title: Standardized discharge orders after stroke: results of the quality improvement in stroke prevention (QUISP) cluster randomized trial.
abstract: OBJECTIVE
  Proven strategies to reduce risk of stroke recurrence are under-utilized. We sought to evaluate the impact of standardized stroke discharge orders on treatment practices in a cluster-randomized trial.
  
  
  METHODS
  The Quality Improvement in Stroke Prevention (QUISP) trial randomized 12 hospitals to continue usual care or to receive assistance in the development and implementation of standardized stroke discharge orders. All patients with ischemic stroke were identified during a 12-month period prior to implementation and for 12 months afterward, and were followed for 6 months after discharge. The primary outcome was optimal treatment at 6 months, defined as taking a statin, having blood pressure <140/90mmHg, and receiving anticoagulation if atrial fibrillation was diagnosed. The primary analysis treated the hospital as the unit of analysis, comparing optimal treatment rates-adjusted for race, age, dementia, atrial fibrillation, and history of bleeding-between intervention and non-intervention hospitals using a paired t test.
  
  
  RESULTS
  In the primary analysis with hospital as the unit of analysis, the odds of optimal treatment was not significantly increased at intervention compared to non-intervention hospitals (odds ratio, 1.39; 95% confidence interval, 0.71-2.76; p = 0.27). However, in analyses conducted at the level of the individual patients (N = 3,361), rates of optimal treatment increased from 37% to 45% in the intervention hospitals (p = 0.001) and did not change significantly in the non-intervention hospitals (39% to 40%; p = 0.27).
  
  
  CONCLUSIONS
  Implementation of standardized discharge orders after stroke was associated with increased rates of optimal secondary prevention; this improvement was not significant in the primary analysis at the hospital level.
authors.affiliation: Department of Neurology, University of California, San Francisco, San Francisco, CA 94143-0114, USA. clay.johnston@ucsfmedctr.org
authors.forename: S Claiborne
authors.initials: SC
authors.lastname: Johnston
authors.forename: Stephen
authors.initials: S
authors.lastname: Sidney
authors.forename: Nancy K
authors.initials: NK
authors.lastname: Hills
authors.forename: David
authors.initials: D
authors.lastname: Grosvenor
authors.forename: Jeffrey G
authors.initials: JG
authors.lastname: Klingman
authors.forename: Allan
authors.initials: A
authors.lastname: Bernstein
authors.forename: Eleanor
authors.initials: E
authors.lastname: Levin
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000925:Anticoagulants / Q000627:therapeutic use; D001794:Blood Pressure / Q000502:physiology; D016001:Confidence Intervals; D005260:Female; D019983:Guideline Adherence / Q000592:standards / Q000706:statistics & numerical data; D006761:Hospitals / Q000592:standards*; D006801:Humans; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors / Q000627:therapeutic use; D038801:International Classification of Diseases / Q000592:standards; D008297:Male; D016017:Odds Ratio; D010043:Outcome and Process Assessment, Health Care; D010351:Patient Discharge / Q000592:standards*; D020521:Stroke / Q000503:physiopathology / Q000628:therapy*
chemical_list: D000925:Anticoagulants; D019161:Hydroxymethylglutaryl-CoA Reductase Inhibitors