Transcript Characteristics, Performance Measures, and In-Hospital Outcomes of the First One Million Stroke and Transient Ischemic Attack Admissions in Get With The Guidelines-Stroke Gregg C.

Characteristics, Performance Measures,
and In-Hospital Outcomes of the First
One Million Stroke and Transient
Ischemic Attack Admissions in Get With
The Guidelines-Stroke
Gregg C. Fonarow, MD; Mathew J. Reeves, PhD; Eric E. Smith, MD, MPH;
Jeffrey L. Saver MD; Xin Zhao, MS; DaWai Olson, PhD, RN; Adrian
Hernandez, MD, MHS; Eric D. Peterson, MD, MPH; Lee H. Schwamm, MD
on behalf of the Get With The Guidelines Steering Committee and Hospitals
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Disclosures
GWTG-Stroke is sponsored by the AHA/ASA and is also supported in
part by an unrestricted educational grant from Merck/ScheringPlough Pharmaceutical.
The individual author disclosure are listed in the manuscript
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Background
• Stroke results in substantial morbidity and mortality.
• While evidence-based guidelines for stroke and TIA
care have been developed along with improved
diagnostic and treatment modalities, there are gaps,
variations, and disparities in how these are applied.
• Furthermore many hospitals may not have the
systems, organization, staff, and equipment to effectively
diagnose, manage, and treat acute stroke patients.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Background
• The Get With The Guidelines (GWTG)-Stroke Program was developed
by the AHA/ASA as a national stroke registry and performance
improvement program with the primary goal of improving the quality of
care and outcomes for stroke and TIA as well as serve as a scientific
resource for new information.
• Although several prior studies have described the quality of care and
outcomes for patients hospitalized with stroke and TIA, uncertainty
remains about care quality and clinical outcomes for contemporary
populations of patients hospitalized with stroke and TIA.
• Furthermore, little is known regarding temporal trends and whether
there have been improvement in clinical outcomes among hospitals
participating in GWTG-Stroke.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Objectives
• The objectives of this study were to analyze the
characteristics, performance measures, in-hospital
outcomes, and temporal trends in the first 1,000,000 acute
ischemic stroke, intracerebral hemorrhage, subarachnoid
hemorrhage, and TIA admissions from 1,392 hospitals that
participated in the GWTG-Stroke Program from 2003 to
2009.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Methods
• GWTG Stroke is an ongoing, voluntary, observational registry and a
continuous performance improvement program for patients hospitalized
with stroke or TIA.
• A web-based Patient Management Tool provides decision support at the
point-of-care, on-demand reporting and patient education features
(Outcome, Cambridge, MA).
• Patient data were abstracted by trained hospital personnel. These
included demographics, medical history, initial CT findings, in-hospital
treatment and events, discharge treatments, treatment contraindications,
counseling, in-hospital mortality, and discharge destination.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Methods
• Trained hospital personnel ascertained consecutive patients admitted
with acute ischemic stroke by either prospective clinical identification,
retrospective identification using ICD-9 discharge codes, or a
combination.
• Methods used for prospective identification varied, but included regular
surveillance of ED records, ward census logs, and/or neurological
consultations.
• The eligibility of each acute stroke or TIA admission was confirmed at
chart review prior to abstraction.
• Performance and quality measures were collected and reported.
• Outcomes included: % of pts with a short length of stay (LOS <4 days);
% discharged home, and in-hospital mortality.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Statistical Methods
• Characteristics, performance measures, in-hospital outcomes, and
temporal trends were evaluated. P-values were based on chi-square rank
based group means score statistics for all categorical row variables
(equivalent to Wilcoxon test for two levels).
• GEE multivariable logistic regression models were developed to
quantify how performance measures, in-hospital mortality, discharge
home, and LOS changed on a continuous basis by quarter from 2003 to
2009 and reported as cumulative change over 6 years adjusting for
patient and hospital variables.
• Since the makeup of participating hospitals may have changed over
time in GWTG-Stroke, we also performed a separate set of analyses for
temporal trends among core hospitals which were participating by 2004
and contributed cases in all subsequent quarters of the study.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Results
• From April 1st 2003 to August 24th 2009, there were 1,000,000 patients
with stroke or TIA entered from 1392 GWTG-Stroke participating
hospitals.
