Quality of Care for Veterans With Transient Ischemic Attack and Minor Stroke

Key Points

Question  What is the quality of care that the Veterans Health Administration—the largest health care system in the United States—is providing to patients with transient ischemic attack and minor stroke?

Findings  This cohort study of 8201 patients identified opportunities to improve care quality, particularly among patients who were discharged from the emergency department and those who did not receive early neurology consultation.

Meaning  This study provides benchmarking data for the Veterans Health Administration system for transient ischemic attack and minor stroke care quality and identifies targets for quality improvement.

Importance  The timely delivery of guideline-concordant care may reduce the risk of recurrent vascular events for patients with transient ischemic attack (TIA) and minor stroke. Although many health care organizations measure stroke care quality, few evaluate performance for patients with TIA or minor stroke, and most include only a limited subset of guideline-recommended processes.

Objective  To assess the quality of guideline-recommended TIA and minor stroke care across the Veterans Health Administration (VHA) system nationwide.

Design, Setting, and Participants  This cohort study included 8201 patients with TIA or minor stroke cared for in any VHA emergency department (ED) or inpatient setting during federal fiscal year 2014 (October 1, 2013, through September 31, 2014). Patients with length of stay longer than 6 days, ventilator use, feeding tube use, coma, intensive care unit stay, inpatient rehabilitation stay before discharge, or receipt of thrombolysis were excluded. Outlier facilities for each process of care were identified by constructing 95% CIs around the facility pass rate and national pass rate sites when the 95% CIs did not overlap. Data analysis occurred from January 16, 2016, through June 30, 2017.

Main Outcomes and Measures  Ten elements of care were assessed using validated electronic quality measures.

Results  In the 8201 patients included in the study (mean [SD] age, 68.8 [11.4] years; 7877 [96.0%] male; 4856 [59.2%] white), performance varied across elements of care: brain imaging by day 2 (6720/7563 [88.9%]; 95% CI, 88.2%-89.6%), antithrombotic use by day 2 (6265/7477 [83.8%]; 95% CI, 83.0%-84.6%), hemoglobin A_1c measurement by discharge or within the preceding 120 days (2859/3464 [82.5%]; 95% CI, 81.2%-83.8%), anticoagulation for atrial fibrillation by day 7 after discharge (1003/1222 [82.1%]; 95% CI, 80.0%-84.2%), deep vein thrombosis prophylaxis by day 2 (3253/4346 [74.9%]; 95% CI, 73.6%-76.2%), hypertension control by day 90 after discharge (4292/5979 [71.8%]; 95% CI, 70.7%-72.9%), neurology consultation by day 1 (5521/7823 [70.6%]; 95% CI, 69.6%-71.6%), electrocardiography by day 2 or within 1 day prior (5073/7570 [67.0%]; 95% CI, 65.9%-68.1%), carotid artery imaging by day 2 or within 6 months prior (4923/7685 [64.1%]; 95% CI, 63.0%-65.2%), and moderate- to high-potency statin prescription by day 7 after discharge (3329/7054 [47.2%]; 95% CI, 46.0%-48.4%). Performance varied substantially across facilities (eg, neurology consultation had a facility outlier rate of 53.0%). Performance was higher for admitted patients than for patients cared for only in EDs with the greatest disparity for carotid artery imaging (4478/5927 [75.6%] vs 445/1758 [25.3%]; P < .001).

Conclusions and Relevance  This national study of VHA system quality of care for patients with TIA or minor stroke identified opportunities to improve care quality, particularly for patients who were discharged from the ED. Health care systems should engage in ongoing TIA care performance assessment to complement existing stroke performance measurement.

Patients with transient ischemic attack (TIA) and minor ischemic stroke are at high risk of recurrent vascular events.^1-4 However, timely delivery of guideline-concordant care may reduce this risk.^5-9 Several prospective studies^5-8 demonstrating improvements in outcomes by delivering timely guideline-concordant care have included patients with TIA and minor stroke. Because TIA and minor stroke events share similar origins and because patients with TIA and minor stroke have similar prognoses, recommendations for care are similar for patients with TIA and minor stroke.^4,9-12 Given that patients with transient neurologic symptoms with evidence of brain infarct by imaging are classified as (minor) stroke rather than TIA,¹³ the resemblance—in terms of prognosis and clinical needs—between patients with minor stroke and those with TIA may be greater than the resemblance between patients with minor stroke and those with major stroke.

