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NEUROLOGY 2009;73:709-716
© 2009 American Academy of Neurology

Influence of stroke subtype on quality of care in the Get With The Guidelines–Stroke Program

E. E. Smith, MD, MPH, L. Liang, PhD, A. Hernandez, MD, M. J. Reeves, PhD, C. P. Cannon, MD, G. C. Fonarow, MD and L. H. Schwamm, MD

From the Calgary Stroke Program (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada; Duke Clinical Research Institute (L.L., A.H.), Durham, NC; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Division of Cardiology (C.P.C.), Brigham & Women's Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles; and Stroke Service (L.H.S.), Massachusetts General Hospital, Boston.

Address correspondence and reprint requests to Dr. Eric E. Smith, Calgery Stroke Program, Hotchkiss Brain Institute, University of Calgary, Department of Clinical Neurosciences, Foothills Medical Centre, 1403 29th Street NW, Calgary, AB, Canada T2N 2T9 eesmith{at}ucalgary.ca

Objective: Little is known about in-hospital care for hemorrhagic stroke. We examined quality of care in intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) admissions in the national Get With The Guidelines–Stroke (GWTG-Stroke) database, and compared them to ischemic stroke (IS) or TIA admissions.

Methods: Between April 1, 2003, and December 30, 2007, 905 hospitals contributed 479,284 consecutive stroke and TIA admissions. The proportions receiving each quality of care measure were calculated by dividing the total number of patients receiving the intervention by the total number of patients eligible for the intervention, excluding ineligible patients or those with contraindications to treatment. Logistic regression models were used to determine associations between measure compliance and stroke subtype, controlling for patient and hospital characteristics.

Results: Stroke subtypes were 61.7% IS, 23.8% TIA, 11.1% ICH, and 3.5% SAH. Performance on care measures was generally lower in ICH and SAH compared to IS/TIA, including guideline-recommended measures for deep venous thrombosis (DVT) prevention (for ICH) and smoking cessation (for SAH) (multivariable-adjusted p < 0.001 for all comparisons). Exceptions were that ICH patients were more likely than IS/TIA to have door-to-CT times <25 minutes (multivariable-adjusted p < 0.001) and to undergo dysphagia screening (multivariable-adjusted p < 0.001). Time spent in the GWTG-Stroke program was associated with improvements in many measures of care for ICH and SAH patients, including DVT prevention and smoking cessation therapy (multivariable-adjusted p < 0.001).

Conclusions: Many hospital-based acute care and prevention measures are underutilized in intracerebral hemorrhage and subarachnoid hemorrhage compared to ischemic stroke /TIA. Duration of Get With The Guidelines–Stroke participation is associated with improving quality of care for hemorrhagic stroke.

Abbreviations: AHA = American Heart Association; DVT = deep venous thrombosis; GEE = generalized estimating equation; GWTG-Stroke = Get With The Guidelines–Stroke; ICH = intracerebral hemorrhage; IS = ischemic stroke; PMT = Patient Management Tool; SAH = subarachnoid hemorrhage.

Disclosure: Author disclosures are provided at the end of the article.

Received November 16, 2008. Accepted in final form May 6, 2009.