Computed tomographic brain scans and antiplatelet therapy after stroke - A study of the quality of care in Dutch hospitals

Background and Purpose We sought to develop a measure (''quality weight'') that indicates the severity of a deviation from optimal care with respect to secondary prevention with antiplatelet treatment after stroke. We also sought to estimate the effects that efforts to improve the quality of secondary prevention may have on health outcome and healthcare costs in the Netherlands. Methods First, we developed quality weights with decision analysis techniques. These quality weights express the excess risk of vascular events in the first 2 years after stroke compared with the optimal strategy (CT brain scan in all patients and aspirin in case of cerebral infarction). Second, these weights were applied in a follow-up study of 738 stroke patients older than 45 years. The number of stroke patients admitted to a hospital in 1991 in the Netherlands was used to estimate nationwide effects. We used data from 23 neurological departments and from the Information Center for Health Care in the Netherlands. Results The 2-year excess risk of fatal and nonfatal vascular events caused by omitting a CT brain scan and giving aspirin to all patients is rather small (on average, 0.6%). The 2-year excess risk caused by not giving aspirin to a patient with cerebral infarction is much higher (4.1%). The follow-up study indicated that only 6% of the admitted patients had not been evaluated with a CT brain scan and that 14% of the patients with cerebral infarction proven by CT scan did not get antiplatelet treatment at discharge. Efforts to improve the duality of secondary prevention after stroke may prevent 74 vascular events annually in the Netherlands at an expense of 6200 Dutch guilders per prevented event (1 Dutch guilder=0.53 US dollar, 1991). Conclusions Efforts to improve the quality of secondary prevention with antiplatelet treatment might reduce the number of new vascular events within the first 2 years after stroke by approximately 3%. The total costs related to the extra diagnostic and therapeutic activities are approximately 0.2% of the total annual hospital costs for acute stroke patients in the Netherlands (250 million Dutch guilders).