Given these similarities, it is reasonable that patients with TIA and minor stroke should be included in quality measurement programs to ensure that patients are receiving the care they need to reduce their risk of recurrent vascular events. However, most quality assessment programs focus on stroke to the exclusion of TIA and do not distinguish between major stroke and minor stroke.¹⁴ For example, the Veterans Health Administration (VHA), which is the largest health care system in the United States, currently assesses the quality of care for all patients with ischemic stroke but not for patients with TIA and not for patients with minor stroke separately from those with major stroke. Therefore, our objective was to assess the quality of TIA and minor ischemic stroke care across the VHA system nationwide. We were interested in identifying guideline-concordant care components that could serve as targets for future quality improvement efforts.

Details of our methods have been described elsewhere.¹⁵ Briefly, we identified veteran patients with TIA or ischemic stroke (minor or major) who were cared for in any VHA emergency department (ED) or inpatient setting during federal fiscal year 2014 (October 1, 2013, through September 31, 2014) based on International Classification of Diseases, Ninth Revision (ICD-9) primary discharge codes for TIA (435.0, 435.1, 435.3, 435.8, and 435.9) or stroke (433.X1, 434.00, 434.X1, and 436). The earliest event was used as the index event. Because electronic health record data did not include a measure of stroke severity, a validated approach to identify patients with major ischemic stroke was used.¹⁶ Patients were classified as having major stroke and were excluded if any of the following were present: length of stay longer than 6 days, ventilator use, feeding tube use, coma, intensive care unit stay, inpatient rehabilitation stay before discharge, or receipt of thrombolysis. This approach to identifying patients with TIA and minor stroke has 99.0% agreement with medical record review.¹⁶ Patients cared for in observation settings were classified as inpatients. Patients cared for in an ED without an inpatient or observation unit admission were classified as ED-only patients. This study received human subjects committee approval from the Indiana University School of Medicine Institutional Review Board and from the Richard L. Roudebush VA Medical Center Research and Development Committee. A waiver of informed consent was obtained for the collection of patient-level data. Data were not deidentified.

Ten electronic quality measures (eQMs) previously validated against medical record review were used to assess quality of care.¹⁶ Briefly, the eQMs were previously compared with medical record review with regard to eligibility (whether an individual patient was included in the denominator) and pass rate (whether an individual was included in the numerator). For example, for the anticoagulation for atrial fibrillation measure, the overall accuracy (the sum of the true-positive plus true-negative results divided by the sum of true-positive, false-positive, true-negative, and false-negative results) of the eQM compared with medical record review was 93% for eligibility and 92% for passing. In the previous validation study,¹⁶ we considered 31 eQMs; however, only those with the best performance for eligibility and passing were included in the present analysis. In addition, only 1 eQM per clinical domain was retained. For example, being discharged with statins and the prescription of moderate- to high-potency statins are 2 processes within the clinical domain of hyperlipidemia. To arrive at a single eQM per clinical domain, we prioritized those processes with the highest validation against medical record review; in cases of similar validation results, we retained the processes with greatest alignment to most recent guidelines. In the previous validation study,¹⁶ no systematic differences in agreement between the electronic health record data and the medical record review data were observed on the basis of diagnosis (TIA vs stroke) or admission status (ED-only vs admitted patients).

