Circ: When hospitals follow stroke guidelines, does it help?

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Does the Get with the Guidelines Stroke program improve outcomes? A study published in the October issue of Circulation: Cardiovascular Quality and Outcomes found that while hospitals participating in this program may increase the number of ischemic stroke patients treated and improve the quality of care provided, it remains unknown whether performance improvements resulted in meaningful changes in outcomes for stroke patients.

“Prior Get With The Guidelines (GWTG)-Stroke reports have shown large and rapid increases in compliance with stroke performance measures over time,” Mathew J. Reeves, PhD, of Michigan State University in East Lansing, Mich., and colleagues wrote. “However, the degree to which these changes reflect actual improvements in patient care has not been determined.”

To understand how this program affects stroke care, Reeves and colleagues evaluated data on 569,883 ischemic stroke admissions to 1,028 GWTG-Stroke hospitals between April 2003 and September 2009. The authors analyzed seven measures: intravenous recombinant tissue plasminogen activator therapy, early antithrombotics, deep vein thrombosis (DVT) prophylaxis, anticoagulants for atrial fibrillation/flutter, discharge antithrombotics, lipid therapy and smoking cessation.

During the study, Reeves and colleagues set out to study the performance trends of ischemic stroke cases treated at GWTG-Stroke hospitals. Patients enrolled in the study had a median age of 73 years, 52.4 percent were women, 26.6 percent were nonwhite, 29 percent had a history of coronary heart disease and 4.7 percent had a history of stroke.

Of the 569,883 patients included in the study, 79 percent had hypertension, 39 percent had dyslipidemia, 32 percent had diabetes, 19 percent had atrial fibrillation and 4.7 percent had carotid stenosis.

For DVT, the proportion of patients treated increased between 2003 and 2009, from 69.4 percent to 91 percent. For lipid treatment, the proportion of eligible patients who received treatment doubled from 39.9 percent in 2003 to 83.7 percent in 2009. The authors also reported that the documentation of contraindications declined significantly over the seven-year period from 58.4 percent in 2003 to 27.1 percent in 2009.

Between 2003 and 2009, the number of current smokers who received intervention increased dramatically from 43 percent to 94.5 percent, respectively.

“The most important conclusion from this study is that the improvements in performance measure compliance in the GWTG-Stroke program appear to reflect an increase in the number of eligible patients who received guideline-based care rather than reflecting shifts in the size of the target populations or increased documentation of contraindications,” Reeves and colleagues wrote.

“We found little evidence that the performance improvements in the GWTG-Stroke program resulted from individual hospitals reducing the number of patients reported as being eligible for an intervention instead of providing more care to those that needed it, which has been identified as one mechanism by which registry hospitals could improve performance.”

During the study, the researchers found that all seven measures analyzed showed an increase in the proportion of eligible patients who received treatment.

“Our results strongly suggest that the GWTG-Stroke quality improvement program increased the number of eligible patients who received guideline-based care during this period, which to the extent that these care processes are clinically effective should result in meaningful improvements in stroke outcomes,” the authors concluded.

“The ultimate question, of course, is whether collecting and reporting on performance measures improves patient outcomes,” wrote Irene L. Katzan, MD, of the Cleveland Clinic, in an accompanying editorial. “Although the relationship between performance measure adherence and improved outcomes is intuitive, it is often difficult to prove a direct relationship exists.

“Indeed, it is possible that a systematic approach to care, exemplified but not limited to improved adherence to process measures, is the key, although the stroke community is still struggling to identify the clinical impact of primary stroke center certification on outcomes after stroke,” Katzan noted. "This is difficult but imperative to sort out. The analysis by Reeves and colleagues adds positive evidence to support continuing the effort to track and report performance measurement.”