Jay Shah, MD
Quality improvement programs are essential in that they provide vital information on process of care but its impact on clinical outcomes is less known. One such program, Get With the Guidelines-Stroke (GTWG-Stroke), began in 2003 and was developed by the American Heart Association to improve stroke care infrastructure. Hospitals that enter this program have access to wide range of resources and staff support. Prior studies have shown that hospital participation was associated with increased frequency of thrombolysis and interventions to prevent complications. However, the impact on program participation has not been established. Therefore, in this study, the authors queried if clinical outcomes at GWTG-Stroke hospitals differed compared to matched patients at non-GWTG-Stroke hospitals.
This study was conducted in Medicare patients admitted within a 5-year span from 2003 to 2008. Three hundred sixty-six GWTG-Stroke hospitals were identified that had 88,000 ischemic stroke admissions compared to 366 non-GWTG-Stroke hospitals that cared for 85,000 ischemic stroke patients. Within 6 months of program participation, GWTG-Stroke hospitals had greater discharges to home and reduced mortality at 30 days and 1 year. The reduction of mortality at 1 year was sustained at 18 months after program participation.
This study found that hospital implementation in GWTG-Stroke program was associated with improved functional outcomes. It is important to note that improvement in outcomes did occur over time at non-GWTG-Stroke hospitals reflecting the overall increase in awareness, knowledge, and care of ischemic stroke patients. Stroke is a leading cause of morbidity but data on post-stroke modified Rankin scale was not available. While improvement in mortality is certainly noteworthy, improvement in morbidity remains a pertinent clinical question. It is possible that a hospital decision to participate in the program was due to hospital personnel, specifically availability of stroke-trained neurologist and nurses. Therefore, the improvement in outcomes could potentially be due to greater stroke expertise at the specific hospital rather than GWTG participation. Nonetheless, ischemic stroke is a complex disease with multiple variables and outcomes have important implications on quality of life and any method that can potentially improve outcomes should be undertaken.
Guidelines are worthless in comparing hospitals to each other. You have to measure results. Get with the Results is the appropriate way to do this.
1. 30 day deaths
2. tPA full efficacy
3. 100% stroke recovery
4. protocols efficacy for every intervention.