Each of the eQMs represented guideline-concordant elements of care.⁹ However, only some of the eQMs were similar to measures included in the Joint Commission (JC) Stroke Core Measure Set or the American Heart Association (AHA)/American Stroke Association (ASA) Performance Measures Set; neither organization has an existing TIA measure set.^17-19 In other words, currently existing ischemic stroke performance assessment programs include only a subset of guideline-recommended elements of care and focus only on patients with stroke (but not TIA). In contrast, we sought to evaluate a wider range of guideline-concordant processes for patients with TIA and minor stroke. eTable 1 in the Supplement provides numerator and denominator definitions. The eQMs included the following diagnostic and therapeutic components of care: (1) brain imaging, (2) carotid artery imaging, (3) electrocardiography, (4) hypertension control, (5) anticoagulation for atrial fibrillation or flutter, (6) moderate- to high-potency statin prescription, (7) hemoglobin A_1c (HbA_1c) measurement, (8) antithrombotic use, (9) deep vein thrombosis (DVT) prophylaxis, and (10) neurology consultation. For each eQM, patients were classified as ineligible, eligible-passed, or eligible-failed. The denominators for the eQMs varied; for example, only patients with atrial fibrillation or flutter were eligible for the anticoagulation metric.

A variety of data sources were used in eQM construction.¹⁶ The VHA Corporate Data Warehouse includes a broad range of information that is obtained from the VHA electronic medical record system known as Veterans Information Systems and Technology Architecture. Veterans Information Systems and Technology Architecture is the electronic medical record system that is used across the entire VHA system nationwide and includes clinical (eg, notes, orders, procedures, pharmacy, and prosthetics) and administrative (eg, billing, security, compensation, and pension) functionality. The Corporate Data Warehouse data that were used in the current analyses included inpatient and outpatient data files (which include information about the date of a clinical encounter and its associated diagnostic and procedure codes) in the 5 years before the event to identify medical history,²⁰ health care use, and receipt of procedures (Current Procedural Terminology, Healthcare Common Procedures Coding System, and ICD-9 procedure codes). The Corporate Data Warehouse data were also used for vital signs, laboratory data, allergies, orders, and consultations. Pharmacy benefits management data were used to identify medications. Linked VHA and Centers for Medicare & Medicaid Services data were used to identify non-VHA hospitalizations. Fee-basis data (which describe health care services that were paid for by the VHA but that were obtained by veterans outside the VHA facilities) were also used to identify inpatient and outpatient use and medical history. The date of death was obtained from the VHA Vital Status File.

Continuous patient characteristics were summarized using means (SDs) or medians (ranges). For the assessment of variation in performance across facilities, we examined the mean facility pass rates and interquartile ranges at facilities with 10 or more eligible patients per fiscal year.²¹ We used χ² tests to compare pass rates between ED-only vs admitted patients, patients with vs without early neurology consultation, and patients with TIA vs minor stroke.

We identified the proportion of outlier facilities for each eQM by constructing unadjusted upper and lower 95% confidence limits around the facility mean pass rate. We also calculated the 95% CIs for the overall mean national rate for each eQM and examined whether the facility confidence boundaries overlapped with the national confidence boundaries. Sites where the 95% CIs did not overlap were considered outliers. SAS statistical software, version 9.2 (SAS Institute Inc) was used for data analysis, which was conducted from January 16, 2016, through June 30, 2017.

The cohort included 8201 patients: 3264 (39.8%) with TIA and 4937 (60.2%) with minor stroke (mean [SD] age, 68.8 [11.4] years; 7877 [96.0%] male; 4856 [59.2%] white). The patients received index-event care at 129 VHA facilities and postevent care at 151 VHA facilities. The baseline characteristics of the patients are provided in Table 1.

Patient-level quality of care data are provided in Table 2 and sorted by performance. Overall performance varied considerably across the eQMs: brain imaging (6720/7563 [88.9%]; 95% CI, 88.2%-89.6%), antithrombotic use (6265/7477 [83.8%]; 95% CI, 83.0%-84.6%), hemoglobin A_1c measurement (2859/3464 [82.5%]; 95% CI, 81.2%-83.8%), anticoagulation for atrial fibrillation (1003/1222 [82.1%]; 95% CI, 80.0%-84.2%), DVT prophylaxis (3253/4346 [74.9%]; 95% CI, 73.6%-76.2%), hypertension control (4292/5979 [71.8%]; 95% CI, 70.7%-72.9%), neurology consultation (5521/7823 [70.6%]; 95% CI, 69.6%-71.6%), electrocardiography (5073/7570 [67.0%]; 95% CI, 65.9%-68.1%), carotid artery imaging (4923/7685 [64.1%]; 95% CI, 63.0%-65.2%), and moderate- to high-potency statin prescription (3329/7054 [47.2%]; 95% CI, 46.0%-48.4%) (Table 2).