• There were 601,599 (60.2%) ischemic strokes, 108,671 (10.9%)
intracerebral hemorrhage s, 34,945 (3.5%) subarachnoid hemorrhages,
26,977 (2.7%) strokes not classified, and 227,788 (22.8%) TIAs.
• Stroke and TIA patients enrolled by year
2003
2004
2005
2006
2007
2008
2009
N= 18,971
N= 41,065
N= 96,139
N= 167,666
N= 220,734
N= 262,785
N= 159,083
(starting April 1st 2003)
(through August 24th, 2009)
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Enrollment in GWTG-Stroke by Quarter
1,065,836
1,000,000
897,817
750,000
598,816
500,000
362,552
250,000
182,595
73,135
26,970
11,032
0
33,997
14,635
83,349
62,649
52,015
87,165
Q2 2003 Q3 2003 Q4 2003 Q1 2004 Q2 2004 Q3 2004 Q4 2004 Q1 2005 Q2 2005 Q3 2005 Q4 2005 Q1 2006 Q2 2006 Q3 2006 Q4 2006 Q1 2007 Q2 2007 Q3 2007 Q4 2007 Q1 2008 Q2 2008 Q3 2008 Q4 2008 Q1 2009 Q2 2009 Q3 2009
New Patients
4,725
3,287
7,926
11,032
9,054
11,706
10,770
14,635
22,519
23,622
Cumulative
4,725
8,012
15,938
26,970
36,024
47,730
58,500
73,135
95,654
119,276 148,598 182,595 222,393 265,506 310,537 362,552 418,055 476,262 536,167 598,816 669,132 742,068 814,468 897,817 978,671 1,065,83
29,322
33,997
39,798
43,113
45,031
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
52,015
55,503
58,207
59,905
62,649
70,316
72,936
72,400
83,349
80,854
87,165
Hospital Participation in GWTG-Stroke by State
N=1392
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Hospital Characteristics
1392 GWTG-Stroke Participating Hospitals
Characteristic
Number of Stroke Discharges
0 - 100
101 - 300
301+
N or %
10.0
46.7
43.2
Number of Beds
Median (IQR)
Region
Northeast
Midwest
South
West
25.9
19.0
37.7
17.3
Hospital Type
Academic
Non Academic
60.5
39.5
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
369 (260-553)
Hospital Participation in GWTG-Stroke
• Hospitals in every state participate in the GWTG-Stroke Program.
• Of participating hospitals, 39.5% were non-academic institutions.
• Divided by regions, the South has the largest number of participating
hospitals (n=500), followed by the Northeast (n=346), the Midwest
(n=325), and the West (n=252).
• GWTG-Stroke participating hospitals account for an estimated
32.3% of US acute care hospitals.
• In 2008, there were 156,000 ischemic stroke patients entered into
GWTG-Stroke out of 663,000 expected in the US (25%) and 47,937
hemorrhagic stroke patients entered out of 117,000 expected in the
US (41%).
