Correlation of Quality Metrics of Acute Stroke Care with Clinical Outcomes in an Indian Tertiary-care University Hospital: A Prospective Evidence-based Study
Bijoy Kumar Panda, Vaibhav R Suryawanshi, Gargi Attarde, Nilima Borkar, Shivakumar Iyer, Jignesh Shah
Adherence, Clinical outcomes, Intracerebral hemorrhage, Ischemic stroke, Quality metrics, Quality of care
Citation Information :
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.
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.
Johnston SC, Mendis S, Mathers CD. Global variation in stroke burden and mortality: estimates from monitoring, surveillance, and modelling. Lancet Neurol 2009;8(4):345–354. DOI: 10.1016/S1474-4422(09)70023-7.
Khurana D, Padma MV, Bhatia R, Kaul S, Pandian J, Sylaja PN, et al. Guideline Core Committee. Recommendations for the early management of acute ischemic stroke: A consensus statement for healthcare professionals from the Indian Stroke Association. J Stroke Med 2018;1(2):79–113. DOI: 10.1177/2516608518777935.
Kamalakannan S, Gudlavalleti ASV, Gudlavalleti VSM, Goenka S, Kuper H. Incidence & prevalence of stroke in India: A systematic review. Indian J Med Res 2017;146(2):175–185. 10.4103/ijmr.IJMR_516_15.
Dalal PM, Bhattacharjee M, Vairale J, Bhat P. Mumbai stroke registry (2005–2006): Surveillance using WHO steps stroke instrument—challenges and opportunities. J Assoc Physicians India 2008;56: 675–680. PMID: 19086353.
Nagaraja D, Gururaj G, Girish N, Panda S, Roy AK, Sharma GRK, et al. Feasibility study of stroke surveillance: Data from Bangalore, India. Indian J Med Res 2009;130(4):396–403. PMID: 19942742.
Reeves MJ, Arora S, Broderick JP, Frankel M, Heinrich JP, Hickenbottom S, et al. Acute stroke care in the US: Results from 4 pilot prototypes of the Paul Coverdell National Acute Stroke Registry. Stroke 2005;36(6):1232–1240. 10.1161/01.STR.0000165902.18021.5b.
Schwamm LH, Fonarow GC, Reeves MJ, Pan W, Frankel MR, Smith EE, et al. Get with the guidelines—stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation 2009;119(1):107–115. DOI: 10.1161/CIRCULATIONAHA.108.783688.
Reeves MJ, Parker C, Fonarow GC, Smith EE, Schwamm LH. Development of stroke performance measures: Definitions, methods, and current measures. Stroke 2010;41(7):1573–1578. DOI: 10.1161/STROKEAHA.109.577171.
Jauch EC, Saver JL, Adams Jr HP, Bruno A, Connors JJ, Demaerschalk BM, et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44(3):870–947. DOI: 10.1161/STR.0b013e318284056a.
Fonarow GC, Reeves MJ, Smith EE, Saver JL, Zhao X, Olson DW, et al. Characteristics, quality indicators, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in get with the guidelines—stroke. Circ Cardiovasc Qual Outcomes 2010;3(3):291–302. DOI: 10.1161/CIRCOUTCOMES.109.921858.
Smith EE, Saver JL, Alexander DN, Furie KL, Hopkins LN, Katzan IL, et al. Clinical performance measures for adults hospitalized with acute ischemic stroke: Performance measures for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014;45(11):3472–3498. DOI: 10.1161/STR.000000 0000000045.
Hemphill III JC, Adeoye OM, Alexander DN, Alexandrov AW, Amin–Hanjani S, Cushman M, et al. Clinical performance measures for adults hospitalized with intracerebral hemorrhage: Performance measures for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018;49(7):e243–e261. DOI: 10.1161/STR.0000000000000171.
Wang Y, Li Z, Zhao X, Liu L, Wang C, Wang C, et al. Evidence-based quality indicators and outcomes in patients with acute ischemic stroke: Findings from the China National Stroke Registry. Circ Cardiovasc Quality Outcomes 2018;11(12):e001968. DOI: 10.1161/CIRCOUTCOMES.115.001968.
Banks JL, Marotta CA. Outcomes validity and reliability of the modified Rankin scale: implications for stroke clinical trials: A literature review and synthesis. Stroke 2007;38(3):1091–1096. DOI: 10.1161/01.STR.0000258355.23810.c6.
