Quality of care for transient ischemic attack and minor stroke vary across country

1. In this study about quality of care for patients with TIA or minor stroke, there was substantial variation in adherence to guidelines for patients treated at Veteran’s Affairs (VA) hospitals across the country.

2. Patients who were evaluated and discharged from the emergency department without inpatient admission were less likely to receive guideline-adherent treatment.

Evidence Rating Level: 3 (Average)      

Study Rundown: Patients with TIA or minor stroke, defined as radiographically confirmed infarct with complete resolution of clinical deficits, are at high risk for recurrent ischemic events. Adherence to guideline-recommended interventions has been shown to improve outcomes in these patients. Many hospital quality assessment programs focus on stroke rather than TIA, but the clinical course and interventions for major stroke and TIA/minor strokes are different. The current study examined the quality of care, as measured by adherence to guideline recommendations, for minor stroke and TIA at VA hospitals across the United States. The study found that among the ten measures of quality of care for minor stroke/TIA, there was variation in the proportion of patients receiving appropriate care, both between the measured index, and across institutions. Patients admitted to hospital and who had neurology consultation were more likely to adhere to guideline-recommended care.

The study highlights the variation in quality of care for patients with minor stroke/TIA who may otherwise not be readily assessed by quality control initiatives that focus on stroke alone. The major strength of this study was its large, modern, cross-national population which was consistently evaluated across ten diverse measures of care. The main limitations included the male-predominant population, and the lack of ability to control for important patient factors and covariates due to lack of data.

Click to read the study in JAMA Neurology

Relevant Reading: Differences in Acute Ischemic Stroke Quality of Care and Outcomes by Primary Stroke Center Certification Organization

In-Depth [retrospective cohort]: The study included all patients with TIA or ischemic stroke treated at a VA-affiliated emergency or inpatient department for the fiscal year of October 2013-September 2014. It excluded patients with major stroke identified as having length of stay greater than 6 days, coma, need for ventilator, feeding tube, intensive care unit, inpatient rehabilitation, or thrombolysis. Ten electronic quality control measures were evaluated which represented adherence to guideline-recommended care.

For the 8201 patients included in the study, 96% were male and 59% were white. The quality control measure with the least adherence was moderate- to high-potency statin prescription [47.2%,95%CI, 46.0%-48.4%]; while brain imaging by day 2 had the highest adherence at 88.9% (95%CI, 88.2%-89.6%). Performance varied significantly across facilities, with outlier percentage ranging from 5.7% to 54.7% for the ten quality control measures. Patients treated as inpatients, and those with neurology consultation were more likely to have guideline-adherent care.

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