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Patient Characteristics Total Cohort
Variable
Level
Total N
Overall
Age
Median Years (IQR)
1000000
Gender
Race/Ethnicity
Female
White
Black
Asian
Hispanic
EMS
Private transport
Median Minutes (IQR)
534467
730927
144140
22713
53691
557937
334961
385304
72 (60-82)
53.45
73.33
14.46
2.28
5.39
58.13
34.90
138 (60-384)
Median (IQR)
337194
4 (1-10)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
158909
297843
257400
281544
45147
723573
176354
358403
17.11
32.07
27.72
30.32
4.86
77.91
18.99
38.59
Arrival Mode
Time to Symptom Onset
to Arrival
NIH Stroke Scale*
Medical History
Atrial Fib/Flutter
Stroke/TIA
CAD/Prior MI
Diabetes Mellitus
PVD
Hypertension
Smoker
Dyslipidemia
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Patient Characteristics by Event Type
Variable
Level
N (%)
Demographic
Age
Median Years
25th-75th
Gender
Female
Race/Ethnicity White
Black
Asian
Hispanic
Arrival Mode
from scene
Private
transport
Time to
Median
Symptom
Minutes
Onset to Arrival 25th-75th
NIH Stroke
Scale*
Median
25th-75th
Ischemic
Stroke
Subarachnoid Intracerebral
Hemorrhage Hemorrhage
Stroke, Not
Classified
TIA
P-value
601599
(60.2%)
34945
(3.5%)
108671
(10.9%)
26977
(2.7%)
227788
(22.8%)
73
61-82
52.45
73.42
14.94
2.21
5.09
59.36
33.90
58
48-71
61.61
67.33
13.79
3.55
7.79
68.60
15.02
71
57-81
49.29
67.97
15.63
3.96
6.61
73.67
16.52
73
60-82
53.14
71.52
17.10
1.76
4.69
55.38
37.50
73
60-82
56.86
76.80
12.43
1.53
5.30
46.27
48.93
<.0001
165
62-465
145
57-386
117
55-327
160
63-472
113
60-258
<.0001
5
2-11
3
0-15
9
3-19
4
1-9
1
0-3
<.0001
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
<.0001
<.0001
<.0001
Patient Characteristics by Event Type
Variable
Total
Ischemic
Stroke
Subarachnoid Intracerebral
Hemorrhage Hemorrhage
Stroke, Not
Classified
TIA
P-value
601599
(60.2%)
34945
(3.5%)
108671
(10.9%)
26977
(2.7%)
227788
(22.8%)
Atrial Fib/Flutter
19.02
7.54
16.60
16.52
13.58
<.0001
Stroke/TIA
CAD/Prior MI
Carotid Stenosis
Diabetes Mellitus
PVD
Hypertension
Smoker
Dyslipidemia
32.36
28.99
4.70
32.10
5.31
78.80
19.91
39.41
12.92
14.40
1.49
17.15
2.31
65.96
34.02
23.48
26.50
22.50
2.07
26.16
3.55
79.58
16.46
28.99
34.45
28.55
5.12
32.75
5.10
77.59
18.71
33.77
36.17
28.40
4.62
28.93
4.57
76.41
15.70
43.43
<.0001
<.0001
<.0001
<.0001
<.0001
<.0001
<.0001
<.0001
Medical History
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Patient Characteristics in GWTG-Stroke
• For the 1,000,000 acute stroke (n=772,212) and TIA (n=227,788)
admissions entered into the program, the mean age was 70.1 ± 14.9
years and over half (53.5%) were women.
• IS and TIA patients were older, more likely to be men, less likely to
be smokers, and more likely to have medical co-morbidities than ICH
and SAH patients.
• ICH patients had a relatively high prevalence of vascular risk factors,
but not as high as for IS or TIA patients.
• Patients with stroke not classified were most similar to IS patients.
• SAH patients were more likely than IS or TIA patients to be younger,
female, non-white and to be cared for in larger academic hospitals.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Performance Measures by Event Type
Performance Measure
IS
SAH
ICH
SNC
TIA
P-value*
IV rt-PA 2 Hour
59.51
NA
NA
NA
NA
.
Early Antithrombotics
95.08
NA
NA
NA
95.86
<.0001
DVT Prophylaxis
88.80
91.53
86.82
80.79
NA
<.0001
Antithrombotics
95.91
NA
NA
NA
95.15
<.0001
Anticoag for AF
91.11
NA
NA
NA
89.11
<.0001
100 or ND
77.46
NA
NA
NA
72.35
<.0001
Smoking Cessation
89.69
84.00
85.28
82.30
89.43
<.0001
All-or-None Measure
73.29
87.75
85.46
79.89
74.01
<.0001
Composite Measure
89.14
89.54
86.44
81.10
87.50
<.0001
Acute PM
Discharge PM
Summary PM
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Quality Measures by Event Type
Quality Measures
IS
SAH
ICH
SNC
TIA
P-value*
Door to CT ≤25 Minutes
35.60
23.89
39.81
27.19
20.19
<.0001
Dysphagia Screen
68.30
56.27
69.58
54.36
NA
<.0001
Stroke Education†
72.34
64.19
66.24
53.67
66.38
<.0001
Rehabilitation †
95.44
92.22
95.68
86.43
NA
<.0001
†Data collected starting 2008
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Temporal Trends in Acute Stroke and TIA Care 2003-2009
2003
2004
2005
2006
2007
2008
2009
Temporal trend P value is
<0.0001 for each measure
100%
Patients Treated .
