title: Quality of care and outcomes for in-hospital ischemic stroke: findings from the National Get With The Guidelines-Stroke.
abstract: OBJECTIVE
  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.
authors.affiliation: 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.).
authors.forename: Ethan
authors.initials: E
authors.lastname: Cumbler
authors.forename: Heidi
authors.initials: H
authors.lastname: Wald
authors.forename: Deepak L
authors.initials: DL
authors.lastname: Bhatt
authors.forename: Margueritte
authors.initials: M
authors.lastname: Cox
authors.forename: Ying
authors.initials: Y
authors.lastname: Xian
authors.forename: Mathew
authors.initials: M
authors.lastname: Reeves
authors.forename: Eric E
authors.initials: EE
authors.lastname: Smith
authors.forename: Lee
authors.initials: L
authors.lastname: Schwamm
authors.forename: Gregg C
authors.initials: GC
authors.lastname: Fonarow
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000628:therapy*; D015331:Cohort Studies; D015897:Comorbidity; D016001:Confidence Intervals; D016208:Databases, Factual; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D058996:Quality Improvement; D011787:Quality of Health Care; D012042:Registries; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D020521:Stroke / Q000628:therapy*; D015912:Thrombolytic Therapy; D016896:Treatment Outcome
keywords: outcome assessment (health care); quality indicators, health care; quality of health care; registries; stroke; thrombolytic therapy