In-hospital management measures, outcomes for stroke, TIA vary in China

Patients with stroke or transient ischemic attack received different levels of care in hospitals, according to results of a quality improvement study conducted in China and published in JAMA Network Open.

“Few studies have assessed gaps in in-hospital management measures and outcomes by the type of cerebrovascular event,” Hong-Qiu Gu, PhD, of China National Clinical Research Center for Neurological Diseases, and colleagues wrote. “Prior reports from [the American Heart Association’s Get With the Guidelines–Stroke program] revealed that there may be differences in performance measures across all cerebrovascular event types, although reasons behind these differences are complex.

“We aimed to characterize the first 1 million hospitalizations and to examine variations and temporal trends in adherence to guideline-based performance measures and in-hospital outcomes in the [Chinese Stroke Center Alliance] program,” they continued.

The researchers analyzed data of 1,006,798 patients admitted to 1,476 hospitals in the Chinese Stoke Center Alliance (CSCA) between Aug. 1, 2015, and July 31, 2019. All patients were admitted to the hospital with stroke or TIA (mean age, 65.7 years; 38.1% women). The data showed 838,229 (83.3%) had an ischemic stroke, 64,929 (6.4%) had TIA, 85,705 (8.5%) had intracerebral hemorrhage and 11,241 (1.1%) had subarachnoid hemorrhage.

Using 11 guideline-recommended performance measures for in-hospital management and two summary measures, the researchers assessed the clinical characteristics, management and in-hospital clinical outcomes and complications among patients with stroke or TIA in China. The measurements included an all-or-none binary outcome and a composite score (range, 0 [nonadherence] to 1 [perfect adherence]) for adherence to evidence-based stroke and TIA care and in-hospital clinical outcomes, such as death or discharge against medical advice and major adverse cardiovascular events, including ischemic stroke, hemorrhagic stroke, TIA, or myocardial infarction, as well as in-hospital complications.

Researchers found that in-hospital management measures and outcomes varied based on the type of cerebrovascular event and hospital level of care. The mean composite score ranged from 0.57 in subarachnoid hemorrhage to 0.83 in TIA. Poor outcomes were most common among patients with subarachnoid hemorrhage (21.9%; 95% CI, 21-22.8 in-hospital death or discharge against medical advice; 9.6%; 95% CI, 9.1-10.2 major adverse cardiovascular events; and 31.4%; 95% CI, 30.6-32.3 in-hospital complications) and patients with intracerebral hemorrhage (17.2%; 95% CI, 16.9-17.5 in-hospital death or discharge against medical advice; 9.3%; 95% CI, 9.1-9.5 MACEs; and 31.3%; 95% CI, 31-31.6 in-hospital complications).

The researchers identified a temporal increase in management measures from 2015 to 2019 in administration of intravenous recombinant tissue plasminogen activator (60.3%), dysphagia screening (14.7%), use of anticoagulants for atrial fibrillation (31.4%), in-hospital death or discharge against medical advice (9.7%) and complications (27.1%).

Study limitations included a poorly designed sampling frame, underrepresented vascular risk factors and missing NIHSS scores and discharge against medical advice information.

“Substantial improvements over time in in-hospital management and outcome measures were observed from 2015 to 2019,” Gu and colleagues concluded. “Whether the improvements in various outcomes over time in the CSCA cohort are the result of improved stroke care, national secular trends or other factors requires further research.”