80%
60%
40%
20%
0%
IV rt-PA 2 Hour
Early AntiThrom
DVT Proph
DC Antithrom
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Anticog for AF
LDL100
Smoking
All-or-None
Temporal Trends in Acute Stroke and TIA Care 2003-2009
Summary Performance Measures
Measures
All-or-None
Measure
Overall
IS
SAH
ICH
SNC
TIA
Composite
Measure
Overall
IS
SAH
ICH
SNC
TIA
N
2003
2004
2005
2006
2007
2008
2009
P-value
657288
412832
18190
53047
10585
162634
43.99
41.10
54.92
60.56
55.83
48.11
57.60
55.42
65.63
69.13
69.62
59.32
62.74
60.72
75.91
73.15
71.29
64.04
69.04
67.13
82.72
79.30
76.97
69.46
74.88
73.72
87.73
84.43
81.87
73.64
81.34
80.34
92.57
91.69
86.06
79.22
84.26
83.87
94.29
92.99
85.34
81.55
<.0001
<.0001
<.0001
<.0001
<.0001
<.0001
2139019
563300
20730
62074
13250
219753
72.30
73.46
60.04
63.03
58.06
74.69
80.22
81.25
68.66
70.85
71.51
80.86
82.86
83.55
78.80
74.77
72.90
82.76
86.07
86.52
85.26
80.57
78.50
85.38
88.97
89.50
89.54
85.49
83.18
87.43
91.72
92.29
93.91
92.40
86.75
89.94
93.08
93.65
95.38
93.54
86.13
90.92
<.0001
<.0001
<.0001
<.0001
<.0001
<.0001
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Temporal Trends in Acute Stroke and TIA Care 2003-2009
All-or-None Performance Measure
Unadjusted (2003 to 2009)
Outcome
Category
OR
Lower
Upper
P(95% CI) (95% CI) value
Adjusted (2003 to 2009) *
OR
Lower
Upper P-value
(95% CI) (95% CI)
All-or-None Overall
7.804
7.054
8.633
<.001
9.390
8.316
10.603
<.001
Measure
8.255
7.428
9.175
<.001
10.079
8.880
11.440
<.001
SAH
10.047
8.016
12.592
<.001
16.712
12.260
22.779
<.001
ICH
10.537
8.743
12.698
<.001
15.826
12.513
20.016
<.001
SNC
7.631
5.426
10.732
<.001
8.025
5.350
12.037
<.001
TIA
6.245
5.496
7.097
<.001
7.316
6.278
8.526
<.001
IS
*Adjusted for age, gender, race, medical history of Afib, stroke/TIA, CAD/prior MI, carotid stenosis, diabetes, PVD, hypertension, dyslipidemia,
smoking, arrival mode (EMS vs. other), on/off hour presentation (7 am-6 pm MF vs other), hospital characteristics of region, number of beds, annual
stroke volume, academic vs. not. Overall cohort also adjusted for stroke type (IS, SNC, SAH, ICH, TIA).
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Performance Measures in GWTG-Stroke
•In each successive year there were clinically meaningful and
statistically significant improvements in all 7 individual PM.
• The absolute improvement from 2003 to 2009 ranged from +4.3% for
discharge antithrombotics to +51.0% for smoking cessation (P <.0001
for all comparisons).
• IV tPA use in eligible patients increased from 29.7% to 71.6%
(+41.9%), P<0.0001.
• There was substantial and significant improvement in the all-or-none
care measure from 2003 to 2009, 44.0% to 84.3% (+40.3%),
P<0.0001 overall and for each cerebrovascular event type.