A few patients (2101/8201 [25.6%]) were discharged from the ED. The proportion of ED-only patients was similar for patients with TIA (907/3264 [27.8%]) and minor stroke (1195/4937 [24.2%]). Nine eQMs were relevant to admitted and ED-only patients (because only inpatients were eligible for DVT prophylaxis). Performance was higher for admitted patients than for ED-only patients on 8 of the 9 eQMs (Table 3). The greatest difference between ED-only and admitted patients was for carotid artery imaging (445/1758 [25.3%] for ED-only vs 4478/5927 [75.6%] for admitted patients; difference, 50.3%; P < .001). In general, performance was better for patients with minor stroke than for patients with TIA (eTable 2 in the Supplement).

Most eligible patients (5521/7823 [70.6%]; 95% CI, 69.6%-71.6%) received early neurology consultation. The baseline characteristics of patients who received early neurology consultation differed from those of patients who did not receive early neurology consultation (eTable 3 in the Supplement). Patients who were admitted were more likely to receive early neurology care than patients who were discharged from the ED (Table 3). Performance was better for patients who received early neurology consultation for 8 of 9 eQMs (Table 4). For example, patients who received early neurology consultation were more likely to receive carotid artery imaging (difference, 29.7%). From these data, we cannot discern what role the neurologist played in the provision of care; we can only identify the unadjusted, observed association between the receipt of early neurology consultation and the other eQMs.

We observed substantial variation in performance across facilities (Table 2). The processes with the most variation were electrocardiography, with a mean facility pass rate of 66.9% (for facilities with at least 10 eligible patients) and a facility percentage outlier of 54.7%, and neurology consultation, with a mean facility pass rate of 65.4% and a facility percentage outlier of 53.0%. However, even for antithrombotic use by day 2, one of the processes with the best performance, 27.6% were statistical outliers. The eQMs thus identified facilities with extreme performance, a characteristic that may be desirable when implementing eQMs for quality improvement. Overall, no association was observed between patient volume and outlier status; smaller sites were, therefore, not more likely to be poor-quality outliers than larger sites.

To our knowledge, this study was the first national benchmarking evaluation of TIA and minor stroke care quality for the VHA. We identified several opportunities for improvement. The processes with the lowest performance included moderate- or high-potency statin prescription, carotid artery imaging, and electrocardiography.

In general, the performance of the VHA nationwide was highest for processes that are included in the JC Stroke Core Measure Set (eg, DVT prophylaxis, antithrombotic use, and anticoagulation for atrial fibrillation and flutter). The JC measures focus on processes delivered during an inpatient stay through discharge. They do not include postdischarge processes (eg, hypertension control). For the JC measures, patients with ischemic stroke are included in the denominator for all measures. Patients with hemorrhagic stroke are included in 3 and patients with TIA in none.¹⁷ It may be that performance on JC measures was higher than for other measures because JC measures were familiar to clinicians and quality managers. Awareness of JC measures in the VHA may have been increased by a 2009 study²² of VHA stroke care quality, which focused on JC-based processes, and the 2011 VHA Acute Ischemic Stroke Directive,²³ which mandated that every VHA hospital self-report 3 quality measures (National Institutes of Health Stroke Scale documentation, thrombolysis, and dysphagia screening). Thrombolysis is a current JC measure, and dysphagia screening is a former JC measure, potentially further enhancing awareness of JC measures.

In contrast to the well-established JC measures, some of the eQMs used in the present study were based on newer guideline recommendations.⁹ For example, although lipid management has been an established stroke quality indicator, we examined the use of moderate- to high-potency statins based on the 2013 American College of Cardiology/AHA lipid guidelines.²⁴ As expected, performance on the new moderate- to high-potency statin eQM was only 47.2% among eligible patients.

