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VA Facilities Exception to Rule with Stroke Belt Mortality

by U.S. Medicine

April 12, 2011

WASHINGTON, DC—Higher risk for post-stroke mortality in the so-called “Stroke Belt” does not seem to apply in VA facilities, according to recent research which cited increased awareness and best practice guidelines as making the difference.

stroke1.jpgResearchers have recognized since the 1960s that the 11 states that make up the “Stroke Belt” (Alabama, Arizona, Georgia, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, and Virginia) have historically shown a higher post-stroke mortality rate—40 per 100,000 people, or 10% higher than the U.S. average. This higher incidence of stroke was first reported by the Centers for Disease Control and Prevention in 1962, with the 10% mortality increase first documented by CDC in 1980.

Most recently, CDC has identified an additional “Diabetes Belt” of higher Type 2 diabetes prevalence that overlaps heavily with the Stroke Belt.

Researchers at VA’s Rehabilitation Outcomes Research Center (RORC) in Gainesville, Fla., compared VA medical centers inside and outside the Stroke Belt on average stroke volume, inpatient stroke care quality, and post-stroke mortality. They identified 3,909 ischemic stroke patients admitted in FY 2007 across 129 VAMCs, excluding those admitted exclusively for post-stroke rehabilitation.

During emergency department admissions and other instances where patients were admitted to the hospital very shortly after having a stroke, researchers looked at hospitals’ use of the NIH stroke scale, thrombolytic therapy, early ambulation, fall risk assessment, pressure ulcer risk assessment, and dysphagia screening. During the patients’ hospital stay, they examined DVT prophylaxis, rehabilitation assessment, atrial fibrillation management, and antithrombotic therapy. And during discharge, they checked for antithrombotic therapy, lipid management, smoking cessation counseling, and stroke education.

Of the 3,909 patients examined, 1,098 were seen in VAMCs within the Stroke Belt, indicating that volume was comparatively high for those facilities. The 30-day post-stroke mortality rate was 8% in the Stroke Belt versus 6% outside, which was not statistically significant. And the 12-month mortality rate was 19% both inside and outside the Stroke Belt.

As for the quality indicators, Stroke Belt facilities ranked higher in dysphagia screening and smoking cessation counseling, but showed no significant difference in the other 12 indicators.

“Despite the fact that Stroke Belt VAMCs had higher volume, there were few differences found in quality of care. They appear to be providing equivalent, if not better, care. And there was no difference in mortality,” explained RORC researcher Jaime Castro at the recent VA Health Services R&D conference. “We want to expand our analysis to non-VA service use and also try to identify patterns by socioeconomic characteristics, such as race and income, and identify further geographic variation, by distance travelled to a VA facility.”

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