Correlation of Quality Metrics of Acute Stroke Care with Clinical Outcomes in an Indian Tertiary-care University Hospital: A Prospective Evidence-based Study

Abstract

A bstract Aim To characterize the impact of adherence to quality metrics of stroke care on the clinical outcomes of ischemic stroke (IS) and intracerebral hemorrhage (ICH) admissions. Methods Consecutive patients with acute stroke were prospectively followed up for their demographic and clinical characteristics, acute stroke management, and associated clinical outcomes at discharge. Stroke quality metrics [adopted from the American Heart Association (AHA)/American Stroke Association's Get with The Guidelines (GWTG)] with a specific interest in an association between acute reperfusion therapies and functional recovery in stroke patients are analyzed and presented. A composite measure of care was considered “0 (non-adherence) to 1 (adherence).” An all-or-none measure of care was calculated to check whether eligible patients received all the quality-of-care interventions. Multivariate Cox regression models were used to study an association between optimal adherence and clinical outcomes. Results During the study period, of the total 256 stroke admissions, 200 (78.1%) patients had IS, and the remaining 56 (21.9%) patients had ICH. The median [interquartile range (IQR)] age of total stroke admissions was 57 (36–78) years. Male preponderance was observed (IS: 80% and ICH: 67.9%). The conformity of performance metrics in IS patients was from 69.1% [95% confidence interval (CI), 68.5–69.6] for the use of deep vein thrombosis prophylaxis (DVTp) to 97.8% (95% CI, 96.2–98.6) for the use of statins. In ICH patients, it ranged from 61.7% (95% CI, 60.4–62.5) for the use of DVTp to 89.9% (95% CI, 88.6–89.7) for stroke rehabilitation. The unadjusted odds ratio (OR) of mortality (in-hospital plus the 28th-day postdischarge) was higher in ICH patients vs IS patients (4.42, p = 0.005). Optimal adherence with intravenous recombinant tissue plasminogen activator (IV-rtPA) therapy [hazards ratio (HR) = 0.23], in-hospital acute measures [IS (HR = 0.41) and ICH (HR = 0.63)], and discharge measures [IS (HR = 0.35) and ICH (HR = 0.45)] were associated with reduced hazards of the 28th-day mortality in both cohorts. Compared to ICH, IS patients had significantly improved neurofunctional recovery [modified Rankin score (mRS) ≤ 2, p < 0.01]. Conclusion Adherence to quality metrics and performance measures was associated with low mortality and favorable clinical outcomes. Also, DVTp as an in-hospital (acute) measure of stroke care needs attention in both cerebrovascular events. How to cite this article Panda BK, Suryawanshi VR, Attarde G, Borkar N, Iyer S, Shah J. Correlation of Quality Metrics of Acute Stroke Care with Clinical Outcomes in an Indian Tertiary-care University Hospital: A Prospective Evidence-based Study. Indian J Crit Care Med 2023;27(11):806–815.

Author Response

“…In our study, 144/200 (72%) did not receive thrombolysis, mainly due to presentation outside the time window. 2 The middle cerebral artery (MCA) stroke accounted for 45% of the patients in our study, followed by internal carotid artery (ICA) (18%), posterior cerebral artery (PCA) (15%), anterior cerebral artery (ACA) (11%), brainstem (7%), and MCA plus ICA (4%). While we believe that the stroke subtype has an important impact on clinical outcomes; acute stroke care, and discharge care, including adequate rehabilitation, enable IS patients to attain functional independence between 30 and 90 days, especially when it's their first-ever stroke.…”

“…Thank you for the opportunity to respond to the letter regarding our article. 1 , 2 We read it with great interest and would like to discuss our viewpoint about the queries raised by Mehri and Finsterer 1 We would like to draw their attention to our study's main objective, which was to determine the compliance rates with stroke quality metrics adopted from AHA/ASA's GWTG approach and to study the clinical outcomes associated with them in ischemic stroke (IS) and intracerebral hemorrhage (ICH) patients. 3 , 4 They have raised a few questions regarding the patient outcomes associated with the quality of interventions provided.…”

“…We have found time delays in DIT in 45% and 40% of IS and ICH patients, respectively. 2 Quality improvement strategies with regards to MTE/TEA and DIT have since been implemented.…”

“… 4 – 6 Assessment of clinical outcomes of individual stroke subtypes and outcomes associated with ICH location and stroke volume is out of the scope of our study. 2 Looking at associations of these factors with individual patients, disease, and/or intervention-based factors will require a larger sample size (probably registry-based). We could not analyze this further as suggested by Mehri and Finsterer 1 due to sample size limitations.…”