A key finding was that patients who are admitted generally receive more elements of care for which they were eligible than ED-only patients. Several studies^25-27 have reported similar findings. These findings support the AHA/ASA suggestion to admit patients with TIA within 72 hours of symptom onset to facilitate the delivery of diagnostic and therapeutic interventions.¹³ Certainly, the establishment of units that provide rapid outpatient assessment may offer cost-effective and patient-centered alternatives to inpatient admission.⁷ Our admission rate of 74.4% for patients with TIA was slightly higher than the 47% to 64% non-VHA admission rates from nationally representative US and Canadian samples.^27-29

Our finding that patients with TIA were less likely to receive some elements of care than patients with minor stroke is similar to a prior report.³⁰ Although it is reasonable that patients with TIA may be less likely than patients with minor stroke to receive certain processes of care, for most elements of care there is no difference in the strength of the recommendation for TIA compared with minor stroke.⁹ Patients who are admitted (as opposed to ED-only patients) and those with a diagnosis of stroke (as opposed to TIA) may represent cases with greater diagnostic certainty, which may account for some of the observed differences in performance.

Our finding of relative underuse of secondary prevention medications is similar to findings from other settings.^31,32 Although the VHA is the largest integrated health care system in the United States, with a robust electronic health record that facilitates communication and primary care clinical reminders related to vascular risk factor control,³³ clinical care is still often provided within silos according to settings and medical specialties.²¹ Existing clinical boundaries will need to be spanned to provide secondary prevention care for patients with TIA and minor stroke.

The eQMs focused on guideline-concordant care; however, not all guideline-recommended processes may be of equal clinical relevance.⁹ The AHA/ASA suggested that 7 measures that were recommended for patients with ischemic stroke could be used to evaluate TIA care quality: antithrombotic use by day 2 and discharge, anticoagulation for atrial fibrillation or flutter, statin prescription at discharge, stroke education, tobacco cessation counseling, and carotid imaging.¹⁹ However, apart from the Centers for Disease Control and Prevention Coverdell program, few national organizations are currently tracking TIA care quality.³⁴ Concern regarding ICD-9 code validity for the identification of patients with TIA¹⁹ and issues related to variation in workup³⁵ have been cited as reasons for limited performance measurement for this population. The diagnostic uncertainty that accompanies the diagnosis of TIA complicates the coding issues and patient identification; however, establishment of quality measurement programs will incentivize improved coding. Given the robust evidence that timely delivery of post-TIA care reduces the risk of recurrent vascular events,^5-8 national organizations should implement quality metrics that are applied to patients with TIA.

The strengths of this study included its national scope and the inclusion of 10 processes of care that had previously been validated against medical record review. The processes of care included diagnostic (eg, carotid artery imaging) and therapeutic (eg, antithrombotic use) components of care as well as both processes that are typically provided early after presentation (eg, brain imaging) and those that are provided later in the clinical course (eg, hypertension control). This study thus provides a comprehensive evaluation of care quality and data for processes that have been included in stroke performance measurement programs (eg, antithrombotic use) and components of care that have been recommended by AHA/ASA guidelines but for which few published data are available to provide benchmarking comparisons (eg, carotid artery imaging).

