Quality of hospital and outpatient care after stroke or transient ischemic attack: insights from a stroke survey in the Netherlands.
OBJECTIVE
Limited data are available on management of outpatients with stroke or transient ischemic attack (TIA) and on clinicians' reasons for withholding procedures recommended by guidelines. We assessed to what extent guidelines are appropriately applied after ischemic stroke or TIA, in admitted patients as well as outpatients.


METHODS
A survey was conducted in 11 centers in the Netherlands, which prospectively enrolled 579 admitted patients and 393 outpatients. Data were collected by trained research assistants. Duplicate assessment in 10% of patients showed good agreement with neurologists (median kappa=0.86). Treating neurologists were asked to provide arguments for withholding recommended procedures in eligible patients.


RESULTS
Recommended acute procedures were provided in the majority of admitted patients, but less often in outpatients: brain imaging (98% and 93%, respectively), 12-lead ECG (96% and 81%), laboratory tests (97% and 86%), aspirin within 48 hours (90% and 68% of eligible patients). Secondary preventive measures were not always taken in both eligible inpatients and eligible outpatients: carotid endarterectomy (provided in 31% and 30% of patients), antiplatelet agents (93% and 90%), oral anticoagulants (60% and 48%), antihypertensive agents (57% and 44%), and cholesterol-lowering therapy (71% and 52%). Reasons for withholding recommended procedures were plausible for almost all admitted patients, but were unclear in the majority of outpatients.


CONCLUSIONS
Compared with other national stroke surveys, we found high-quality acute care in admitted ischemic stroke patients, whereas secondary prevention was comparably poor. Although the majority of our centers have rapid-access TIA clinics, there is still substantial potential to improve quality of stroke care in outpatients.
Scholte op Reimer
Wilma J M
WJ
Erasmus Medical Center, Department of Cardiology, Rotterdam, The Netherlands. w.scholteopreimer@erasmusmc.nl
Dippel
Diederik W J
DW
Franke
Cees L
CL
van Oostenbrugge
Robert J
RJ
de Jong
Gosse
G
Hoeks
Sanne
S
Simoons
Maarten L
ML
D000368:Aged; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D002317:Cardiovascular Agents / Q000627:therapeutic use; D003952:Diagnostic Imaging / Q000706:statistics & numerical data; D003955:Diagnostic Tests, Routine / Q000706:statistics & numerical data; D004363:Drug Utilization / Q000706:statistics & numerical data; D042241:Early Diagnosis; D016894:Endarterectomy, Carotid / Q000706:statistics & numerical data; D005260:Female; D019983:Guideline Adherence / Q000706:statistics & numerical data*; D006306:Health Surveys; D006757:Hospital Units / Q000706:statistics & numerical data*; D006785:Hospitals, University / Q000706:statistics & numerical data; D006801:Humans; D007297:Inpatients; D002546:Ischemic Attack, Transient / Q000453:epidemiology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D009426:Netherlands / Q000453:epidemiology; D010044:Outpatient Clinics, Hospital / Q000706:statistics & numerical data; D010045:Outpatients; D011446:Prospective Studies; D011785:Quality Assurance, Health Care; D011787:Quality of Health Care / Q000706:statistics & numerical data*; D020521:Stroke / Q000145:classification / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control / Q000628:therapy*; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data; D013997:Time Factors; D028761:Withholding Treatment / Q000706:statistics & numerical data*
D002317:Cardiovascular Agents