Saver JL, Chaisinanunkul N, Campbell BC, Grotta JC, Hill MD, Khatri P, et al. Stroke Treatment Academic Industry Roundtable. Standardized nomenclature for modified Rankin scale global disability outcomes: Consensus recommendations from stroke therapy academic industry roundtable XI. Stroke 2021;52(9):3054–3062. DOI: 10.1161/STROKEAHA.121.034480.
Li Z, Pandian J, Sylaja PN, Wang Y, Zhao X, Liu L, et al. Quality of care for ischemic stroke in China vs India: Findings from national clinical registries. Neurology 2018;91(14):e1348– e1354. DOI: 10.1212/WNL.0000000000006291.
Gu HQ, Yang X, Wang CJ, Zhao XQ, Wang YL, Liu LP, et al. Clinical characteristics, management, and in-hospital outcomes in patients with stroke or transient ischemic attack in China. JAMA Network Open 2021;4(8):e2120745. DOI: 10.1001/jamanetworkopen.2021.20745.
Ren N, Ogata S, Kiyoshige E, Nishimura K, Nishimura A, Matsuo R, et al. Associations between adherence to evidence-based, stroke quality indicators and outcomes of acute reperfusion therapy. Stroke 2022;53(11):3359–3368. DOI: 10.1161/STROKEAHA.121.038483.
Haas K, Rücker V, Hermanek P, Misselwitz B, Berger K, Seidel G, et al. Association between adherence to quality indicators and 7-day in-hospital mortality after acute ischemic stroke. Stroke 2020;51(12):3664–3672. DOI: 10.1161/STROKEAHA.120.029968.
Machline–Carrion MJ, Santucci EV, Damiani LP, Bahit MC, Málaga G, Pontes–Neto OM, et al. Effect of a quality improvement intervention on adherence to therapies for patients with acute ischemic stroke and transient ischemic attack: A cluster randomized clinical trial. JAMA neurology 2019;76(8):932–941. DOI: 10.1001/jamaneurol.2019.1012.
Samavedam S. If time is neuron, what are we waiting for? Indian J Crit Care Med 2023;27(2):87–88. DOI: 10.5005/jp-journals-10071-24412.
Shah A, Diwan A. Stroke thrombolysis: Beating the clock. Indian J Crit Care Med 2023;27(2):107–110. DOI: 10.5005/jp-journals-10071- 24405.
Fonarow GC, Zhao X, Smith EE, Saver JL, Reeves MJ, Bhatt DL, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA 2014;311:1632–1640. DOI: https://doi.org/10.1001/jama.2014.3203.
Nagendra CV, Kumar TSS, Bohra V, Wilben V, Karan V, Huded V. Factors affecting the effective management of acute stroke: A prospective observational study. Indian J Crit Care Med 2018;22(3):138–143. DOI: 10.4103/ijccm.IJCCM_232_17.
Gurav SK, Zirpe KG, Wadia RS, Pathak MK, Deshmukh AM, Sonawane RV, et al. Problems and limitations in thrombolysis of acute stroke patients at a tertiary care center. Indian J Crit Care Med 2015;19(5): 265–269. DOI: 10.4103/0972-5229.156468.
Barber PA, Zhang J, Demchuk AM, Hill MD, Buchan AM. Why are stroke patients excluded from TPA therapy? An analysis of patient eligibility. Neurology 2001;56(8):1015–1020. DOI: 10.1212/wnl.56.8.1015.
Kleindorfer D, Kissela B, Schneider A, Woo D, Khoury J, Miller R, et al. Eligibility for recombinant tissue plasminogen activator in acute ischemic stroke: A population-based study. Stroke 2004;35(2): e27–e29. DOI: 10.1161/01.STR.0000109767.11426.17.
Turana Y, Tengkawan J, Chia YC, Nathaniel M, Wang JG, Sukonthasarn A, et al. Hypertension and stroke in Asia: A comprehensive review from HOPE Asia. J Clin Hypertens (Greenwich) 2021;23(3):513–521. DOI: 10.1111/jch.14099.
Chen R, Ovbiagele B, Feng W. Diabetes and stroke: Epidemiology, pathophysiology, pharmaceuticals and outcomes. Am J Med Sci 2016;351(4):380–386. DOI: 10.1016/j.amjms.2016.01.011.
Boulanger M, Poon MT, Wild SH, Al-Shahi Salman R. Association between diabetes mellitus and the occurrence and outcome of intracerebral hemorrhage. Neurology 2016;87(9):870–878. DOI: 10.1212/WNL.0000000000003031.