Background:
It is estimated that 7%–15% of all strokes occur in the hospital. It might be expected that strokes occurring in the inpatient setting would receive higher quality of care, more rapid evaluation, and a better chance for treatment than those that happen outside the hospital. However evidence from prior research indicates significant in‐hospital evaluation delays and lower adherence to some measures of quality care.
Methods:
Quality of care for strokes with onset in the hospital was examined using cohort analysis of a prospective statewide stroke database maintained by the Colorado Stroke Alliance (CSA), a voluntary consortium of 35 hospitals participating in the Get‐with‐the‐Guidelines stroke quality initiative.
Results:
Sixteen of 35 Colorado hospitals reported both in‐hospital and community strokes from 2005 to 2009. They contributed 116 in‐hospital strokes and 4946 strokes from the community. The percentage of in‐hospital strokes reported varied widely, from 0% to 18.5% of all strokes reported by CSA hospitals. Demographics of in‐hospital strokes were similar to those occurring in the community with the exception that patients with in‐hospital strokes were significantly mone likely to have a prior history of coronary artery disease (36.7% versus 26.5%, P = 0,02). and in‐hospital strokes were more severe (NIHSS 9.5 versus 7.0. P = 0.01). Time to evaluation was twice the goal of 25 minutes but not significantly different than community strokes (54 versus 43 minutes, P = 0.13). Quality of care was better for in‐hospital strokes for the consensus quality measures of stroke education delivered (90.4% versus 73.1%, P = 0.0002) and assessment for rehabilitation (67.7% versus 45.2%, P < 0.0001). Total deficit‐free care was better for in‐hospital strokes compared with strokes in the community (52.6% versus 32.3%, P < 0.0001). Thrombolytic treatment rates were similar (9.7% versus 11.7%, P = 0.54). However in‐hospital strokes had a significantly higher rate of medical contraindications to intravenous thrombolysis (68% versus 37%, P < 0.0001).
Conclusions:
Quality of care for in‐hospital strokes is comparable for many measures to strokes with onset in the community, and it may be better for the delivery of stroke education and assessment for rehabilitation needs. Data from this statewide registry suggests that few patients with strokes in the hospital receive thrombolysis despite the natural advantage of having stroke onset in a monitored setting, which may relate to a higher rate of medical contraindications. Variability in reporting by participating hospitals suggests in‐hospital strokes are underrecognized or underreported. This may overestimate quality of care for in‐hospital stroke because of reporting bias and limits the ability to evaluate and improve quality of care for this important subset of stroke patients. In‐hospilal stroke evaluation limes remain more than twice the recommended benchmark of 25 minutes, and this represents an opportunity for process quality improvement.
Author Disclosure:
E. Cumbler, none; D. Smith, none; P. Murphy, none; W. Jones, none; H. Wald, none; J. Kutner, none.