[Design and Application of an IVD Reagent Management Information Systems Based on Unique Code].

The management of in vitro diagnostic (IVD) reagents in hospitals often faces issues such as the lack of a unified coding system, unclear consumption patterns, and unknown cost-to-income ratios. It is necessary to employ information systems to achieve comprehensive, detailed, and traceable management of IVD reagents. An information management system for IVD reagents based on unique coding is introduced, which integrates admission, acceptance, and consumption processes through unique codes. The system calculates the income per experimental item based on the consumption of IVD reagents and the charge for each experimental item. The system enhances the efficiency of the IVD reagent supply chain management and promotes detailed oversight of IVD reagent usage.

Bone marrow-derived mesenchymal stem cells transplantation attenuates renal fibrosis following acute kidney injury by repairing the peritubular capillaries.

After the severe initial insults of acute kidney injury, progressive kidney tubulointerstitial fibrosis may occur, the peritubular capillary (PTC) rarefaction plays a key role in the disease progression. However, the mechanisms of PTC damage were not fully understood and potential therapeutic interventions were not explored. Previous studies of our research team and others in this field suggested that bone marrow-derived mesenchymal stem cells (BMSCs) transplanted into the AKI rat model may preserve the kidney function and pathological changes. In the current study, with the ischemia/reperfusion AKI rat model, we revealed that BMSCs transplantation attenuated the renal function decrease in the AKI model through preserving the peritubular capillaries (PTCs) function. The density of PTCs is maintained by BMSCs transplantation in the AKI model, detachment and relocation of pericytes in the PTCs diminished. Then we established that BMSCs transplantation may attenuate the renal fibrosis and preserve the kidney function after AKI by repairing the PTCs. Improving the vitality of pericytes, suppressing the detachment and trans-differentiation of pericytes, directly differentiation of BMSCs into pericytes by BMSCs transplantation all participate in the PTC repair. Through these processes, BMSCs rescued the microvascular damage and improved the density of PTCs. As a result, a preliminary conclusion can be reached that BMSCs transplantation can be an effective therapy for delaying renal fibrosis after AKI.

[Design and Implementation of Medical Consumables Management Information Systems Based on Cloud Server].

There are common problems in realistic medical consumables management such as inconsistent material names, irregular billing, extensive management of sub-warehouse. It is necessary to use information systems to achieve full-process, refined, traceable management of medical consumables. A cloud-based information management system of medical consumables is introduced, which connects consumables access, acceptance, consumption and settlement by matching UDI code, charge code and medical insurance code. The system connects to external systems such as charging system. The system realizes traceable management of full-process from manufacture, supplier to hospital material management department, and finally to consumption department. The management efficiency of medical consumables supply chain is improved.

Compliance with guideline-directed therapy in diabetic patients admitted with acute coronary syndrome: Findings from the American Heart Association's Get With The Guidelines-Coronary Artery Disease (GWTG-CAD) program.

BACKGROUND: To evaluate and compare baseline characteristics, outcomes and compliance with guideline based therapy at discharge among diabetic and non-diabetic patients admitted with acute coronary syndromes (ACS). METHODS AND RESULTS: Study population consisted of 151,270 patients admitted with ACS from 2002 through 2008 at 411 sites participating in the American Heart Association's Get with the Guidelines (GWTG) program. Demographic variables, physical exam findings, laboratory data, left ventricular ejection fraction, length of stay, in-hospital mortality and discharge medications were compared between diabetic and non-diabetic patients. Temporal trends in compliance with guidelines directed therapy were evaluated. Of 151,270 patients, 48,938 (32%) had diabetes. Overall, diabetic patients were significantly older and more likely non-white. They had significantly more hypertension, atherosclerotic disease, CKD, and LV dysfunction and were more likely to present as NSTEMI. They had longer hospital stay and higher hospital mortality than non-diabetic patients. Diabetic patients were less likely to get LDL checks (65% vs 70%) and less frequently prescribed statins (85% vs 89%), RAAS blockers for LV dysfunction (80% vs 84%) and dual-antiplatelet therapy (69% vs 74%). Diabetic patients were less likely to achieve BP goals before discharge (75% vs 82%). Fewer diabetic patients met first medical contact to PCI time for STEMI (44% vs 52%). Temporal trends, however, showed continued progressive improvement in most performance measures from 2002 to 2008 (all P<.001). CONCLUSIONS: These data from a large cohort of ACS patients demonstrate gaps in compliance with guidelines directed therapy in diabetic patients but also indicate significant and continued improvement in most performance measures over time. Concerted efforts are needed to continue this positive trend.