Several limitations of this study merit description. First, these results may differ from those in settings without consolidated electronic medical records. Second, these results may not generalize to nonveteran populations because of the male predominance in the veteran population and because veterans’ use of VHA EDs might differ from how nonveterans use non-VHA EDs. Third, these analyses are descriptive. Following the approach used by the JC, we reported the proportion of eligible patients who receive processes of care¹⁷ rather than constructing risk-adjusted models. For example, the observed differences in receipt of care between admitted and ED-only patients may be attributed in part to differences in patient characteristics. Similarly, we observed differences in the baseline characteristics of patients who received vs those who did not receive early neurology consultation (eTable 3 in the Supplement); therefore, differences in quality of care may have been attributable to differences in patient characteristics and not to the neurology consultation. Fourth, although we conducted stochastic testing on the differences in quality of care for admitted vs ED-only patients and for patients with vs without neurology consultation, we did not correct for multiple comparisons. Fifth, as indicated above, all the processes that were included were guideline-recommended elements of care; however, they varied in terms of their evidence grade. For example, brain imaging has an evidence grade of IA, and hypertension control has an evidence grade of IIb, C. Sixth, although most patients in this cohort (all of whom had an index TIA or minor stroke event at a VHA facility) sought primary care services after the index event at a VHA facility, some patients may have received care only at non-VHA facilities. We may have underestimated the pass rates for the few patients who received care only at non-VHA facilities. The process of care for which the issue of non-VHA care has the theoretical potential for greatest bias is hypertension control because the numerator of that measure is based on blood pressure values from the 90 days after the event. We did not have access to blood pressure data from non-VHA outpatient visits. If patients had no valid blood pressure data (eg, no VHA blood pressure measurement), they were excluded from the denominator of the hypertension control quality measure. Seventh, although we used eQMs that had been previously validated against medical record review, the use of electronic health record data may have resulted in misclassification of patients in terms of receipt of certain processes or eligibility for certain processes. In addition, specifications of numerator and denominator inclusions may be a source of misclassification (eg, as recommended by the AHA/ASA Performance Measures Set, the carotid imaging processes did not include or exclude patients on the basis of symptoms or event classification). Future research should examine whether patient characteristics account for differences in admission and differences in quality of care.

These results demonstrate that the VHA system is providing high-quality care for patients with TIA and minor stroke for many processes but also identified improvement opportunities. These results informed the design of a new VHA program (clinical trials.gov Identifier: NCT02769338) that focuses on timeliness of care and includes an intervention to improve acute care and secondary prevention service for patients with TIA or minor stroke and has led to new initiatives within the VHA emergency medicine service nationwide to expand the existing collaborations between ED and neurology to now focus on ensuring that all veterans with TIA receive the care they need.³⁶

Accepted for Publication: October 17, 2017.

Corresponding Author: Dawn M. Bravata, MD, VA HSR&D Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Mail Code 11H, 1481 W 10th St, Indianapolis, IN 46202 (dawn.bravata2@va.gov).

Published Online: February 5, 2018. doi:10.1001/jamaneurol.2017.4648

Author Contributions: Drs Bravata and Myers had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Bravata, Arling, Damush, Sico, Zillich, Yu, Williams, Rhude, Cheng.

Acquisition, analysis, or interpretation of data: Bravata, Myers, Arling, Miech, Phipps, Zillich, Yu, Reeves, Williams, Johanning, Chaturvedi, Baye, Ofner, Austin, Ferguson, Graham, Rhude, Kessler, Higgins, Cheng.

Drafting of the manuscript: Bravata, Myers, Sico, Austin.

Critical revision of the manuscript for important intellectual content: Bravata, Myers, Arling, Miech, Damush, Sico, Phipps, Zillich, Yu, Reeves, Williams, Johanning, Chaturvedi, Baye, Ofner, Ferguson, Graham, Rhude, Kessler, Higgins, Cheng.

Statistical analysis: Bravata, Myers, Arling, Miech, Yu, Baye, Ofner, Rhude.

Obtained funding: Bravata, Yu, Williams.

Administrative, technical, or material support: Bravata, Miech, Damush, Zillich, Williams, Johanning, Austin, Ferguson, Graham, Rhude, Kessler, Higgins.

Study supervision: Bravata, Yu, Chaturvedi, Graham, Cheng.

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by service directed project 12-178 from the Department of Veterans Affairs (VA) Health Services Research & Development Service (HSR&D), Stroke Quality Enhancement Research Initiative. Dr Sico is supported by VA HSR&D Career Development Award HX001388-01A1. Support for VA and Centers for Medicare & Medicaid Service data was provided by grants SDR 02-237 and 98-004 from the VA Information Resource Center.

Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.