Keywords:
quality indicators, health care - transient ischemic attack - stroke, prevention & control
Palavras-chave:
indicadores de qualidade em assistência à saúde - ataque isquêmico transitório - acidente vascular cerebral, prevenção & controle
Despite the widely-available evidence supporting that clinical interventions can improve health outcomes for patients hospitalized with transient ischemic attack (TIA) or acute ischemic stroke (AIS), many patients do not receive these recommended approaches[1]. Recognizing that both knowledge and acceptance of guidelines do not necessarily indicate guideline adherence, the American Stroke Association developed a national quality improvement program for TIA and AIS, the “Get With The Guidelines®–Stroke” (GWTG-S). The program is aimed at closing the adherence gap by making different hospital systems of care more uniform[2],[3]. After implementation, a significant improvement in stroke treatment quality was found after one year in hospitals using the GWTG-S program[4].
Patients with TIA have a high risk of stroke, up to 15% in three months. Unlike patients with stroke, those with TIA frequently present to the hospital after symptom resolution, giving them and caregivers a false sense of safety[5]. A head-to-head comparison of adherence rates between TIA and AIS, however, has not been previously addressed[4],[6]. Therefore, based on the GWTG-S program, we compared the performance measures between TIA and AIS, in a private joint commission-accredited tertiary hospital.
METHODS
Patients and data collection
We retrospectively analyzed a database of consecutive patients admitted with TIA or AIS to a private tertiary hospital certified by the Joint Commission International as a Primary Stroke Centre in São Paulo, Brazil, from August 2008 to December 2013. This database is an ongoing institutional initiative created as part of a quality assurance/quality improvement program for stroke treatment.
Eligible patients were those without any documented medical contraindication, as well any reason for non-treatment for each of the applicable measures[4],[6].
A TIA was defined as a brief episode of neurological dysfunction caused by focal brain or retinal ischemia, with clinical symptoms typically lasting less than one hour, and without evidence of acute infarction on neuroimaging[5]. This study was approved by the Local Ethics Committee of the Hospital Israelita Albert Einstein.
Measurement of quality indicators
The GWTG-S treatment quality indicators applicable to both AIS and TIA evaluated were: 1) antithrombotic medication (antiplatelet or anticoagulant) use within 48 hours of admission; 2) discharge use of antithrombotic medication; 3) discharge use of anticoagulation for atrial fibrillation; 4) dosing of low density lipoprotein (LDL) and treatment for LDL ≥ 100 mg/dl in patients meeting National Cholesterol Education Program Adult Treatment Panel III guidelines; 5) counseling for smoking cessation; and 6) stroke education provided to patient and/or caregiver.
All measures indicate the proportion of eligible patients (those without documented reasons for non-treatment) who received the intervention described[7]. A composite measure score of performance was calculated by summing the numerators for each measure across the patients evaluated to create a composite numerator (all the care that was given), summing the denominators for each measure to form a composite denominator (all the care that should have been given), and reporting the ratio of all the needed care that was given. The percentage of adherence to these measures was also obtained for each individual patient through an all-or-none adherence-eligibility index, which was calculated by the ratio between eligible measures and compliance to them in a single patient[6],[7].
Statistical analysis
Data were reported as mean and standard deviation or median and interquartile range. Categorical variables were reported as percentage and were compared among groups with the Χ2 test or Fisher's exact test, as appropriate. Associations between dichotomous and continuous variables were assessed by the Mann-Whitney U test. Appropriateness of parametric testing was analyzed with the Kolmogorov-Smirnov test, Q-Q plots, and histograms. Multiple linear regression was used to adjust for potential confounders of the association between cerebrovascular disease subtype (AIS or TIA) and the adherence-eligibility index. All variables that showed an association in the univariate analysis with a p value < 0.1 were included in the multivariate model. The statistical significance was set at the α ≤ 0.05 level. All analyses were performed by the statistical department of the hospital using SPSS Statistics version 17.0 (IBM Corp. Armonk, NY).
RESULTS
A total of 1,144 consecutive patients with TIA (n = 357; 31.2%) and AIS (n = 787; 68.8%) were evaluated from August 2008 to December 2013. Patients with TIA were younger (66.1 ± 15.7 versus 71.8 ± 16.1 years old, p < 0.01) and had a lower frequency of previous stroke (16.9% versus 25.8%, p < 0.01) than patients with AIS. The median ABCD[2] score, a risk assessment tool designed to improve the prediction of short-term stroke risk in patients with TIA, was 3 (95% CI [2,4]) ([Table 1]).