The association between socioeconomic status and disability after stroke: findings from the Adherence eValuation After Ischemic stroke Longitudinal (AVAIL) registry.

BACKGROUND: Stroke is the leading cause of disability among adults in the United States. The association of patients' pre-event socioeconomic status (SES) with post-stroke disability is not well understood. We examined the association of three indicators of SES--educational attainment, working status, and perceived adequacy of household income--with disability 3-months following an acute ischemic stroke. METHODS: We conducted retrospective analyses of a prospective cohort of 1965 ischemic stroke patients who survived to 3 months in the Adherence eValuation After Ischemic stroke--Longitudinal (AVAIL) study. Multivariable logistic regression was used to examine the relationship of level of education, pre-stroke work status, and perceived adequacy of household income with disability (defined as a modified Rankin Scale of 3-5 indicating activities of daily living limitations or constant care required). RESULTS: Overall, 58% of AVAIL stroke patients had a high school or less education, 61% were not working, and 27% perceived their household income as inadequate prior to their stroke. Thirty five percent of patients were disabled at 3-months. After adjusting for demographic and clinical factors, stroke survivors who were unemployed or homemakers, disabled and not-working, retired, less educated, or reported to have inadequate income prior to their stroke had a significantly higher odds of post-stroke disability. CONCLUSIONS: In this cohort of stroke survivors, socioeconomic status was associated with disability following acute ischemic stroke. The results may have implications for public health and health service interventions targeting stroke survivors at risk of poor outcomes.

Predictors of late neurological deterioration after spontaneous intracerebral hemorrhage.

BACKGROUND: Although intracerebral hemorrhage (ICH) is a common form of cerebrovascular disease, little is known about factors leading to neurological deterioration occurring beyond 48 h after hematoma formation. The purpose of this study was to characterize the incidence, consequences, and associative factors of late neurological deterioration (LND) in patients with spontaneous ICH. METHODS: Using the Duke University Hospital Neuroscience Intensive Care Unit database from July 2007 to June 2012, a cohort of 149 consecutive patients with spontaneous supratentorial ICH met criteria for analysis. LND was defined as a decrease of two or more points in Glasgow Coma Scale score or death during the period from 48 h to 1 week after ICH symptom onset. Unfavorable outcome was defined as a modified Rankin Scale score of >2 at discharge. RESULTS: Forty-three subjects (28.9 %) developed LND. Logistic regression models revealed hematoma volume (OR = 1.017, 95 % CI 1.003-1.032, p = 0.019), intraventricular hemorrhage (OR = 2.519, 95 % CI 1.142-5.554, p = 0.022) and serum glucose on admission (OR = 2.614, 95 % CI 1.146-5.965, p = 0.022) as independent predictors of LND. After adjusting for ICH score, LND was independently associated with unfavorable outcome (OR = 4.000, 95 % CI 1.280-12.500, p = 0.017). In 65 subjects with follow-up computed tomography images, an increase in midline shift, as a surrogate for cerebral edema, was independently associated with LND (OR = 3.822, 95 % CI 1.157-12.622, p = 0.028). CONCLUSIONS: LND is a common phenomenon in patients with ICH; further, LND appears to affect outcome. Independent predictors of LND include hematoma volume, intraventricular hemorrhage, and blood glucose on admission. Progression of perihematomal edema may be one mechanism for LND.

Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke.

