Improved quality of stroke care for hospitalized medicare beneficiaries in Michigan

Background and Purpose-We reported previously that acute ischemic stroke patients encountered delays in obtaining neuroimaging and receiving thrombolysis, and that deep venous thrombosis prophylaxis was used only in a minority of eligible patients. We investigated whether these and other measures improved after a quality improvement initiative. Methods-Medicare fee-for-service ischemic stroke and transient ischemic attack discharges in 136 acute care hospitals in Michigan were identified by International Classification of Diseases, 9th Revision, Clinical Modification codes. Only patients with stroke symptoms persisting for >1 hour and present on arrival were included in the analysis. Seven quality indicators were abstracted from chart review at baseline ( discharges between July 1, 1998, and June 30, 1999) and at remeasurement ( discharges between January 1, 2001, and June 30, 2001) after an intensive quality improvement initiative throughout Michigan hospitals. Quality indicators were compared at baseline and remeasurement. Results-Indicators of care were determined in 5146 patients at baseline and 4980 patients on remeasurement. Four quality-of-care indicators showed significant improvement on remeasurement: antithrombotic prescribed at discharge (81.9 baseline versus 83.7% remeasurement; P = 0.026), avoidance of sublingual nifedipine in patients with acute ischemic stroke (97.1 versus 99.7%; P < 0.0001), documentation of a computed tomography (CT)/MRI during hospitalization (98.0 versus 99.1%; P = 0.024), and appropriate deep venous thrombosis prophylaxis (13.8 versus 26.9%; P < 0.0001). Time to CT/MRI did not significantly change, but time to thrombolysis improved ( 113 versus 88.5 minutes; P = 0.045). Conclusions-Improvement occurred in several indicators of quality of care in Michigan Medicare beneficiaries presenting with acute stroke symptoms.