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Stroke. 2014 Jan;45(1):231-8. doi: 10.1161/STROKEAHA.113.003617. Epub 2013 Nov 19.

Quality of care and outcomes for in-hospital ischemic stroke: findings from the National Get With The Guidelines-Stroke.

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  • 1From the Department of Medicine, University of Colorado School of Medicine Anschutz Medical Campus, Aurora, CO (E.C., H.W.); VA Boston Healthcare System, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA (D.L.B.); Duke Clinical Research Institute, Duke University Medical Center, Durham, NC (M.C., Y.X.); Department of Epidemiology, Michigan State University, East Lansing, MI (M.R.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston, MA (L.S.); and Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA (G.C.F.).



Analysis of quality of care for in-hospital stroke has not been previously performed at the national level. This study compares patient characteristics, process measures of quality, and outcomes for in-hospital strokes with those for community-onset strokes in a national cohort.


We performed a retrospective cohort study of the Get With The Guidelines-Stroke (GWTG-Stroke) database of The American Heart Association from January 2006 to April 2012, using data from 1280 sites that reported ≥1 in-hospital stroke. Patient characteristics, comorbid illnesses, medications, quality of care measures, and outcomes were analyzed for 21 349 in-hospital ischemic strokes compared with 928 885 community-onset ischemic strokes.


Patients with in-hospital stroke had more thromboembolic risk factors, including atrial fibrillation, prosthetic heart valves, carotid stenosis, and heart failure (P<0.0001), and experienced more severe strokes (median National Institutes of Health Stroke Score 9.0 versus 4.0; P<0.0001). Using GWTG-Stroke achievement measures, the proportion of patients with defect-free care was lower for in-hospital strokes (60.8% versus 82.0%; P<0.0001). After accounting for patient and hospital characteristics, patients with in-hospital strokes were less likely to be discharged home (adjusted odds ratio 0.37; 95% confidence intervals [0.35-0.39]) or be able to ambulate independently at discharge (adjusted odds ratio 0.42; 95% confidence intervals [0.39-0.45]). In-hospital mortality was higher for in-hospital stroke (adjusted odds ratio 2.72; 95% confidence intervals [2.57-2.88]).


Compared with community-onset ischemic stroke, patients with in-hospital stroke experienced more severe strokes, received lower adherence to process-based quality measures, and had worse outcomes. These findings suggest there is an important opportunity for targeted quality improvement efforts for patients with in-hospital stroke.


outcome assessment (health care); quality indicators, health care; quality of health care; registries; stroke; thrombolytic therapy

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