IMPORTANCE: Randomized clinical trials suggest the benefit of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke is time dependent. However, modest sample sizes have limited characterization of the extent to which onset to treatment (OTT) time influences outcome; and the generalizability of findings to clinical practice is uncertain. OBJECTIVE: To evaluate the degree to which OTT time is associated with outcome among patients with acute ischemic stroke treated with intraveneous tPA. DESIGN, SETTING, AND PATIENTS: Data were analyzed from 58,353 patients with acute ischemic stroke treated with tPA within 4.5 hours of symptom onset in 1395 hospitals participating in the Get With The Guidelines-Stroke Program, April 2003 to March 2012. MAIN OUTCOMES AND MEASURES: Relationship between OTT time and in-hospital mortality, symptomatic intracranial hemorrhage, ambulatory status at discharge, and discharge destination. RESULTS: Among the 58,353 tPA-treated patients, median age was 72 years, 50.3% were women, median OTT time was 144 minutes (interquartile range, 115-170), 9.3% (5404) had OTT time of 0 to 90 minutes, 77.2% (45,029) had OTT time of 91 to 180 minutes, and 13.6% (7920) had OTT time of 181 to 270 minutes. Median pretreatment National Institutes of Health Stroke Scale documented in 87.7% of patients was 11 (interquartile range, 6-17). Patient factors most strongly associated with shorter OTT included greater stroke severity (odds ratio [OR], 2.8; 95% CI, 2.5-3.1 per 5-point increase), arrival by ambulance (OR, 5.9; 95% CI, 4.5-7.3), and arrival during regular hours (OR, 4.6; 95% CI, 3.8-5.4). Overall, there were 5142 (8.8%) in-hospital deaths, 2873 (4.9%) patients had intracranial hemorrhage, 19,491 (33.4%) patients achieved independent ambulation at hospital discharge, and 22,541 (38.6%) patients were discharged to home. Faster OTT, in 15-minute increments, was associated with reduced in-hospital mortality (OR, 0.96; 95% CI, 0.95-0.98; P < .001), reduced symptomatic intracranial hemorrhage (OR, 0.96; 95% CI, 0.95-0.98; P < .001), increased achievement of independent ambulation at discharge (OR, 1.04; 95% CI, 1.03-1.05; P < .001), and increased discharge to home (OR, 1.03; 95% CI, 1.02-1.04; P < .001). CONCLUSIONS AND RELEVANCE: In a registry representing US clinical practice, earlier thrombolytic treatment was associated with reduced mortality and symptomatic intracranial hemorrhage, and higher rates of independent ambulation at discharge and discharge to home following acute ischemic stroke. These findings support intensive efforts to accelerate hospital presentation and thrombolytic treatment in patients with stroke.

Death and rehospitalization after transient ischemic attack or acute ischemic stroke: one-year outcomes from the adherence evaluation of acute ischemic stroke-longitudinal registry.

BACKGROUND: Longitudinal data directly comparing the rates of death and rehospitalization of patients discharged after transient ischemic attack (TIA) versus acute ischemic stroke (AIS) are lacking. METHODS: Data were analyzed from 2802 patients (TIA n = 552; AIS n = 2250) admitted to 100 U.S. hospitals participating in the Get With The Guidelines-Stroke and the Adherence Evaluation of Acute Ischemic Stroke-Longitudinal registry. The primary composite outcome was the adjusted rate of all-cause death and rehospitalization over 1 year after discharge. Four additional single or combined outcomes were explored. RESULTS: Compared with AIS, TIA patients were older (median 69 v 66 years; P = .007) and more likely female (53.3% v 44.2%; P < .0001). Secondary prevention medication use after hospital discharge was less intensive after TIA, with underuse for both conditions. All-cause death or rehospitalization at 1 year was similar for TIA and AIS patients (37.7% v 34.6%; P = .271); the frequency for TIA patients was higher after covariate adjustment (hazard ratio [HR] 1.19; 95% confidence interval [CI] 1.01-1.41). One-year all-cause mortality was similar among those with TIA compared to AIS patients (3.8% v 5.7%; P = .071; adjusted HR 0.86; 95% CI 0.52-1.42). All-cause rehospitalizations were higher for TIA compared to AIS patients (36.4% v 33.0%; P = .186; adjusted HR 1.20; 95% CI 1.02-1.42), but similar for stroke rehospitalizations (10.1% v 7.4%; P = .037; adjusted HR 1.38, 95% CI 0.997-1.92). CONCLUSIONS: Patients with TIA have similar or worse 12-month postdischarge risk of death or rehospitalization as compared with those with AIS. Outcomes after TIA and AIS might be improved with better adherence to secondary preventive guidelines.

