It's the Company You Keep: Participation in Get With The Guidelines-Stroke Is Associated with Improved Inpatient Stroke Care
Disclosure: Dr. Ovbiagele has no conflicts, and Dr. Saver has modest consultant/advisory relationships with AGA Medical and Pfizer.
Pub Date: Monday, December 15, 2008
Author: Bruce Ovbiagele, MD
An unacceptably high proportion of hospitalized ischemic stroke and transient ischemic attack (TIA) patients do not receive treatment with evidence-based guideline-recommended therapies when exposed to conventional care. As such, there has been profound interest in identifying effective strategies and systems that increase the use of evidence-based therapies in the hospital to reduce the substantial morbidity and mortality that can result following an index cerebrovascular event. One strategy is the implementation of stroke hospitalization quality-improvement programs geared at optimizing appropriate therapy in the hospital, intensifying patient education, and ensuring early recognition and management of problems.
The Get With The Guidelines (GWTG)-Stroke program is an interactive, nationwide, quality-improvement initiative developed as a means for volunteer hospitals to ensure they are consistently and promptly treating stroke and TIA patients according to the most current clinical practice guidelines. GWTG-Stroke has a toolbox that contains resources to guide practitioners on identifying stroke champions, evaluating baseline data, and determining areas for improvement. Other components of GWTG-Stroke include organizational stakeholder meetings, collaborative workshops for hospital teams, and hospital recognition.
In this prospective nonrandomized study by Schwamm and colleagues, comprising baseline and consecutive quarters of participation in GWTG-Stroke from April 2003 to July 2007, the primary objective was to assess whether participation in the GWTG-Stroke program was associated with a boost in the quality of inpatient stroke care beyond that expected on the basis of secular trends. To measure quality of inpatient stroke care among eligible patients, seven performance measures, including the consideration of intravenous thrombolysis, prompt implementation of antithrombotics and deep venous thrombosis (DVT) prophylaxis, discharge treatment with antithrombotics and lipid modifiers, as well as smoking cessation management, were prospectively selected.
A safety measure, symptomatic intracranial hemorrhage within 36 hours after intravenous thrombolysis and a composite score reflecting a summary score of performance on all seven individual performance indices ("defect free" performance), were also assessed. In addition to program duration, the authors also examined secular trends based on actual calendar date of patient discharge. A multivariable logistic regression analysis determined the independent effect of time in GWTG-Stroke on the composite performance score, adjusted for secular trends, as well as hospital and patient characteristics.
Over 300,000 ischemic stroke or TIA patients with demographic and vascular risk factors comparable to large stroke registries were enrolled from 790 participating academic/community hospitals of all sizes during approximately 4 years of the program. From baseline to year 5, across all seven individual performance measures, time spent in GWTG-Stroke was associated with significant gains in adherence, particularly with regard to rates of intravenous thrombolysis (absolute rate increase +30.75%), DVT prophylaxis (+15.75%), discharge lipid modifier use for low-density lipoprotein cholesterol levels ≥100 mg/dL (+14.66%), and smoking cessation management (+28.40%). Time in the program also favorably influenced the composite measure score (+10.45%). The rate of symptomatic intracerebral hemorrhage remained low and did not significantly change. Multivariable modeling revealed that time in GWTG-Stroke was associated with a 1.18-fold yearly rise in the odds of receiving each performance measure independent of secular trends (p <0.0001). Indeed, patients treated at all types of hospitals benefited from time spent in the program, with the greatest improvement noted among larger hospitals with more bed capacity (linearly), higher stroke-discharge rates, and teaching hospitals.
This study of the GWTG-Stroke program represents the largest and longest assessment of acute and secondary preventive care among hospitalized ischemic stroke and TIA patients so far and strongly reinforces the results seen in the pilot phase of the program. Furthermore, these data build greatly upon the results of other much smaller prior studies, which have shown that a focused, timely, systematic, and evidence-based multimodal approach to the management of ischemic stroke and TIA patients significantly enhances treatment rates.[4,5]
GWTG-Stroke was independently associated with robust and persistent improvements in several indicators of quality inpatient stroke care, including prompt use of acute and secondary preventive therapies. Beyond its very broad scope, the incorporation of multivariable modeling to account for secular trends, the latter being a major confounder in studies of this kind, was another major strength of this investigation and suggested that participation in the program itself might be an effective way of boosting guideline adherence to stroke treatments. However, because program participation was voluntary, the hospitals involved in GWTG-Stroke may have been those hospitals in the country already interested and motivated to administer and improve inpatient stroke care.