• There was also an increase in composite care from 72.3% to 93.1%
(+20.8%), P<0.0001 overall and for each event type.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Stroke-Related In-Hospital Outcomes by Cerebrovascular Event Type
Variable
Level
Overall
Ischemic Subarachnoi Intracerebral
Stroke
d Hemorrhage
Hemorrhage
Stroke, Not
Classified
TIA
P-value
Total
Admissions
1,000,000
601,599
(60.2%)
34,945
(3.5%)
108,671
(10.9%)
26,977
(2.7%)
227,788
(22.8%)
Discharge
Status
Died
Discharge
Destination
6.97
5.52
20.42
25.04
5.49
0.26
<.0001
Home
Skilled Nursing
Facility
52.54
17.44
45.98
20.38
41.01
11.39
24.21
19.44
51.01
20.87
85.47
9.19
<.0001
Rehabilitation
Hospice
Transfer
Left AMA/Other
16.58
3.00
2.84
0.63
21.33
3.56
2.68
0.53
15.31
2.31
9.14
0.43
20.73
5.64
4.61
0.32
14.47
3.25
4.19
0.73
2.43
0.32
1.27
1.06
Ambulatory
Status
Independent
With Assistance
Unable
Not Documented
53.64
25.26
17.86
3.25
47.52
29.85
19.54
3.09
45.53
19.53
28.95
5.99
28.22
27.35
39.80
4.64
49.39
28.11
17.24
5.26
81.22
13.11
3.17
2.50
<.0001
Length of Stay
Median
25th-75th
Mean
>4 Days
4
2-6
5.43
39.32
4
3-7
5.78
45.60
8
3-16
11.69
67.03
5
3-9
8.15
55.42
4
2-6
5.31
40.46
2
1-4
3.05
15.65
<.0001
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
<.0001
Clinical Outcomes by Cerebrovascular Event Type
Unadjusted
Lower Upper P-value
(95% CI) (95% CI)
OR
Adjusted +
Lower Upper P-value
(95% CI) (95% CI)
Outcome
Event Type
(vs. IS)
OR
In-Hospital
Mortality
SAH
ICH
SNC
TIA
4.25
5.70
1.07
0.04
4.03
5.50
0.99
0.04
4.52
5.91
1.16
0.05
<.001
<.001
0.102
<.001
5.42
5.82
1.11
0.06
5.13
5.62
1.02
0.05
5.72
6.03
1.20
0.06
<.001
<.001
0.011
<.001
Discharge
Home
SAH
ICH
SNC
TIA
1.05
0.49
1.28
6.30
1.00
0.48
1.23
6.14
1.10
0.50
1.33
6.47
0.052
<.001
<.001
<.001
0.64
0.42
1.29
6.96
0.61
0.41
1.23
6.77
0.67
0.43
1.35
7.16
<.001
<.001
<.001
<.001
LOS (> 4 days) SAH
ICH
SNC
TIA
2.23
1.44
0.84
0.22
2.04
1.40
0.80
0.21
2.44
1.48
0.88
0.23
<.001
<.001
<.001
<.001
2.57
1.49
0.84
0.23
2.33
1.44
0.80
0.23
2.83
1.54
0.89
0.24
<.001
<.001
<.001
<.001
+ Adjusted for patient and hospital characteristics.
See manuscript for variables
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Clinical Outcomes in GWTG-Stroke
• SAH and ICH patients had substantially higher in-hospital mortality
rates, were less likely to be discharged home, and were more likely to
be discharged to a SNF or hospice compared to IS patients.
• As expected, in-hospital mortality was very low in patients
hospitalized with TIA (0.3%).
• Adjustment for potential confounding variables and clustering of data
within hospitals did little to attenuate the cerebrovascular event type
related differences for clinical outcomes.
•The adjusted OR for in-hospital mortality for ICH compared to IS was
5.8; for SAH it was 5.4.
• After adjustment the odds of being hospitalized longer than 4 days
remained significantly elevated for SAH and ICH compared to IS.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Temporal Trends in Mortality 2003-2009
30
29.52
26.79
25.66
25
25.26
24.68
24.64
24.96
19.82
20.01
22.7
21.39
20.3
19.55
20.53
Mortality, %
20
IS
ICH
SAH
TIA
15
All
10
7.32
7.29
7.09
6.92
6.94
6.77
5.81
5.94
5.77
5.71
5.53
5.47
5.16
0.33
0.33
0.31
0.24
0.25
0.27
0.24
2003
2004
2005
2006
2007
2008
2009
Year
Temporal trend P value for ischemic stroke (P<0.0001),
intracerebral hemorrhage (P=0.0036), subarachnoid hemorrhage
(P=0.0106), transient ischemic attack (P=0.2091).