Dysphagia screening and hospital-acquired pneumonia in patients with acute ischemic stroke: findings from Get with the Guidelines--Stroke.

BACKGROUND: National guidelines recommend dysphagia screening (DS) before oral intake in stroke patients to reduce hospital-acquired pneumonia (HAP). We examined the relationship between DS and HAP after ischemic stroke. METHODS: Get with the Guidelines-Stroke defines HAP as postadmission diagnosis of pneumonia requiring antibiotics, and DS as the use of bedside swallow screening prior to oral intake. Univariable and multivariable analyses examined the relationship between DS and HAP. RESULTS: Among 314,007 ischemic stroke patients at 1244 Get with the Guidelines-Stroke hospitals from 2003-2009 who were eligible for DS and had completed HAP data, a total of 216,372 (68.9%) underwent DS and a total of 17,906 (5.7%) developed HAP. When compared with patients without HAP, patients with HAP were older, had admission National Institutes of Health Stroke Scale (NIHSS) score (median NIHSS score: 10 versus 4), were more likely to undergo DS (75.5% versus 68.5%), and had increased length of stay and in-hospital mortality (12.4% versus 2.3%). In multivariable analyses, factors independently associated with a lower risk of HAP were female gender (odds ratio [OR] 0.84), dyslipidemia (OR 0.84), and hypertension (OR 0.94). DS was associated with a higher adjusted OR for HAP (OR 1.40), but the OR was greatly attenuated after adding NIHSS score to the model (OR 1.10). CONCLUSIONS: HAP occurs in 1 of 17 hospitalized stroke patients and is associated with a greater than 5-fold increase in mortality. DS did not occur in 31.1% of eligible patients, with increased screening among those with more severe strokes and those who developed HAP. The attenuation of the relationship between DS and HAP risk when controlling for NIHSS score suggests the association between screening and pneumonia is confounded by severity. Controlled trials are needed to determine DS effectiveness.

Challenges in assessing hospital-level stroke mortality as a quality measure: comparison of ischemic, intracerebral hemorrhage, and total stroke mortality rates.

BACKGROUND AND PURPOSE: Public reporting efforts currently profile hospitals based on overall stroke mortality rates, yet the "mix" of hemorrhagic and ischemic stroke cases may impact this rate. METHODS: Using the 2005 to 2006 New York state data, we examined the degree to which hospital stroke mortality rankings varied regarding ischemic versus hemorrhagic versus total stroke. Observed/expected ratio was calculated using the Agency for Healthcare Research and Quality Inpatient Quality Indicator software. The observed/expected ratio and outlier status based on stroke types across hospitals were examined using Pearson correlation coefficients (r) and weighted κ. RESULTS: Overall 30-day stroke mortality rates were 15.2% and varied from 11.3% for ischemic stroke and 37.3% for intracerebral hemorrhage. Hospital risk-adjusted ischemic stroke observed/expected ratio was weakly correlated with its own intracerebral hemorrhage observed/expected ratio (r=0.38). When examining hospital performance group (mortality better, worse, or no different than average), disagreement was observed in 35 of 81 hospitals (κ=0.23). Total stroke mortality observed/expected ratio and rankings were correlated with intracerebral hemorrhage (r=0.61 and κ=0.36) and ischemic stroke (r=0.94 and κ=0.71), but many hospitals still switched classification depending on mortality metrics. However, hospitals treating a higher percent of hemorrhagic stroke did not have a statistically significant higher total stroke mortality rate relative to those treating fewer hemorrhagic strokes. CONCLUSIONS: Hospital stroke mortality ratings varied considerably depending on whether ischemic, hemorrhagic, or total stroke mortality rates were used. Public reporting of stroke mortality measures should consider providing risk-adjusted outcome on separate stroke types.

Representativeness of the Get With The Guidelines-Stroke Registry: comparison of patient and hospital characteristics among Medicare beneficiaries hospitalized with ischemic stroke.