Table 1
Baseline characteristics of the patients.
|
Variable
|
TIA (n = 357)
|
AIS (n = 787)
|
p-value
|
|
Age (mean ± SD)
|
66.1 ± 15.7
|
71.8 ± 16.1
|
< 0.01
|
|
Females gender
|
47.1%
|
42.4%
|
0.14
|
|
NIHSS at admission
|
0 [0, 1]
|
3 [1, 10.75]
|
< 0.01
|
|
Atrial fibrillation
|
11%
|
15.5%
|
0.04
|
|
Previous stroke
|
16.9%
|
25.5%
|
< 0.01
|
|
Previous TIA
|
5.3%
|
2.3%
|
< 0.01
|
|
Coronary artery disease
|
14.9%
|
16.6%
|
0.45
|
|
Diabetes mellitus
|
27.5%
|
29.9%
|
0.42
|
|
Hypertension
|
53.1%
|
59.2%
|
0.05
|
|
Smoking
|
5.3%
|
6.7%
|
0.36
|
|
Dyslipidemia
|
31.2%
|
26.4%
|
0.09
|
Data reported as mean and standard deviation (± SD) or median and interquartile range; NIHSS: National Institutes of Health Stroke Scale; TIA: transient ischemic attack; AIS: acute ischemic stroke.
The following performance measures were similar between TIA and AIS groups: antithrombotic medication use within 48 hours of admission (96.8% in versus 98.5%, p = 0.08), discharge on anticoagulation for atrial fibrillation (93% versus 88.5%, p = 0.4) and counseling for smoking cessation (61.1% versus 80.4%, p = 0.1), respectively. On the other hand, the use of antithrombotics, lipid lowering treatment and stroke education at discharge were all less-frequently observed in the TIA group than in the AIS group (95% versus 98%, p = 0.01; 57.7% versus 64.1%, p < 0.01; and 56.5% versus 74.5%, p < 0.01, respectively) ([Table 2]).
Table 2
Individual performance measures of care by cerebrovascular event type.
|
Quality indicator of care
|
TIA (n = 357)
|
AIS (n = 787)
|
p-value
|
|
Early antithrombotics
|
96.8%
|
98.5%
|
0.08
|
|
Antithrombotics at discharge
|
95%
|
98%
|
0.01
|
|
Anticoagulation for atrial fibrillation
|
93%
|
88.5%
|
0.4
|
|
LDL 100
|
57.7%
|
64.1%
|
< 0.01
|
|
Smoking cessation counseling
|
61.1%
|
80.4%
|
0.01
|
|
Stroke education
|
56.5%
|
74.5%
|
< 0.01
|
|
Perfect care composite measure
|
66%
|
75%
|
< 0.01
|
Early antithrombotics: antithrombotic medication (antiplatelet or anticoagulant) use within 48 hours of admission; LDL: low density lipoprotein; LDL 100, dosing of LDL and treatment for LDL ≥ 100 mg/dl in patients meeting the National Cholesterol Education Program Adult Treatment Panel III; TIA: transient ischemic attack; AIS: acute ischemic stroke.
The median of composite measure score was 75 (95%CI [50,78]). In comparative analyses, the composite measure score was significantly lower in patients with TIA than in the AIS group (66 versus 75, p < 0.01). Moreover, a previous diagnosis of hypertension (p = 0.04), dyslipidemia (p < 0.01) and having a previous AIS rather than a TIA (p < 0.01) were found to be independently associated with a higher adherence-eligibility index.
DISCUSSION
This study characterized patterns of TIA care in the context of contemporary guidelines and is among the first to compare the quality of care with the care delivered to patients with AIS. The monitored performance measures found to be less-frequently performed in patients with TIA were the use of antithrombotics, lipid-lowering treatment and stroke education at discharge. This finding could indicate an opportunity for improvements in quality of care in this population.
The GWTG-S is a remarkable initiative from the American Heart Association/American Stroke Association, which is associated with substantial and sustained improvements in acute stroke care and secondary prevention performance measures[4]. Optimizing care of both TIA and AIS is a global priority. Since a TIA shares the same pathophysiology as an AIS, preventive measures are similar for the two conditions, and both conditions have been addressed in the same guidelines for stroke prevention. Because TIA, by definition, is reversible in the short term, this is consequently much less alarming than an AIS to patients, family members and even to caregivers[5]. The milder and reversible clinical presentation may lead to the lower adherence to preventive measures. Consistent with this idea, this study observed that adherence to the GWTG-S quality indicators was lower in patients with TIA. This difference has also been reported in the United States[6]
-
[9]. This is a systematically underestimated, alarming finding, especially because a TIA comprises a major risk factor for further stroke.
This study has some limitations. Firstly, this was a retrospective observational single-center study with a relatively-small sample size and non-matched groups. Moreover, long-term follow up to determine the actual clinical impact of adherence to the GWTG-S quality indicators was not evaluated. However, it is the first study in Brazil to analyze compliance with the GWTG-S recommendations in TIA patients and could serve as an important alert to the differences in care between patients with AIS and TIA. The implementation of a national stroke quality improvement program designed specifically for Brazil or Latin America should be developed.
In conclusion, adherence to the GWTG-S quality indicators was lower in patients with TIA compared to patients with AIS. Measures should be undertaken to reinforce the importance of such clinical interventions in patients with TIA.
