A recent study reports data indicative of higher quality healthcare for hospitalised patients with ischaemic stroke at hospitals participating in the Get With The Guidelines – Stroke (GWTG-Stroke) programme. The study, conducted by George Howard (University of Alabama at Birmingham, Birmingham, USA) and colleagues, published in JAMA Neurology, advocates for additional efforts to be made in order to enhance hospital participation in GWTG-Stroke, given the important clinical benefits the programme delivers.
The GWTG-Stroke programme was developed by the American Heart Association/American Stroke Association (AHA/ASA) as a stroke-care quality-improvement programme, and has so far been implemented in over 2000 hospitals—treating approximately half of the patients discharged with stroke in the USA. The programme’s success in terms of guideline adherence as well as the proportion of patients discharged to home, 30-day mortality and one-year mortality for patients admitted to GWTG-Stroke hospitals have been acknowledged by the implementation of similar programmes in other countries.
However, the authors noted that what remains unclear is whether the improvement in guideline adherence seen amongst the GWTG-Stroke hospitals result directly from programme itself, or whether there is a national upturn of acceptance for guidelines—improving care at all hospitals.
Moreover, Howard and colleagues noted that data collected as part of the GWTG-Stroke programme cannot be used in isolation to document better care compared with non-GWTG-Stroke hospitals. Taking this into account, Howard and colleagues aimed to use national data describing hospital care quality that were collected independently of the programme in order to assess the association of the GWTG-Stroke programme with the quality of care of patients with stroke.
A subpopulation of 546 participants from the Reasons for geographical and racial differences in stroke (REGARDS) study was used; inclusive of patients with ischaemic stroke occurring during a nine-year follow-up among a general population sample of community-dwelling participants who were previously randomly selected; recruited between 2003–2007. Within this sample, 207 (36%) were treated in a hospital participating in GWGT-Stroke, while 339 (64%) were treated in a nonparticipating hospital. Data from these patients were analysed between July 2017 and April 2018.
Quality of care measures that were contrasted between the two cohorts included: use of tissue plasminogen activator, performance of swallowing evaluation, antithrombotic use in the first 48 hours, lipid profile assessment, discharge receiving antithrombotic therapy, discharge receiving a statin, neurologist evaluation, providing weight loss and exercise counselling, education on stroke risk factors and warning signs, and assessment for rehabilitation.
Participants treated at participating hospitals (mean age: 74, 48% male) were more likely to receive five of 10 evidence-based interventions recommended for patients hospitalised with ischaemic stroke, compared with patients seen at nonparticipating hospitals (mean age: 73, 48% male). Specifically, patients treated in the GWTG-Stroke hospitals were more likely to receive tissue plasminogen activator, education on risk factors, lipid and swallowing evaluation, as well as an evaluation by a neurologist. In summary, those seen in participating hospitals received a mean of 5.4 (95% CI, 5.2–5.6) interventions compared with 4.8 (95% CI, 4.6–5.0) in nonparticipating hospitals (p<0.001).
On a relative basis, Howard et al noted that the most dramatic difference associated with admission to a GWTG-Stroke hospital was for t-PA use—where the relative risk of use was nearly four times higher for patients treated at a participating GWTG-Stroke hospital. However, the authors acknowledged that their reliance on medical records to assess whether the participants had received the intervention was perhaps the study’s largest shortcoming. For example, the authors noted that patients who were not administered t-PA may have simply been ineligible for its use; a factor that was challenging to assess from medical records.
In conclusion, Howard and colleagues maintained that the current study has revealed that patients cared for at a GWTG-Stoke participating hospital receive better care and have better outcomes. They stressed the clinical implications of these findings, as currently, only approximately 50% of patients with stroke are treated at participating GWTG-Stroke hospitals; leaving a sizeable proportion of stroke patients in the USA treated with sub-optimal care and compromised outcomes.
In light of this, they suggested that additional efforts should be made in order to enhance hospital participation in GWTG-Stroke, as the programme presents with meaningful benefits for both patients and hospitals, in terms of stroke care and outcomes.
