Following Guidelines Reduced Mortality in Veterans at High Risk of Recurrent Stroke

Lower Odds of Death

Overall, the study team determined that nine processes were independently associated with lower odds of both 90-day and one-year mortality after adjustment for multiple comparisons. Those were:

1. Carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72);

2. Antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83);

3. Lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78);

4. Lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85);

5. Discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88);

6. Cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77);

7. Antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87);

8. Antithrombotics at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88); and

9. Neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87).

In addition, anticoagulation for atrial fibrillation was associated with lower odds of one-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85).

On the other hand, the researchers reported that no processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons.

The goal was to identify the processes of care that were associated with improvements in vascular risk and could be implemented across healthcare systems. “It might not be possible to identify individual processes that confer benefit because patients may receive several processes at the same time or through a shared structure of care (e.g., an admission order set),” the researchers pointed out. “Although the VA system does not use a specific TIA or stroke admission order set or care pathway, we hypothesized that a bundle of processes might be routinely ordered, and therefore, we examined the six processes that were found to be effective in acute TIA management studies (i.e., brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation).”

The study team emphasized that the six without-fail processes should be routinely available, because they do not require advanced structures of care. The issue was more complex when it came to individual process of care, however.

“We were surprised that not more individual processes of care were independently associated with improved outcomes,” the authors wrote. “Our analyses may have been limited by relatively high pass rates on several processes. For example, although antithrombotic medications were associated with lower odds of mortality, they were not associated with recurrent stroke risk. A meta-regression of trials from the 1970s to 1990s indicated that approximately 14% of patients with stroke have a recurrent stroke during 32 months of follow-up, and the recurrent stroke risk can be reduced by 15% (95% CI, 6%-23%) with aspirin. It may be that our cohort of patients with TIA and nonsevere ischemic stroke, who had a one-year recurrent stroke rate of 10.7% and a pass rate of antithrombotics at discharge of 87%, may have included too few eligible patients who did not receive antithrombotics to detect differences in recurrent stroke risk.

“However, among 67 892 patients in the Get With the Guidelines-Stroke cohort, aspirin use was also not statistically associated with a reduction in one-year recurrent stroke risk. Therefore, it may be that the effect of antithrombotics on stroke risk is less robust now than was observed in the clinical trials, many of which were conducted before the advent of high-potency statins.”

The study urged widespread implementation of the six without-fail interventions at the VA and other healthcare system, as well as individual processes of care .

Researchers from Indiana University, the Regenstrief Institute, Michigan State University, UCLA, Yale University, Purdue University and the University of Maryland also participated in the study.

1. 1. Bravata DM, Myers LJ, Reeves M, Cheng EM, et. Al. Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke. JAMA Netw Open. 2019 Jul 3;2(7):e196716. doi: 10.1001/jamanetworkopen.2019.6716. PubMed PMID: 31268543.