Circulation: Stroke guideline program improves care, especially among elderly

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Hospitals that participate in the Get With The Guidelines–Stroke initiative have narrowed the age-related gaps in care and outcomes for acute ischemic stroke patients in all age groups, but particularly benefiting the elderly, according to a study published online Feb. 8 in Circulation.

Gregg C. Fonarow, MD, from the University of California, Los Angeles, and colleagues wrote that despite the fact that ischemic stroke is disproportionately borne by older patients, it is these very patients who have been subject to a lower use of guideline-recommended therapy and who have had worse post-stroke outcomes.

Researchers analyzed more than 500,000 ischemic stroke admissions to 1,256 hospitals participating in the American Heart Association/American Stroke Association’s Get With The Guidelines–Stroke initiative from 2003 to 2009. Patients were grouped according to age: less than 50 years, 50 to 59, 60 to 69, 70 to 79, 80 to 89, and older than 90.

Fonarow and colleagues used seven predefined performance and discharge measures:

  • IV recombinant tissue plasminogen activator (tPA) used in patients who arrive less than two hours after symptom onset and treated within three hours of symptom onset;
  • Antithrombotic medication prescribed within 48 hours of admission;
  • Deep venous thrombosis (DVT) prophylaxis within 48 hours of admission in patients at risk for DVT ;
  • Antithrombotic medication prescribed at discharge;
  • Anticoagulation prescribed at discharge in patients with documented atrial fibrillation;
  • Lipid-lowering medication prescribed at discharge if LDL was greater than 100 mg/dL, if patient was treated with lipid-lowering agent before admission, or if LDL was not documented; and
  • Smoking cessation intervention

 
Researchers found that performance on all individual process measures was lower in older patients in two group–those ages 80 to 89 years and those ages 90 years or older–compared to younger patients.

Patients with ischemic stroke were 31 percent less likely to be discharged home and were 27 percent more likely to die in the hospital with each 10-year age increase.

The use of guideline-recommended therapies, however, improved substantially in older patients from 2003 to 2009, according to the study. Use of IV tPA increased more than three-fold from 20.4 percent in 2003 to 62.4 percent in 2009 in eligible patients age 90 and older. Use of lipid lowering therapy increased dramatically from 15.6 percent in 2003 to 71.7 percent in 2009 in patients age 90 and older. Significant improvements were also noted in the other performance measures.

“By the end of the study, many of the age-related treatment differences were substantially reduced or eliminated. These findings suggest that Get With The Guidelines–Stroke may have contributed to these very impressive improvements in care,” Fonarow said.

Researchers noted that black and Hispanic patients disproportionately represented those less than 50 years old, while women represented the majority of older patients. They also attributed current or recent smoking as a factor associated with stroke at a younger age

“These age-related differences in clinical characteristics provide insight into which factors and comorbid conditions may be associated with ischemic stroke in different age groups,” they wrote.