6.75
5
0
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Temporal Trends in Clinical Outcomes 2003-2009
Variable (%)
Discharge Home
Overall
IS
SAH
ICH
SNC
TIA
LOS > 4
Overall
IS
SAH
ICH
SNC
TIA
2003
2004
2005
2006
2007
2008
2009
P-value
53.81
46.76
45.17
33.01
47.64
82.73
54.50
47.09
50.73
31.74
52.89
86.29
55.72
48.30
50.24
32.15
52.48
86.06
56.44
48.35
51.18
33.01
53.40
86.06
57.08
48.60
52.05
32.37
56.41
85.84
56.35
48.81
49.97
32.32
53.05
85.03
57.07
49.61
54.86
31.66
55.53
86.11
<.0001
<.0001
0.0010
0.1238
0.0227
0.2978
40.11
46.51
61.75
51.15
33.28
18.30
41.66
47.47
61.61
54.20
42.47
18.49
40.40
46.50
64.73
53.94
42.57
16.88
40.42
47.14
65.86
55.43
43.07
16.31
39.03
46.02
66.91
55.13
39.47
15.54
38.06
43.51
69.28
56.64
39.56
14.27
35.55
39.71
65.12
51.33
31.15
14.91
<.0001
<.0001
<.0001
<.0001
0.0027
<.0001
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Temporal Trends in Clinical Outcomes 2003-2009
Outcome
Category
Unadjusted (2003 to 2009)
OR
Lower
Upper
P(95% CI) (95% CI) value
OR
Adjusted (2003 to 2009) *
Lower
Upper P-value
(95% CI)
(95% CI)
In-Hospital
Mortality
Overall
IS
SAH
ICH
SNC
TIA
0.86
0.81
0.84
0.89
0.65
0.59
0.80
0.76
0.73
0.81
0.52
0.38
0.92
0.87
0.96
0.97
0.81
0.91
<.001
<.001
0.013
0.006
<.001
0.017
0.98
0.90
1.17
1.09
0.77
0.62
0.92
0.84
1.01
0.99
0.61
0.44
1.03
0.96
1.36
1.20
0.96
0.87
0.392
0.002
0.034
0.088
0.020
0.006
Discharge
Home
Overall
IS
SAH
ICH
SNC
TIA
1.09
1.12
1.23
0.97
1.20
1.08
1.04
1.07
1.08
0.89
1.04
0.99
1.13
1.16
1.39
1.06
1.38
1.18
<.001
<.001
0.002
0.468
0.012
0.101
0.99
1.02
0.86
0.74
1.10
1.05
0.95
0.97
0.74
0.67
0.95
0.95
1.03
1.06
0.99
0.82
1.27
1.15
0.631
0.519
0.041
<.001
0.210
0.352
LOS
(> 4 days)
Overall
IS
SAH
ICH
SNC
TIA
0.74
0.72
1.26
1.04
0.84
0.58
0.70
0.68
1.00
0.94
0.72
0.53
0.79
0.77
1.60
1.14
0.99
0.64
<.001
<.001
0.055
0.494
0.037
<.001
0.72
0.71
1.12
0.97
0.85
0.58
0.69
0.67
0.84
0.87
0.72
0.53
0.77
0.76
1.50
1.09
1.01
0.64
<.001
<.001
0.427
0.625
0.067
<.001
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
* Adjusted for patient and hospital characteristics.
