title: Impact of systems of care and blood pressure management on stroke outcomes.
abstract: Stroke is the third leading cause of death in the United States and the leading cause of disability. Stroke patients' outcomes are strongly determined by how long they remain untreated ("time is brain"). The Joint Commission's adoption of stroke performance improvement measures combined with the Centers for Medicare and Medicaid's more recent adoption in October 2009 make a systems approach to improving stroke outcomes a higher priority. As hospitals establish local and regional stroke care systems to meet these performance measures, treatment of emergent high blood pressure (BP) is a major consideration to improve rapid triage and management of acute stroke patients. Intravenous thrombolysis with tissue plasminogen activator (tPA) is a critical quality of care component for acute ischemic stroke (AIS) treatment, but its administration is contingent on BP management. For patients with AIS who are potentially eligible for tPA and patients with intracerebral hemorrhage, timely, controlled BP may improve patient outcomes. Appropriate BP management, however, is still controversial given the heterogeneity of stroke subtypes, the varying attributes of candidate antihypertensive agents, and both local and central hemodynamics. Additionally, organizational delivery system factors may be suboptimal at some hospitals. Under current hospital stroke performance measures, payment mechanisms, and emergency department throughput measures, the impact of BP management may become transparent to patients and payers, and have important consequences for hospital-derived stroke outcomes.
authors.affiliation: Morristown Memorial Hospital, New Jersey, USA.
authors.forename: David J
authors.initials: DJ
authors.lastname: Shulkin
authors.forename: Kay E
authors.initials: KE
authors.lastname: Jewell
authors.forename: A W
authors.initials: AW
authors.lastname: Alexandrov
authors.forename: David B
authors.initials: DB
authors.lastname: Bernard
authors.forename: Gretchen M
authors.initials: GM
authors.lastname: Brophy
authors.forename: David C
authors.initials: DC
authors.lastname: Hess
authors.forename: Janis
authors.initials: J
authors.lastname: Kohlbrenner
authors.forename: Sheryl
authors.initials: S
authors.lastname: Martin-Schild
authors.forename: Stephen A
authors.initials: SA
authors.lastname: Mayer
authors.forename: W Frank
authors.initials: WF
authors.lastname: Peacock
authors.forename: Adnan I
authors.initials: AI
authors.lastname: Qureshi
authors.forename: Gene Y
authors.initials: GY
authors.lastname: Sung
authors.forename: Alan
authors.initials: A
authors.lastname: Lyles
mesh_terms: D004632:Emergency Medical Services / Q000458:organization & administration*; D004636:Emergency Service, Hospital; D006801:Humans; D006973:Hypertension / Q000188:drug therapy*; D017063:Outcome Assessment, Health Care; D020521:Stroke / Q000628:therapy*; D013997:Time Factors; D014481:United States