Hospitals using quality improvement program increase compliance to stroke treatment guidelines

Hospitals participating in a voluntary quality improvement program for stroke treatment increased adherence to national recommendations, researchers reported in Circulation: Journal of the American Heart Association.

In the five-year study, the largest on acute stroke care for hospitalized patients, researchers tracked guidelines compliance among hospitals participating in the American Heart Association/American Stroke Association's Get With The Guidelines–Stroke (GWTG–Stroke) program. They found:

• Among all possible interventions to prevent another stroke or reduce stroke disability, the overall absolute percentage of interventions performed in eligible patients increased from 83.5 percent in year one to 93.7 percent in year five.
• For every year of participation, hospitals were 18 percent more likely to deliver guidelines-based care.

"These results indicate there is a very powerful effect to participating in the program," said Lee H. Schwamm, M.D., lead author of the study and a steering committee member of the GWTG program. "Participation in the program is improving the quality of care."

GWTG–Stroke is a comprehensive program that provides an online interactive assessment and report tool, resources, quarterly workshops, training and feedback to staff at participating hospitals. The goal is to improve implementation of evidence-based interventions that are proven to reduce complications after stroke and the chances of a subsequent stroke or heart attack.

"Simply publishing guidelines doesn't change physician or patient behavior," said Schwamm, who is also vice chairman of neurology at Massachusetts General Hospital in Boston. "Get With The Guidelines–Stroke helps hospitals emphasize the changes necessary to implement the guidelines effectively and consistently."

"We don't object to having an airplane pilot go through a checklist every time before takeoff and landing," he said. "We want to make sure the wheels are down before landing. Similarly, this program helps hospitals provide highly reliable care in a chaotic environment."

The analysis measured adherence to guideline recommendations in 790 hospitals across the US. Hospitals volunteered to participate in the study and provided information on 322,847 patients admitted from 2003 to 2007.

The overall composite analysis measured how often hospitals followed seven recommendations for eligible patients. Some of the key recommendations include initiation of intravenous clot-busting drugs within two hours of stroke onset; medication to prevent blood clots within 48 hours of admission and at discharge; antithrombotic treatment for irregular heartbeat and high cholesterol; and counseling to quit smoking.

Among the individual measures, researchers said GWTG–Stroke participation:

• increased the absolute percentage of ischemic stroke patients treated with clot-busters within two hours of stroke onset from 42 percent to 72.8 percent;
• increased the absolute percentage of patients beginning smoking cessation from 65.2 percent to 93.6 percent; and
• increased the absolute percentage of patients being started on cholesterol-lowering drugs from 73.3 percent to 88.3 percent.

The study showed that all hospitals improved regardless of size, geography and teaching status. However, researchers said there is still significant opportunity for improvement.

"When there are more than 700,000 strokes every year in this country, each percentage point represents a huge reduction in actual risk," Schwamm said. "We shouldn't rest until we're at 100 percent for all measures."