Stroke QUERI Project - Quality Evaluation in Stroke and TIA (QUEST)

Project Number IIR 01-104 funded by HSR&D.
July 1, 2003 - June 30, 2007

Stroke patients cared for in stroke units have better outcomes than patients treated in general wards. Although the benefits of stroke unit care have been demonstrated in numerous studies, the processes of stroke care that are responsible for the observed improvements in patient outcomes have not been identified.

The primary aim of this study is to identify processes of care received by patients hospitalized with acute ischemic stroke or transient ischemic attack (TIA) that are independently associated with a reduction in in-hospital mortality or institutionalization to a skilled nursing facility, adjusting for patient characteristics. We will examine seven processes of acute stroke care: fever management, hypoxia management, blood pressure management, neurology assessment, swallowing evaluation, deep vein thrombosis prophylaxis, and early mobilization. Our hypothesis is that specific processes of acute stroke care improve patient outcomes. The secondary aim of this study is to further examine those processes that are associated with reduced in-hospital mortality or institutionalization to a skilled nursing facility to detect the specific components of each process that account for improved patient outcomes. For example, if fever management is associated with improved outcomes in the primary analysis, then we will examine specific components of fever management in the secondary analysis (i.e., prescription of antibiotics). Our hypothesis is that for each essential process of stroke care, specific components of that process improve patient outcomes.

This is a retrospective medical record review of 2000 patients hospitalized with acute ischemic stroke or TIA between 1998 and 2004 at three VA hospitals and three non-VA hospitals.

Our accomplishments to date include: obtaining human subjects approvals at our participating sites; hiring and training our staff; and refining our data collection procedures, including revising the data collection instrument and establishing our data quality management processes. We are actively engaged in data collection; with 600 completed charts, we are on-target for data collection to be completed by the end of the study period.

The challenge within the VA is to provide excellent stroke care across the spectrum of medical centers. The QUEST Project supports this mission by identifying the processes of care that are associated with improved patient outcomes. These results can be used to enhance care within the VA nationwide and lead to improved outcomes for veterans with stroke. We will use the Stroke QUERI infrastructure to disseminate our research findings.