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Quality of Care and Outcomes for In-Hospital Ischemic Stroke

Findings From the National Get With The Guidelines-Stroke


  1. Ethan Cumbler, MD,
  2. Heidi Wald, MD, MSPH,
  3. Deepak L. Bhatt, MD, MPH,
  4. Margueritte Cox, MS,
  5. Ying Xian, MD, PhD,
  6. Mathew Reeves, BVSc, PhD,
  7. Eric E. Smith, MD, MPH,
  8. Lee Schwamm, MD and
  9. Gregg C. Fonarow, MD

Author Affiliations:

From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.S.); and Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA (G.C.F.).      

Traci Yamashita helped in the initial analysis of the Colorado Stroke Alliance's data back in 2009.                  

Background and Purpose—Analysis of quality of care for in-hospital stroke has not been previously performed at the national level. This study compares patient characteristics, process measures of quality, and outcomes for in-hospital strokes with those for community-onset strokes in a national cohort.

Methods—We performed a retrospective cohort study of the Get With The Guidelines-Stroke (GWTG-Stroke) database of The American Heart Association from January 2006 to April 2012, using data from 1280 sites that reported ≥1 in-hospital stroke. Patient characteristics, comorbid illnesses, medications, quality of care measures, and outcomes were analyzed for 21 349 in-hospital ischemic strokes compared with 928 885 community-onset ischemic strokes.                        
Results—Patients with in-hospital stroke had more thromboembolic risk factors, including atrial fibrillation, prosthetic heart valves, carotid stenosis, and heart failure (P<0.0001), and experienced more severe strokes (median National Institutes of Health Stroke Score 9.0 versus 4.0; P<0.0001). Using GWTG-Stroke achievement measures, the proportion of patients with defect-free care was lower for in-hospital strokes (60.8% versus 82.0%; P<0.0001). After accounting for patient and hospital characteristics, patients with in-hospital strokes were less likely to be discharged home (adjusted odds ratio 0.37; 95% confidence intervals [0.35–0.39]) or be able to ambulate independently at discharge (adjusted odds ratio 0.42; 95% confidence intervals [0.39–0.45]). In-hospital mortality was higher for in-hospital stroke (adjusted odds ratio 2.72; 95% confidence intervals [2.57–2.88]).                        
Conclusions—Compared with community-onset ischemic stroke, patients with in-hospital stroke experienced more severe strokes, received lower adherence to process-based quality measures, and had worse outcomes. These findings suggest there is an important opportunity for targeted quality improvement efforts for patients with in-hospital stroke.