Impressively, the biggest (and steepest rise) among the performance measures from baseline to year 5 was seen with the use of intravenous thrombolysis, the only FDA-approved treatment for acute ischemic stroke, and this was without any significant increase in intracerebral bleeding rates. It must, however, be noted that this increase slowed over the last 3 years of program participation and then plateaued, still leaving over 25% of eligible patients not receiving this treatment. It is clear that more needs to be done to facilitate optimal adherence to this measure. The smoking cessation management measure was the other index of quality care that showed a very large boost in adherence, which in this case was linear through year 5. The impact of GWTG-Stroke on five individual performance measures were more modest but certainly clinically worthwhile, especially when considering the potential deleterious impact of DVT on stroke outcomes and the high early risk of secondary stroke after an index cerebrovascular event.
There is little doubt that participation in GWTG-Stroke will go a long way in bridging the stroke treatment evidence-practice gap and possibly enhancing clinical outcomes among hospitalized stroke and TIA patients, with major implications for public policy given its impressive results at relatively little cost. However, optimal inpatient care is not the entire story when it comes to enhancing stroke outcomes. The reality is that many patients aren’t staying on secondary prevention drugs even in the minimum amount of time. Several studies have shown that there is a high rate of discontinuation of medications prescribed for vascular disease patients following the index vascular event.[6,7] Communication between physicians caring for the patient in the hospital and the physicians who will care for the patient afterward is essential but often suboptimal. Strategies to enhance longer-term maintenance of secondary stroke prevention medications could be important, particularly during the period of highest vascular risk. As such, there is an urgent need to craft and validate effective postdischarge adherence promotion programs to complement in-hospital intervention initiation programs, i.e. to develop "Stay With the Guidelines-Stroke" type programs that reinforce and build upon this highly successful GWTG-Stroke program.
To fully convince skeptics and ensure broader health care provider/facility participation, better quality implementation science will be needed to discriminate which specific aspects of these quality-improvement programs actually work, whether they are actually cost effective, if they can be broadly applied to various health care settings, and most importantly, how they influence clinical outcomes. Fortunately, funding agencies are increasingly recognizing this, as evidenced by the recent National Institutes of Health sponsorship of the Preventing Recurrence of Thromboembolic Events through Coordinated Treatment Trial in District of Columbia (PROTECT-DC) program (more information can be found at http://www.nrhrehab.org/Home+Page+Articles/744.aspx), and the American Heart Association sponsorship of the Systematic Use of STroke Averting INterventions (SUSTAIN) trial, both of which are randomized studies exploring interventions in the poststroke hospitalization setting.
In conclusion, the reasons for care gaps in stroke treatment are multifactorial and can be traced to patient and provider issues as well as health care-delivery processes. Fortunately, our understanding of the reasons for these gaps and avenues for bridging them has improved considerably, but there is room for growth. The study by Schwamm and colleagues is the latest and most comprehensive example of the powerful, uniform, and sustained influence a systematic quality-improvement program can have on the processes of inpatient stroke care.
- Ovbiagele B, Saver JL. Ensuring management of vascular risk factors after stroke. Rev Neurol Dis 2006;3(3):93-100.
- Ovbiagele B. Pessin award lecture 2008: lessons from the Stroke PROTECT program. J Neurol Sci 2008;275(1-2):1-6.
- LaBresh KA, Reeves MJ, Frankel MR, et al. Hospital treatment of patients with ischemic stroke or transient ischemic attack using the "Get With The Guidelines" program. Arch Intern Med 2008;168(4):411-417.
- Ovbiagele B, Saver JL, Fredieu A, et al. In-hospital initiation of secondary stroke prevention therapies yields high rates of adherence at follow-up. Stroke 2004;35(12):2879-2883.
- Californian Acute Stroke Pilot Registry (CASPR) Investigators. The impact of standardized stroke orders on adherence to best practices. Neurology 2005;65(3):360-365.
- Aronow H, Novaro GM, Lauer MS. In-hospital initiation of lipid-lowering therapy after coronary intervention as a predictor of long-term utilization: a propensity analysis. Arch Intern Med 2003;163(21):2576-2582.
- Dergalust S, Rofail MT, Bateshansky DS, Cohen SN. The incidence of discontinuation of extended release dipyridamole/aspirin, clopidogrel and warfarin for the secondary prevention of stroke. Presented at the 55th American Academy of Neurology Annual Meeting in Honolulu, Hawaii on April 3rd, 2003.
- Ovbiagele B, Drogan O, Koroshetz WJ, et al. Outpatient practice patterns after stroke hospitalization among neurologists. Stroke 2008;39(6):1850-1854.
- Sanossian N, Ovbiagele B. The risk of stroke within a week of minor stroke or transient ischemic attack. Expert Opin Pharmacother 2008;9(12):2069-2076.
-- The opinions expressed in this commentary are not necessarily those of the editors or of the American Heart Association