Clinical Outcomes by Calendar Year for
Ischemic Stroke Patients
Total Ischemic Stroke Patients N = 601,599
2003
Outcome
Mortality
2004
(12,549) (26,252)
2005
(60,414)
2006
2007
2008
(102,282) (131,891) (159,825)
2009
P value
(108,386)
5.8
5.9
5.8
5.7
5.5
5.5
5.2
<.001
Discharge
Home
46.8
47.1
48.3
48.4
48.7
48.9
49.6
<.001
LOS
(> 4 days)
46.5
47.5
46.5
47.1
46.0
43.5
39.7
<.001
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Temporal Trends in Outcomes for Ischemic Stroke
Odd Ratios for 6 Year Change 2003 to 2009
Unadjusted
Outcome
Adjusted+
OR
95 CI
95 CI
P value
OR
95. CI
95 CI
P value
Mortality
0.811
0.758
0.868
<.001
0.900
0.841
0.963
0.002
Discharge
Home
1.117
1.072
1.163
<.001
1.015
0.971
1.060
0.519
LOS
(> 4 days)
0.724
0.683
0.768
<.001
0.713
0.672
0.757
<.001
+Adjusted for PATIENT CHARACTERISTICS of age, gender, race, medical history of atrial
fibrillation, previous stroke/TIA, coronary artery disease, carotid stenosis, diabetes, peripheral
vascular disease, hypertension, dyslipidemia, smoking, arrival mode (EMS vs. other), on/off hour
presentation (7 am-6 pm M-F vs. other), and HOSPITAL CHARACTERISTICS of region, number of
beds, annual stroke volume, and teaching hospital vs. not.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Temporal Trends in Clinical Outcomes
• There were temporal trends for improvement in clinical outcomes
from 2003 to 2009.
• The portion of patients discharged home in 2003 was 53.8%
compared to 57.1% in 2009 (P<0.0001) and LOS > 4 days was seen
in 40.1% in 2003 compared to 35.6% in 2009.
• After adjustment, the portion of patients with hospital LOS >4 days
declined significantly, adjusted OR 0.72, 95% CI 0.69-0.77, P<0.0001.
• In-hospital mortality also declined significantly over time, unadjusted
OR 0.87, 95% CI 0.80-92, P<0.001, 2003 to 2009, but after risk
adjustment was only significant for ischemic stroke and TIA.
• There was a 10% risk adjusted reduced odds of mortality in patients
with IS from 2003 to 2009.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Limitations
• Data were collected by medical chart review and are dependent
upon the accuracy of documentation and abstraction.
• Residual measured and unmeasured confounding variables may
have influenced the findings.
• Further study will be needed to determine if these improvements in
outcomes are due to improved care (faster in-hospital response times,
guideline-adherence, and reduced complications or errors), secular
trends, or other reasons.
• These findings may not apply to hospitals that differ in patient
characteristics or care patterns from GWTG-Stroke Hospitals.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Conclusions
• GWTG-Stroke is the largest registry and performance improvement
programs for hospitalized stroke and TIA patients, with data from
1,000,000 admissions including more than 600,000 IS, 100,000 ICH,
30,000 SAH, and 225,000 TIA admissions.
• This study has characterized the demographics, performance
measures, and in-hospital clinical outcomes in a very broad cohort of
acute stroke and TIA hospitalizations from every state in the country.
• Among GWTG-Stroke participating hospitals there were substantial
improvements over time in performance measures, overall and for each
cerebrovascular event type.
• Composite care performance increased substantially from 72.3% to
93.1% (+20.8%) from 2003 to 2009.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Conclusions
• Among hospitals participating in GWTG-Stroke, there have been
reductions in LOS and mortality at discharge over the past 6 years in the
patients with acute ischemic stroke.
• These findings persist after adjustment for patient and hospital
characteristics.
• Further research is warranted to determine if these reductions in
mortality are due to increased adherence to inpatient care process
measures, secular trends, unmeasured confounders, or other reasons.
• Other factors might include increased public education and awareness,
increased use of EMS, improvements in in-hospital response times,
guideline-adherence, and prevention of complications or medical errors.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22
Conclusions
• This study demonstrates the ongoing value of GWTG-Stroke as an
integrated stroke and TIA national registry providing national surveillance,
supporting vigorous efforts to improve evidence-based stroke/TIA care,
and fostering innovative research.
Fonarow GC et al. Circ Cardiovasc Qual Outcomes. 2010 epub Feb 22