Get With the Guidelines Participation and Clinical Outcome After Ischemic Stroke
Is implementation of the Get With The Guidelines (GWTG)-Stroke program associated with better clinical outcomes after ischemic stroke?
GWTG-Stroke is a national quality improvement initiative and registry. The authors compared hospitals that implemented GWTG-Stroke between 2003 and 2008 with matched control hospitals. Matching was determined based on a variety of factors, including teaching status, stroke volume, and stroke mortality. A single control hospital was identified for each GWTG-Stroke hospital. The study examined four time points: Pre period, 18-6 months prior to joining GWTG-Stroke; Run-Up, 6 months to 1 day prior to joining GWTG-Stroke; Early, day 0-6 months after joining GWTG-Stroke; and Sustained, 6-18 months after joining GWTG-Stroke. The primary comparison was between the Pre and Sustained periods. Ischemic stroke patients were identified using International Classification of Diseases Ninth Revision codes. Patient outcome information was identified using Centers for Medicare and Medicaid Service (CMS) data sets, and stroke admissions were linked to CMS data.
The primary outcomes analyzed included discharge disposition (home versus other) and mortality at 30 days and 1 year. Differences in outcome between GWTG-Stroke hospitals and controls were compared across the four time epochs using Cox proportional hazard models, adjusted for hospital as well as patient factors. A difference-in-differences analysis was used to compare temporal changes in GWTG-Stroke hospitals with the control hospitals. Cox proportional hazard models were used for time to event outcomes, and logistic regression models were used for dichotomous outcomes.
There were 366 GWTG-Stroke hospitals and 366 matched control hospitals included in the analysis. Non-GWTG-Stroke hospitals were more likely to be rural, had fewer beds, and had a smaller percentage of white patients. In the adjusted analysis, during the Sustained period versus the Pre period at GWTG-Stroke hospitals, patients were more likely to be discharged home (hazard ratio [HR], 1.08; 95% confidence interval [CI], 1.04-1.12), had lower 30-day mortality (HR, 0.91; 95% CI, 0.87-0.95), and lower 1-year mortality (HR, 0.91; 95% CI, 0.88-0.94). At non-GWTG-Stroke hospitals, the only significant change between the Sustained versus Pre periods was decreased 30-day mortality (HR, 0.95; 95% CI, 0.91-0.99). Discharge home and 1-year mortality were unchanged between the Sustained and Pre times. When GWTG-Stroke hospitals were compared with non-GWTG-Stroke hospitals in the Sustained versus Pre periods, only 1-year mortality was improved at GWTG-Stroke hospitals (HR, 0.92; 95% CI, 0.88-0.97), although there was a trend toward more patients being discharged home and reduced 30-day mortality.
Patients with ischemic stroke cared for at hospitals that participated in the GWTG-Stroke program had lower mortality than patients cared for at non-GWTG-Stroke hospitals.
While implementation of stroke quality improvement programs has been associated with improvements in process measures, there are a lack of data showing that these initiatives improve outcomes. This study links hospital participation with GWTG-Stroke and discharge disposition and mortality and showed that GWTG-Stroke is associated with a trend toward better outcomes on these metrics, even when accounting for secular improvement in stroke outcomes. While these findings are important, caution is warranted as this study has limitations. Participation in GWTG-Stroke is voluntary and hospitals that participate likely differ in important unmeasured ways from hospitals that choose not to participate. The mechanism by which GWTG-Stroke improves outcomes is unclear. Additionally, one of the strongest predictors of stroke outcome, stroke severity, was not measured and therefore, not accounted for in this analysis.
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