Get With The Guidelines Stroke Performance Indicators in a Brazilian Tertiary Hospital

Abstract

Background: Stroke is the fourth leading killer in the US, the first in Brazil and a leading cause of adult long-term disability in both countries. In spite of widespread recommendation, clinical practice guidelines have had limited effect on changing physician behavior. Recognizing that both knowledge and acceptance of guidelines do not necessarily imply guideline adherence, the American Heart Association/American Stroke Association (AHA/ASA) developed a national stroke quality improvement program, the ‘Get With The Guidelines (GWTG) stroke’. Even though GWTG has produced remarkable results in the US, other countries have not adopted the program. Methods: We compared the stroke treatment quality indicators from a private Brazilian tertiary hospital to those published by the GWTG stroke program. Seven predefined performance measures selected by the GWTG stroke program as targets for stroke quality improvement were evaluated: (1) tissue plasminogen activator use in patients who arrived <2 h from symptom onset; (2) antithrombotic medication use within 48 h of admission; (3) deep vein thrombosis prophylaxis within 48 h of admission for nonambulatory patients; (4) discharge use of antithrombotics; (5) discharge use of anticoagulation for atrial fibrillation; (6) dosing of LDL and treatment for LDL >100 mg/dl in patients meeting the National Cholesterol Education Program Adult Treatment Panel (NCEP) III guidelines, and (7) counseling for smoking cessation. Results: A total of 343 consecutive patients with acute ischemic stroke (70.8%) or transient ischemic attack (29.2%) were evaluated from August 2008 to December 2010. Antithrombotic medication within 48 h was used in 98.5% of the eligible patients and deep vein thrombosis prophylaxis in 100%. A total of 123 patients arrived within 2 h from symptoms onset, 23 were eligible for intravenous thrombolysis and 16 were treated (69.5%). All eligible patients were discharged using antithrombotic medication, and 86.9% of the eligible patients who had atrial fibrillation received anticoagulation. Only 56.1% of the eligible patients were treated according to the NCEP III guidelines. Counseling for smoking cessation was done in 63.6% of the eligible patients. Conclusions: Our study is the first in Brazil and the second outside the US to analyze compliance with the GWTG recommendations. Close attention to a better implementation of these measures may produce an improvement in such results similar to what happened after the full implementation of the program in the US. Whether or not a US disease-based registry such as GWTG can be adopted with success beyond the US is still a matter of debate.

Key performance indicators for stroke from the Ministry of Health of Brazil: benchmarking and indicator parameters

“…For the in-hospital treatment KPIs, two important factors related to mortality and disability after stroke were evaluated, venous thromboembolism prophylaxis and antithrombotic therapy. These reached approximately 90% in both the centers, which was very similar to the previously reported national and international data 15,16 .…”

Get With The Guidelines®–Stroke performance indicators in patients with transient ischemic attack

“…Consistent with this idea, this study observed that adherence to the GWTG-S quality indicators was lower in patients with TIA. This difference has also been reported in the United States [6][7][8][9] . This is a systematically underestimated, alarming finding, especially because a TIA comprises a major risk factor for further stroke.…”

“…All measures indicate the proportion of eligible patients (those without documented reasons for non-treatment) who received the intervention described 7 . A composite measure score of performance was calculated by summing the numerators for each measure across the patients evaluated to create a composite numerator (all the care that was given), summing the denominators for each measure to form a composite denominator (all the care that should have been given), and reporting the ratio of all the needed care that was given.…”

“…A composite measure score of performance was calculated by summing the numerators for each measure across the patients evaluated to create a composite numerator (all the care that was given), summing the denominators for each measure to form a composite denominator (all the care that should have been given), and reporting the ratio of all the needed care that was given. The percentage of adherence to these measures was also obtained for each individual patient through an all-or-none adherenceeligibility index, which was calculated by the ratio between eligible measures and compliance to them in a single patient 6,7 .…”

Brazilian guidelines for endovascular treatment of patients with acute ischemic stroke

“…the Canadian Stroke Network 14 . In more recent years, improvements in acute stroke care and prevention have led to a decrease in stroke mortality and stroke incidence 15,16,17 .…”