Vascular Events Lead to Stroke About a Fourth of the Time.

INDIANAPOLIS — While many healthcare systems measure the quality of their stroke care, looking at performance early in the vascular disease process can help avoid acute events altogether.

That’s why a new study—touted as the first ever—focused on how well the VHA delivers guideline-concordant care for patients with transient ischemic attack (TIA) and minor stroke.

Results published in JAMA Neurology were generally positive but also identified potential improvement areas, especially for patients discharged from emergency departments (ED) without admission to a VAMC.

“We found high quality care including ordering of brain imaging and administration of antithrombotic agents but gaps in care quality for other important processes such as high potency statin prescription, carotid artery imaging, and electrocardiography,” said lead author Dawn Bravata, MD. “It’s imperative that the best post-TIA care possible be provided to make a subsequent stroke less likely to occur.”

Bravata is with the VA’s Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative in Washington and the VA HSR&D Center for Health Information and Communication at, Richard L. Roudebush VAMC, the Indiana University School of Medicine and the Regenstrief Institute, all in Indianapolis.

Included in the cohort study were 8,201 patients with TIA or minor stroke cared for in any VHA ED or inpatient setting from Oct. 1, 2013, through Sept. 31, 2014. The almost all-male participants, 96%, averaged 68.8 years old, with most, 59.2%, of white race.

The study excluded patients with length of stay longer than six days, ventilator use, feeding tube use, coma, intensive care unit stay, inpatient rehabilitation stay before discharge or receipt of thrombolysis. Data analysis occurred from Jan.16, 2016, through June 30, 2017, with researchers assessing 10 elements of care using validated electronic quality measures.

The study team found that performance varied across elements of care:

  • Brain imaging by Day 2 (6720/7563 [88.9%]; 95% CI, 88.2%-89.6%),
  • Antithrombotic use by Day 2 (6265/7477 [83.8%]; 95% CI, 83.0%-84.6%),
  • Hemoglobin A1c measurement by discharge or within the preceding 120 days (2859/3464 [82.5%]; 95% CI, 81.2%-83.8%),
  • Anticoagulation for atrial fibrillation by Day 7 after discharge (1003/1222 [82.1%]; 95% CI, 80.0%-84.2%),
  • Deep vein thrombosis prophylaxis by Day 2 (3253/4346 [74.9%]; 95% CI, 73.6%-76.2%),
  • Hypertension control by Day 90 after discharge (4292/5979 [71.8%]; 95% CI, 70.7%-72.9%),
  • Neurology consultation by Day 1 (5521/7823 [70.6%]; 95% CI, 69.6%-71.6%),
  • Electrocardiography by Day 2 or within one day prior (5073/7570 [67.0%]; 95% CI, 65.9%-68.1%),
  • Carotid artery imaging by Day 2 or within six months prior (4923/7685 [64.1%]; 95% CI, 63.0%-65.2%), and
  • Moderate- to high-potency statin prescription by Day 7 after discharge (3329/7054 [47.2%]; 95% CI, 46.0%-48.4%).

The report noted that quality levels also varied substantially across facilities—for example, neurology consultation had a facility outlier rate of 53.0%—although, overall, performance was higher for admitted patients than for patients cared for only in EDs. In that situation, the greatest disparity was with carotid artery imaging (4478/5927 [75.6%] vs 445/1758 [25.3%]; P < .001), according to the review.

“We found that quality of care was higher for patients who were admitted to the hospital than for patients who were cared for in the Emergency Department. For example, three-quarters of eligible patients received carotid artery imaging if they were admitted, but only one-quarter received it if they were discharged from the ED,” Bravata pointed out.

One significance of the study was that appropriate treatment of TIAs, which have symptoms similar to those of a stroke but typically last only a few minutes and usually cause no permanent damage, can help prevent full-blown strokes. Background information in the article emphasized that as many as one-fourth of patients who experience a TIA will eventually have a stroke, with about half of these strokes occurring within a year.

“The timely delivery of guideline-concordant care may reduce the risk of recurrent vascular events for patients with transient ischemic attack (TIA) and minor stroke,” the study team explained. “Although many health care organizations measure stroke care quality, few evaluate performance for patients with TIA or minor stroke, and most include only a limited subset of guideline-recommended processes.”

The VHA, which is the largest healthcare system in the United States, currently assesses the quality of care for all patients with ischemic stroke, but not for patients with TIA, and doesn’t looks at patients with minor stroke separately from those with major stroke, the article pointed out.

“This national study of VHA system quality of care for patients with TIA or minor stroke identified opportunities to improve care quality, particularly for patients who were discharged from the ED,” the study authors concluded. “Healthcare systems should engage in ongoing TIA care performance assessment to complement existing stroke performance measurement.”

1Bravata DM, Myers LJ, Arling G, Miech EJ, et. al. Quality of Care for Veterans With Transient Ischemic Attack and Minor Stroke. JAMA Neurol. 2018 Feb 5. doi: 10.1001/jamaneurol.2017.4648. [Epub ahead of print] PubMed PMID: 29404578.