher risk of stroke recurrence within 12 months, and adherence to evidence-based KPI did not reduce the risk significantly.

Trends and predictors of myocardial infarction or vascular death after ischaemic stroke or TIA in China, 2007-2018: insights from China National Stroke Registries

Background

Although stroke management, primary and secondary preventions have been improved in China last decades, the trends and predictors of major vascular events after ischaemic stroke or transient ischaemic attack (TIA) at national scale are less known.

Methods

Data were obtained from the three phases of China National Stroke Registry (CNSR), including CNSR-Ⅰ (years 2007–2008), CNSR-Ⅱ (years 2012–2013) and CNSR-III (years 2015–2018). For comparison, patients who were diagnosed as ischaemic stroke or TIA were included. Kaplan-Meier estimates of myocardial infarction (MI) or vascular death were calculated at 1 year. Independent predictors were further assessed with a Cox proportional hazards regression.

Results

From 2007 to 2018, a total of 50 284 patients with ischaemic stroke or TIA were enrolled in this study. A declining trend was found in 1-year MI or vascular death (p for trend <0.001), while recurrent stroke depicted a U-shape curve with a nadir in 2012–2013 cohort. A similar trend was also observed in patients who were admitted to 26 hospitals in all three CNSRs. In 2015–2018 cohort, only 251 (1.7%; 95% CI 1.5% to 1.9%) MI or vascular death had occurred at 1 year. Older age, previous stroke or TIA, history of coronary artery disease and the National Institutes of Health Stroke Scale >6 were associated with both an increased risk of MI or vascular death and recurrent stroke. While early antiplatelet therapy and lipid-lowering agents at discharge predicted a reduced risk.

Conclusion

A declining trend and current low incidence of MI or vascular death, rather than recurrent stroke, after ischaemic stroke or TIA were observed in China. Traditional factors were found as independent predictors. These findings suggested there is still much room to improve for stroke management.

Impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke

Background:

Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are on the increase in the Asia Pacific, particularly in Malaysia. Various health organizations have recommended guidelines for managing ischemic stroke, but adherence to key performance indicators (KPI) from the guidelines and impact on patient outcomes, particularly mortality, are rarely explored.

Objective:

This study aims to evaluate the impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke.

Methods:

We included all first-ever ischemic stroke patients enrolled in the multiethnic Malaysian National Neurology Registry (NNeuR) - a prospective cohort study and followed-up for six months. Patients’ baseline clinical characteristics, risk factors, neurological findings, treatments, KPI and mortality outcome were evaluated. The KPI nonadherence (NAR) and relationship with mortality were evaluated. NAR>25% threshold was considered suboptimal.

Results:

A total of 579 first-ever ischemic stroke patients were included in the final analysis. The overall mortality was recorded as 23 (4.0%) in six months, with a median (interquartile) age of 65 (20) years. Majority of the patients (dead or alive) had partial anterior circulation infarct, PACI (43.5%; 34.0%) and total anterior circulation infarct, TACI (26.1%; 8.8%). In addition, DVT prophylaxis (82.8%), anticoagulant for atrial fibrillation (AF) patients (48.8%) and rehabilitation (26.2%) were considered suboptimal. NAR < 2 was significantly associated with a decrease in mortality (odds ratio 0.16; 0.02-0.12) compared to NAR>2. Survival analysis showed that death is more likely in patients with NAR>2 (p=0.05).

Conclusions:

KPI nonadherence was associated with mortality among ischemic stroke patients. The adherence to the KPI was sub-optimal, particularly in DVT prophylaxis, anticoagulant for AF patients and rehabilitation. These findings reflect the importance of continuous quality measurement and implementation of evidence recommendations in healthcare delivery to achieve optimal outcome among stroke patients.