BACKGROUND AND PURPOSE: Get With The Guidelines (GWTG)-Stroke is a large quality improvement-based registry of acute stroke; however, its generalizability is unclear. We used fee-for-service Medicare claims to ascertain the representativeness of ischemic stroke admissions in GWTG-Stroke. METHODS: All 228 815 ischemic stroke admissions aged ≥65 years enrolled in GWTG-Stroke between April 2003 and December 2007 were linked to 926 756 unique fee-for-service Medicare patients with ischemic stroke (primary International Classification of Diseases, 9th Revision discharge code 434 or 436) from the same period. Patient characteristics and in-hospital outcomes were compared between the linked GWTG-Stroke Medicare cohort and the remaining unlinked Medicare cohort. Characteristics of GWTG-Stroke hospitals were compared with non-GWTG-Stroke hospitals. RESULTS: A total of 144 344 of the 228,815 GWTG-Stroke admissions (63.1%) were successfully linked to the 926 756 Medicare ischemic stroke beneficiaries, leaving 782 412 unlinked Medicare patients. Differences in patient characteristics, including age, race, gender, and comorbidities, between the linked and unlinked Medicare cohorts were minimal. Length of stay and rate of discharge home were almost identical between the linked and unlinked groups; however, in-hospital mortality was slightly lower in the linked Medicare cohort (6.3%) compared with the unlinked cohort (7.0%). There were large differences in hospital characteristics between GWTG-Stroke and non-GWTG-Stroke hospitals; GWTG-Stroke hospitals tended to be larger, urban, teaching centers. CONCLUSIONS: Despite substantial differences between GWTG-Stroke and non-GWTG-Stroke hospitals, Medicare beneficiaries with acute ischemic stroke entered in the GWTG-Stroke program were similar to other Medicare beneficiaries. These data suggest that the Medicare-aged GWTG-Stroke ischemic stroke admissions are generally representative of the national fee-for-service Medicare ischemic stroke population.

Depression and antidepressant use after stroke and transient ischemic attack.

BACKGROUND AND PURPOSE: Patients with stroke and transient ischemic attack (TIA) often have comparable comorbidities, but it is unclear whether they have similar rates of depression or antidepressant use. METHODS: This study was a secondary analysis of a prospective cohort registry that enrolled subjects from 2006 to 2008 in the United States. Depression (defined by the Patient Health Questionnaire-8 score ≥ 10) and medication use were prospectively assessed 3 and 12 months after hospitalization in 1450 subjects with ischemic stroke and 397 subjects with TIA. RESULTS: The proportional frequency of depression after stroke and TIA was similar at 3 months (17.9% versus 14.3%, P=0.09) and at 12 months (16.4% versus 12.8%, P=0.08). The rates of newly identified depression between 3 and 12 months were also similar (8.7% versus 6.2%, P=0.12). Persistent depression (defined as Patient Health Questionnaire-8 score ≥ 10 at both 3 and 12 months) was present in 134 (9.2%) of those with stroke and in 30 (7.6%) of those with TIA. Younger age, greater stroke-related disability, and inability to work at 3 months were associated with persistent depression in subjects with stroke. Among subjects with persistent depression, 67.9% of those with stroke and 70.0% of those with TIA were not using antidepressants at either time point (P=0.920). CONCLUSIONS: Stroke and TIA subjects had a similar frequency of depression at 3 and 12 months after hospitalization and similar rates of newly identified depression between 3 and 12 months. A high proportion of those with persistent depression was untreated.

Quality of life after late invasive therapy for occluded arteries.

