By speeding up diagnosis and treatment, experts hope that proposed new quality measures will benefit the care of stroke patients and thereby improve the cardiovascular health of Americans and reduce deaths due to cardiac diseases.
The American Heart Association (AHA) and the American Stroke Association’s recommendations suggest new measures for healthcare professionals to monitor the diagnosis and treatment of stroke patients.
Aimed at stroke centers, they also lay the groundwork for future certification of Comprehensive Stroke Centers (CSCs), which would exist alongside the Primary Stroke Centers currently certified by The Joint Commission, but would be held to stricter standards of care.
The recommendations, in the form of a Scientific Statement, are published in the 13 January online issue of Stroke, a journal of the American Heart Association.
The new measures also incorporate ideas from previous quality improvement initatives, such as the Get With The Guidelines program issued by the two Associations.
Several studies have shown that such programs improve patient care and outcomes when they use metrics to monitor quality of care, said Dr Dana Leifer, lead author of the new statement and associate professor of neurology at Weill Cornell Medical College in New York.
Stroke is a disease of the arteries leading to and within the brain, and occurs when a blood vessel carrying oxygen and nutrients to the brain is either blocked by a clot or bursts, with the result that the associated part of the brain, starved of oxygen and nutrients, dies.
In the US, stroke is a major cause of disability and death, and killed more than 137,000 Americans in 2006, says the AHA. It is the third largest cause of death, ranking behind “diseases of the heart” and all forms of cancer.
The Brain Attack Coalition, a group of professional, voluntary and government medical bodies dedicated to reducing the occurrence, disabilities and death associated with stroke, proposed that the best way to give patients the care they need was to set up primary and comprehensive stroke centers: the first to provide basic, and the second to provide more advanced care, for stroke patients.
The first of these has been up and running for several years. The Joint Commission, an independent, not-for-profit organization that accredits and certifies more than 18,000 health care organizations and programs in the US, has been accrediting Primary Stroke Centers since designating them in 2003, as have various states.
Now that it’s time to consider the designation of the more advanced level of care, the Comprehensive Stroke Centers (CSCs), which among others, will provide neurosurgery and interventional neuroradiologic procedures for patients with ischemic strokes (caused from blocked blood vessels) and hemorrhagic strokes (caused from bleeding in or around the brain).
In order to help set up CSCs, the American Heart Association and the American Stroke Association, suggest they follow more stringent quality measures, hence the new Scientific Statement recommendations.
To arrive at the new recommendations, working groups from the two Associations analyzed available guideline statements, reviews and other papers, identified major features that distinguish CSCs from Primary Stroke Centers, and drafted a set of metrics to measure the key aspects of stroke care. They then kept discussing and redrafting the measures until they reached a consensus on:
“… a set of metrics and related data elements that cover the major aspects of specialized care for patients with ischemic cerebrovascular disease and nontraumatic subarachnoid and intracerebral hemorrhages at CSCs.”
By creating a common language of measures, which the two Associations describe as a “framework for standardized data collection” at CSCs, they hope the recommendations will improve quality of care both at the local level and at the national level, the latter helped by gathering and pooling data from all CSCs to create national standards of performance, they wrote in their conclusions.
Leifer said the conrnerstone of the recommendations is improving how quickly patients with ischemic and hemorrhagic strokes are diagnosed and treated, so the standards include:
- Tracking the proportion of patients targeted for tissue plasminogen activator (tPA), the only clot-busting treatment approved for ischemic strokes and which is only effective if given within a few hours of stroke onset.
- Measuring the proportion of tPA patients treated within the suggested 60 minute “door-to-needle time” (measured from when they come through the door of the Center to when they start getting the treatment).
- Tracking the time from hospitalization to treatment to repair blood vessels for ruptured aneurysm patients.
- Performing 90-day follow up assessments of ischemic stroke patients who receive acute interventions, eg tPA treatment.
Leifer told the press that some of the metrics are supported by stronger evidence or have greater clinical significance and recommend all CSCs should monitor these “core measures”.
“Initially, Comprehensive Stroke Centers may have the option to track only some of the other metrics, just as Primary Stroke Centers were only required to track a few measures at first,” said Leifer.
“Metrics for Measuring Quality of Care in Comprehensive Stroke Centers: Detailed Follow-Up to Brain Attack Coalition Comprehensive Stroke Center Recommendations.”
A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association.
Dana Leifer, Dawn M. Bravata, J.J. (Buddy) Connors, III, Judith A. Hinchey, Edward C. Jauch, S. Claiborne Johnston, Richard Latchaw, William Likosky, Christopher Ogilvy, Adnan I. Qureshi, Debbie Summers, Gene Y. Sung, Linda S. Williams, Richard Zorowitz, and on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group, Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing.
DOI:10.1161/STR.0b013e318208eb99
Additional sources: AHA (press release, 13 Jan 2011, website), the Brain Attack Coalition (website), The Joint Commission (website).
Written by: Catharine Paddock, PhD