Processes of care associated with acute stroke outcomes

Dawn M. Bravata, Carolyn K. Wells, Albert C. Lo, Steven E. Nadeau, Jean Melillo, Diane Chodkowski, Frederick Struve, Linda S. Williams, Aldo J. Peixoto, Mark Gorman, Punit Goel, Gregory Acompora, Vincent McClain, Noshene E Ranjbar, Paul B. Tabereaux, John L. Boice, Michael Jacewicz, John Concato

Research output: Contribution to journalArticle

50 Citations (Scopus)

Abstract

Background: Many processes of care have been proposed as metrics to evaluate stroke care. We sought to identify processes of stroke care that are associated with improved patient outcomes after adjustment for both patient characteristics and other process measures. Methods: This retrospective cohort study included patients 18 years or older with an ischemic stroke or transient ischemic attack (TIA) onset no more than 2 days before admission and a neurologic deficit on admission. Patients were excluded if they resided in a skilled nursing facility, were already admitted to the hospital at stroke onset, or were transferred from another acute-care facility. The combined outcome included in-hospital mortality, discharge to hospice, or discharge to a skilled nursing facility. Seven processes of stroke care were evaluated: fever management, hypoxia management, blood pressure management, neurologic evaluation, swallowing evaluation, deep vein thrombosis (DVT) prophylaxis, and early mobilization. Risk adjustment included age, comorbidity (medical history), concomitant medical illness present at admission, preadmission symptom course, prestroke functional status, code status, stroke severity, nonneurologic status, modified APACHE (Acute Physiology and Chronic Health Evaluation) III score, and admission brain imaging findings. Results: Among 1487 patients, the outcome was observed in 239 (16%). Three processes of care were independently associated with an improvement in the outcome after adjustment: swallowing evaluation (adjusted odds ratio [OR], 0.64; 95% confidence interval [CI], 0.43-0.94); DVT prophylaxis (adjusted OR, 0.60; 95% CI, 0.37-0.96); and treating all episodes of hypoxia with supplemental oxygen (adjusted OR, 0.26; 95% CI, 0.09-0.73). Conclusion: Outcomes among patients with ischemic stroke or TIA can be improved by attention to swallowing function, DVT prophylaxis, and treatment of hypoxia.

Original languageEnglish (US)
Pages (from-to)804-810
Number of pages7
JournalArchives of Internal Medicine
Volume170
Issue number9
DOIs
StatePublished - May 10 2010
Externally publishedYes

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Stroke
Deglutition
Venous Thrombosis
Skilled Nursing Facilities
Odds Ratio
Transient Ischemic Attack
Confidence Intervals
Risk Adjustment
Early Ambulation
Hospices
APACHE
Process Assessment (Health Care)
Neurologic Manifestations
Hospital Mortality
Neuroimaging
Nervous System
Comorbidity
Cohort Studies
Fever
Retrospective Studies

ASJC Scopus subject areas

  • Internal Medicine

Cite this

Bravata, D. M., Wells, C. K., Lo, A. C., Nadeau, S. E., Melillo, J., Chodkowski, D., ... Concato, J. (2010). Processes of care associated with acute stroke outcomes. Archives of Internal Medicine, 170(9), 804-810. https://doi.org/10.1001/archinternmed.2010.92

Processes of care associated with acute stroke outcomes. / Bravata, Dawn M.; Wells, Carolyn K.; Lo, Albert C.; Nadeau, Steven E.; Melillo, Jean; Chodkowski, Diane; Struve, Frederick; Williams, Linda S.; Peixoto, Aldo J.; Gorman, Mark; Goel, Punit; Acompora, Gregory; McClain, Vincent; Ranjbar, Noshene E; Tabereaux, Paul B.; Boice, John L.; Jacewicz, Michael; Concato, John.

In: Archives of Internal Medicine, Vol. 170, No. 9, 10.05.2010, p. 804-810.

Research output: Contribution to journalArticle

Bravata, DM, Wells, CK, Lo, AC, Nadeau, SE, Melillo, J, Chodkowski, D, Struve, F, Williams, LS, Peixoto, AJ, Gorman, M, Goel, P, Acompora, G, McClain, V, Ranjbar, NE, Tabereaux, PB, Boice, JL, Jacewicz, M & Concato, J 2010, 'Processes of care associated with acute stroke outcomes', Archives of Internal Medicine, vol. 170, no. 9, pp. 804-810. https://doi.org/10.1001/archinternmed.2010.92
Bravata DM, Wells CK, Lo AC, Nadeau SE, Melillo J, Chodkowski D et al. Processes of care associated with acute stroke outcomes. Archives of Internal Medicine. 2010 May 10;170(9):804-810. https://doi.org/10.1001/archinternmed.2010.92
Bravata, Dawn M. ; Wells, Carolyn K. ; Lo, Albert C. ; Nadeau, Steven E. ; Melillo, Jean ; Chodkowski, Diane ; Struve, Frederick ; Williams, Linda S. ; Peixoto, Aldo J. ; Gorman, Mark ; Goel, Punit ; Acompora, Gregory ; McClain, Vincent ; Ranjbar, Noshene E ; Tabereaux, Paul B. ; Boice, John L. ; Jacewicz, Michael ; Concato, John. / Processes of care associated with acute stroke outcomes. In: Archives of Internal Medicine. 2010 ; Vol. 170, No. 9. pp. 804-810.
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abstract = "Background: Many processes of care have been proposed as metrics to evaluate stroke care. We sought to identify processes of stroke care that are associated with improved patient outcomes after adjustment for both patient characteristics and other process measures. Methods: This retrospective cohort study included patients 18 years or older with an ischemic stroke or transient ischemic attack (TIA) onset no more than 2 days before admission and a neurologic deficit on admission. Patients were excluded if they resided in a skilled nursing facility, were already admitted to the hospital at stroke onset, or were transferred from another acute-care facility. The combined outcome included in-hospital mortality, discharge to hospice, or discharge to a skilled nursing facility. Seven processes of stroke care were evaluated: fever management, hypoxia management, blood pressure management, neurologic evaluation, swallowing evaluation, deep vein thrombosis (DVT) prophylaxis, and early mobilization. Risk adjustment included age, comorbidity (medical history), concomitant medical illness present at admission, preadmission symptom course, prestroke functional status, code status, stroke severity, nonneurologic status, modified APACHE (Acute Physiology and Chronic Health Evaluation) III score, and admission brain imaging findings. Results: Among 1487 patients, the outcome was observed in 239 (16{\%}). Three processes of care were independently associated with an improvement in the outcome after adjustment: swallowing evaluation (adjusted odds ratio [OR], 0.64; 95{\%} confidence interval [CI], 0.43-0.94); DVT prophylaxis (adjusted OR, 0.60; 95{\%} CI, 0.37-0.96); and treating all episodes of hypoxia with supplemental oxygen (adjusted OR, 0.26; 95{\%} CI, 0.09-0.73). Conclusion: Outcomes among patients with ischemic stroke or TIA can be improved by attention to swallowing function, DVT prophylaxis, and treatment of hypoxia.",
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AU - Bravata, Dawn M.

AU - Wells, Carolyn K.

AU - Lo, Albert C.

AU - Nadeau, Steven E.

AU - Melillo, Jean

AU - Chodkowski, Diane

AU - Struve, Frederick

AU - Williams, Linda S.

AU - Peixoto, Aldo J.

AU - Gorman, Mark

AU - Goel, Punit

AU - Acompora, Gregory

AU - McClain, Vincent

AU - Ranjbar, Noshene E

AU - Tabereaux, Paul B.

AU - Boice, John L.

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AU - Concato, John

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