BACKGROUND: The open-artery hypothesis postulates that late opening of an infarct-related artery after myocardial infarction will improve clinical outcomes. We evaluated the quality-of-life and economic outcomes associated with the use of this strategy. METHODS: We compared percutaneous coronary intervention (PCI) plus stenting with medical therapy alone in high-risk patients in stable condition who had a totally occluded infarct-related artery 3 to 28 days after myocardial infarction. In 951 patients (44% of those eligible), we assessed quality of life by means of a battery of tests that included two principal outcome measures, the Duke Activity Status Index (DASI) (which measures cardiac physical function on a scale from 0 to 58, with higher scores indicating better function) and the Medical Outcomes Study 36-Item Short-Form Mental Health Inventory 5 (which measures psychological well-being). Structured quality-of-life interviews were performed at baseline and at 4, 12, and 24 months. Costs of treatment were assessed for 458 of 469 patients in the United States (98%), and 2-year cost-effectiveness was estimated. RESULTS: At 4 months, the medical-therapy group, as compared with the PCI group, had a clinically marginal decrease of 3.4 points in the DASI score (P=0.007). At 1 and 2 years, the differences were smaller. No significant differences in psychological well-being were observed. For the 469 patients in the United States, cumulative 2-year costs were approximately $7,000 higher in the PCI group (P<0.001), and the quality-adjusted survival was marginally longer in the medical-therapy group. CONCLUSIONS: PCI was associated with a marginal advantage in cardiac physical function at 4 months but not thereafter. At 2 years, medical therapy remained significantly less expensive than routine PCI and was associated with marginally longer quality-adjusted survival. (ClinicalTrials.gov number, NCT00004562.)

Medication coaching program for patients with minor stroke or TIA: a pilot study.

BACKGROUND: Patients who are hospitalized with a first or recurrent stroke often are discharged with new medications or adjustment to the doses of pre-admission medications, which can be confusing and pose safety issues if misunderstood. The purpose of this pilot study was to assess the feasibility of medication coaching via telephone after discharge in patients with stroke. METHODS: Two-arm pilot study of a medication coaching program with 30 patients (20 intervention, 10 control). Consecutive patients admitted with stroke or TIA with at least 2 medications changed between admission and discharge were included. The medication coach contacted intervention arm patients post-discharge via phone call to discuss risk factors, review medications and triage patients' questions to a stroke nurse and/or pharmacist. Intervention and control participants were contacted at 3 months for outcomes. The main outcomes were feasibility (appropriateness of script, ability to reach participants, and provide requested information) and participant evaluation of medication coaching. RESULTS: The median lengths of the coaching and follow-up calls with requested answers to these questions were 27 minutes and 12 minutes, respectively, and participant evaluations of the coaching were positive. The intervention participants were more likely to have seen their primary care provider than were control participants by 3 months post discharge. CONCLUSIONS: This medication coaching study executed early after discharge demonstrated feasibility of coaching and educating stroke patients with a trained coach. Results from our small pilot showed a possible trend towards improved appointment-keeping with primary care providers in those who received coaching.

Comparison of 30-day mortality models for profiling hospital performance in acute ischemic stroke with vs without adjustment for stroke severity.

CONTEXT: There is increasing interest in reporting risk-standardized outcomes for Medicare beneficiaries hospitalized with acute ischemic stroke, but whether it is necessary to include adjustment for initial stroke severity has not been well studied. OBJECTIVE: To evaluate the degree to which hospital outcome ratings and potential eligibility for financial incentives are altered after including initial stroke severity in a claims-based risk model for hospital 30-day mortality for acute ischemic stroke. DESIGN, SETTING, AND PATIENTS: Data were analyzed from 782 Get With The Guidelines-Stroke participating hospitals on 127,950 fee-for-service Medicare beneficiaries with ischemic stroke who had a score documented for the National Institutes of Health Stroke Scale (NIHSS, a 15-item neurological examination scale with scores from 0 to 42, with higher scores indicating more severe stroke) between April 2003 and December 2009. Performance of claims-based hospital mortality risk models with and without inclusion of NIHSS scores for 30-day mortality was evaluated and hospital rankings from both models were compared. MAIN OUTCOMES MEASURES: Model discrimination, hospital 30-day mortality outcome rankings, and value-based purchasing financial incentive categories. RESULTS: Across the study population, the mean (SD) NIHSS score was 8.23 (8.11) (median, 5; interquartile range, 2-12). There were 18,186 deaths (14.5%) within the first 30 days, including 7430 deaths (5.8%) during the index hospitalization. The hospital mortality model with NIHSS scores had significantly better discrimination than the model without (C statistic, 0.864; 95% CI, 0.861-0.867, vs 0.772; 95% CI, 0.769-0.776; P < .001). Among hospitals ranked in the top 20% or bottom 20% of performers by the claims model without NIHSS scores, 26.3% were ranked differently by the model with NIHSS scores. Of hospitals initially classified as having "worse than expected" mortality, 57.7% were reclassified to "as expected" by the model with NIHSS scores. The net reclassification improvement (93.1%; 95% CI, 91.6%-94.6%; P < .001) and integrated discrimination improvement (15.0%; 95% CI, 14.6%-15.3%; P < .001) indexes both demonstrated significant enhancement of model performance after the addition of NIHSS. Explained variance and model calibration was also improved with the addition of NIHSS scores. CONCLUSION: Adding stroke severity as measured by the NIHSS to a hospital 30-day risk model based on claims data for Medicare beneficiaries with acute ischemic stroke was associated with considerably improved model discrimination and change in mortality performance rankings for a substantial portion of hospitals.

