title: Processes of care associated with acute stroke outcomes.
abstract: BACKGROUND
  Many processes of care have been proposed as metrics to evaluate stroke care. We sought to identify processes of stroke care that are associated with improved patient outcomes after adjustment for both patient characteristics and other process measures.
  
  
  METHODS
  This retrospective cohort study included patients 18 years or older with an ischemic stroke or transient ischemic attack (TIA) onset no more than 2 days before admission and a neurologic deficit on admission. Patients were excluded if they resided in a skilled nursing facility, were already admitted to the hospital at stroke onset, or were transferred from another acute-care facility. The combined outcome included in-hospital mortality, discharge to hospice, or discharge to a skilled nursing facility. Seven processes of stroke care were evaluated: fever management, hypoxia management, blood pressure management, neurologic evaluation, swallowing evaluation, deep vein thrombosis (DVT) prophylaxis, and early mobilization. Risk adjustment included age, comorbidity (medical history), concomitant medical illness present at admission, preadmission symptom course, prestroke functional status, code status, stroke severity, nonneurologic status, modified APACHE (Acute Physiology and Chronic Health Evaluation) III score, and admission brain imaging findings.
  
  
  RESULTS
  Among 1487 patients, the outcome was observed in 239 (16%). Three processes of care were independently associated with an improvement in the outcome after adjustment: swallowing evaluation (adjusted odds ratio [OR], 0.64; 95% confidence interval [CI], 0.43-0.94); DVT prophylaxis (adjusted OR, 0.60; 95% CI, 0.37-0.96); and treating all episodes of hypoxia with supplemental oxygen (adjusted OR, 0.26; 95% CI, 0.09-0.73).
  
  
  CONCLUSIONS
  Outcomes among patients with ischemic stroke or TIA can be improved by attention to swallowing function, DVT prophylaxis, and treatment of hypoxia.
authors.affiliation: Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center of Excellence on Implementing Evidence-Based Practice and the HSR&D Stroke Quality Enhancement Research Initiative, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 W 10th St, Indianapolis, IN 46202, USA. dawn.bravata2@va.gov
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Bravata
authors.forename: Carolyn K
authors.initials: CK
authors.lastname: Wells
authors.forename: Albert C
authors.initials: AC
authors.lastname: Lo
authors.forename: Steven E
authors.initials: SE
authors.lastname: Nadeau
authors.forename: Jean
authors.initials: J
authors.lastname: Melillo
authors.forename: Diane
authors.initials: D
authors.lastname: Chodkowski
authors.forename: Frederick
authors.initials: F
authors.lastname: Struve
authors.forename: Linda S
authors.initials: LS
authors.lastname: Williams
authors.forename: Aldo J
authors.initials: AJ
authors.lastname: Peixoto
authors.forename: Mark
authors.initials: M
authors.lastname: Gorman
authors.forename: Punit
authors.initials: P
authors.lastname: Goel
authors.forename: Gregory
authors.initials: G
authors.lastname: Acompora
authors.forename: Vincent
authors.initials: V
authors.lastname: McClain
authors.forename: Noshene
authors.initials: N
authors.lastname: Ranjbar
authors.forename: Paul B
authors.initials: PB
authors.lastname: Tabereaux
authors.forename: John L
authors.initials: JL
authors.lastname: Boice
authors.forename: Michael
authors.initials: M
authors.lastname: Jacewicz
authors.forename: John
authors.initials: J
authors.lastname: Concato
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003680:Deglutition Disorders / Q000517:prevention & control; D005260:Female; D019983:Guideline Adherence; D017052:Hospital Mortality; D006801:Humans; D000860:Hypoxia / Q000628:therapy; D002546:Ischemic Attack, Transient / Q000628:therapy*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010043:Outcome and Process Assessment, Health Care; D010102:Oxygen Inhalation Therapy; D012189:Retrospective Studies; D020379:Risk Adjustment; D020521:Stroke / Q000628:therapy*; D014481:United States; D020246:Venous Thrombosis / Q000517:prevention & control