Canopy Roychoudhury

Recurrent Stroke Risk Is Higher Than Cardiac Event Risk After Initial Stroke/Transient Ischemic Attack

Background and Purpose— Patients with ischemic stroke and transient ischemic attack (TIA) are at risk for recurrent cerebrovascular and cardiac events. Understanding which of these adverse events is more likely to occur next is instructive for preventive therapy planning. Methods— Subjects (n=1923) were identified from a sample of hospital discharges from administrative claims for the Michigan Medicare population from January 2001 to June 2001 using International Classification of Diseases, 9th Revision codes for ischemic stroke/TIA. Outcomes (cardiac events, myocardial infarction [MI], percutaneous transluminal coronary angioplasty [PTCA], coronary artery bypass grafting [CABG] and ischemic strokes) were identified for 2001 to 2003. Comparison between cardiac and stroke as secondary events were made using cumulative incidence estimates. Results— Over the follow-up period, 172 patients had a cardiac event (62.8% MI, 7.6% CABG, 14.5% PTCA, 9.3% MI and PTCA, and 5.8% MI and CABG) and 239 had a stroke as their first event. Cardiac event at 2 years had occurred in 7.7%, and stroke occurred in 11.8%. Conclusion— The risk of stroke after initial stroke/TIA is higher than the risk of cardiac events. The propensity after stroke/TIA to have the first recurrent ischemic event in the brain, rather than in the heart, has implications for prophylactic therapy selection.

Evidence of disparity in the application of quality improvement efforts for the treatment of acute myocardial infarction: The American College of Cardiology's Guidelines Applied in Practice Initiative in Michigan

BACKGROUNDnRacial disparities exist in the management of patients with cardiovascular disease in the United States. The aim of the study was to evaluate if a structured initiative for improving care of patients with acute myocardial infarction (Guidelines Applied in Practice [GAP]) led to comparable care of white and nonwhite patients admitted to GAP hospitals in Michigan.nnnMETHODSnMedicare patients comprised 2 cohorts: (1) those admitted before GAP implementation (n = 1,368) and (2) those admitted after GAP implementation (n = 1,489). The main outcome measure was adherence to guideline-based medications/recommendations and use of the GAP discharge tool. chi(2) and Fisher exact tests were used to determine differences between white patients (n = 2,367) and nonwhite patients (n = 490).nnnRESULTSnIn-hospital GAP tool and aspirin use significantly improved for white and nonwhite patients. beta-Blocker use in hospital improved significantly for nonwhite patients only (66% vs 83.3%; P = .04). At discharge, nonwhite patients were 28% and 64% less likely than white patients to have had the GAP discharge tool used (P = .004) and receive smoking cessation counseling (P < .001), respectively. Among white patients, GAP improved discharge prescription rates for aspirin by 10.8% (P < .001) and beta-blockers by 7.0% (P = .047). Nonwhite patients aspirin prescriptions increased by 1.0% and beta-blocker prescriptions decreased by 6.0% (both P values nonsignificant).nnnCONCLUSIONSnThe GAP program led to significant increases in rates of evidence-based care in both white and nonwhite Medicare patients. However, nonwhite patients received less quality improvement discharge tool and smoking cessation counseling. Policies designed to reduce racial disparities in health care must address disparity in the delivery of quality improvement programs.

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.

Acute Ischemic Stroke in Hospitalized Medicare Patients: Evaluation and Treatment

Background and Purpose— This study describes several quality indicators of care in hospitalized stroke patients in Michigan from 1998 to 1999. Summary of Report— Median times from admission to head CT/MRI (89.5 minutes) and thrombolysis (113 minutes) exceeded recommended guidelines. Deep venous thrombosis prophylaxis was used in only 13.8% of eligible patients. Conclusions— Timing for brain imaging and acute ischemic stroke symptom onset need to be better documented, along with more provider education for routine deep venous thrombosis prophylaxis.

Do gender and race impact the use of antithrombotic therapy in patients with stroke/TIA?

The authors examined the relationships between sex and race and antithrombotics prescribed at discharge in the Michigan Medicare population using retrospective medical record abstraction (n = 2,715) for the period January 1, 2001, to June 30, 2001. There were no differences in the use of antithrombotics at discharge by race or sex and no differences in the prescribing of aspirin, warfarin, aspirin/extended release dipyridamole, or clopidogrel by race or sex after adjustment for confounders.