Race/ethnicity, quality of care, and outcomes in ischemic stroke.

BACKGROUND: Prior studies suggest differences in stroke care associated with race/ethnicity. We sought to determine whether such differences existed in a population of black, Hispanic, and white patients hospitalized with stroke among hospitals participating in a quality-improvement program. METHODS AND RESULTS: We analyzed in-hospital mortality and 7 stroke performance measures among 397,257 patients admitted with ischemic stroke to 1181 hospitals participating in the Get With The Guidelines-Stroke program 2003 through 2008. Relative to white patients, black and Hispanic patients were younger and more often had diabetes mellitus and hypertension. After adjustment for both patient- and hospital-level variables, black patients had lower odds relative to white patients of receiving intravenous thrombolysis (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.77 to 0.91), deep vein thrombosis prophylaxis (OR, 0.88; 95% CI, 0.83 to 0.92), smoking cessation (OR, 0.85; 95% CI, 0.79 to 0.91), discharge antithrombotics (OR, 0.88; 95% CI, 0.84 to 0.92), anticoagulants for atrial fibrillation (OR, 0.84; 95% CI, 0.75 to 0.94), and lipid therapy (OR, 0.91; 95% CI, 0.88 to 0.96), and of dying in-hospital (OR, 0.90; 95% CI, 0.85 to 0.95). Hispanic patients received similar care as their white counterparts on all 7 measures and had similar in-hospital mortality. Black (OR, 1.31; 95% CI, 1.28 to 1.35) and Hispanic (OR, 1.16; 95% CI, 1.11 to 1.20) patients had higher odds of exceeding the median length of hospital stay relative to whites. During the study, quality of care improved in all 3 race/ethnicity groups. CONCLUSIONS: Black patients with stroke received fewer evidence-based care processes than Hispanic or white patients. These differences could lead to increased risk of recurrent stroke. Quality of care improved substantially in the Get With The Guidelines-Stroke Program over time for all 3 racial/ethnic groups.

Antithrombotic therapy use at discharge and 1 year in patients with atrial fibrillation and acute stroke: results from the AVAIL Registry.

BACKGROUND AND PURPOSE: Current American Heart Association/American Stroke Association guidelines identify warfarin use as a class IA indication in patients with atrial fibrillation (AF) and ischemic stroke (IS) or transient ischemic attack (TIA). However, few studies have examined factors associated with long-term antithrombotic therapy use in IS/TIA patients with AF. METHODS: We utilized the Get With The Guidelines-Stroke national quality improvement registry and the Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) Registry to examine patterns of antithrombotic use at discharge and at 12 months in IS/TIA patients with AF. A multivariate logistic regression model was developed to identify predictors of warfarin use in this patient population at 12 months. RESULTS: Of the 2460 IS/TIA patients, 291 (11.8%) had AF, of which 5.5% of patients were discharged on aspirin alone, 49.1% on warfarin alone, 1.4% on clopidogrel alone, 34.7% on warfarin plus aspirin, 2.1% on aspirin plus clopidogrel, and 1.0% on aspirin plus clopidogrel plus warfarin. Paradoxically, there was a decrease in the rate of warfarin use in patients with a CHADS2 score>3. The only factor associated with warfarin use at 12-month follow-up was male gender (adjusted odds ratio, 2.27; confidence interval, 1.22-4.35; P=0.01). CONCLUSIONS: Overall, the use of warfarin therapy is high at discharge in IS/TIA patients with AF; however, there was a decrease in the rate of warfarin use in patients with a CHADS2 score>3. Compared to women, men were more likely to be on warfarin at 1 year after the index stroke event. Therefore, opportunities exist to improve antithrombotic use in all IS/TIA patients with AF.

Hospital-level variation in mortality and rehospitalization for medicare beneficiaries with acute ischemic stroke.

BACKGROUND AND PURPOSE: stroke is the second leading cause of hospital admission among older adults in the United States. However, little is known regarding contemporary ischemic stroke mortality and rehospitalization rates for Medicare beneficiaries and how they vary by hospital. METHODS: we analyzed outcome data from 91 134 Medicare fee-for-service beneficiaries treated at 625 Get With The Guidelines-Stroke hospitals between April 2003 and December 2006. Within each hospital, 30-day and 1-year death or all-cause readmission rates were calculated with and without risk adjustment. RESULTS: in this cohort, mean age was 79.3 years, 58% were female, and 82% were white. In-hospital, 30-day, and 1-year unadjusted mortality from admission were 6.1%, 14.1%, and 31.1%, respectively, for participating hospitals. The median hospital-level 30-day unadjusted death or readmission rate after discharge was 21.4% (10th to 90th 14.4% to 28.6%). The overall rate of death or rehospitalization within 1 year of hospital discharge was 61.9%. Risk-adjusted rates varied widely by hospital at each time point. There were no improvements in death or rehospitalization from 2003 to 2006. Hospital-level performance in risk-adjusted outcomes did not significantly differ by size or primary stroke center designation, but academic hospitals and those in the Northeast or West had slightly more favorable outcomes. CONCLUSIONS: nearly two thirds of the Medicare beneficiaries discharged after ischemic stroke died or were rehospitalized within 1 year, but hospital-level outcomes varied considerably. These findings underscore the need to better understand the patterns and causes of deaths and readmission after ischemic stroke and to develop strategies aimed at avoiding those that are preventable.

Estimating mean cost using auxiliary covariates.

We study the estimation of mean medical cost when censoring is dependent and a large amount of auxiliary information is present. Under missing at random assumption, we propose semiparametric working models to obtain low-dimensional summarized scores. An estimator for the mean total cost can be derived nonparametrically conditional on the summarized scores. We show that when either the two working models for cost-survival process or the model for censoring distribution is correct, the estimator is consistent and asymptotically normal. Small-sample performance of the proposed method is evaluated via simulation studies. Finally, our approach is applied to analyze a real data set in health economics.

Get With the Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack.

BACKGROUND: Adherence to evidence-based guidelines for treatment of stroke or transient ischemic attack is suboptimal. We sought to establish whether participation in Get With the Guidelines-Stroke was associated with improvements in adherence. METHODS AND RESULTS: This prospective, nonrandomized, national quality improvement program measured adherence to guideline recommendations in 322 847 hospitalized patients discharged with a diagnosis of ischemic stroke or transient ischemic attack. A volunteer sample of 790 US academic and community hospitals participated from 2003 through 2007. The main outcome measures were change in adherence over time to 7 prespecified performance measures and a composite measure (total number of interventions provided in eligible patients divided by total number of care opportunities among eligible patients). Generalized estimating equations were used to identify factors associated with improvement. Participation in Get With the Guidelines-Stroke was associated with improvements in the 7 individual and 1 composite measures from baseline to the fifth year: intravenous thrombolytics (42.09% versus 72.84%), early antithrombotics (91.46% versus 97.04%), deep vein thrombosis prophylaxis (73.79% versus 89.54%), discharge antithrombotics (95.68% versus 98.88%), anticoagulation for atrial fibrillation (95.03% versus 98.39%), lipid treatment for low-density lipoprotein >100 mg/dL (73.63% versus 88.29%), smoking cessation (65.21% versus 93.61%), and composite (83.52% versus 93.97%) (P<0.0001 for all comparisons). Multivariate analysis showed that time in Get With the Guidelines-Stroke was associated with a 1.18-fold yearly increase in the odds of fulfilling care opportunities that was independent of secular trends. CONCLUSIONS: Get With the Guidelines-Stroke participation was associated with increased adherence to all stroke performance measures. Markedly improved stroke care was seen in all hospitals regardless of size, geography, and teaching status.