Correlation of inpatient and outpatient measures of stroke care quality within veterans health administration hospitals

Abstract

Background and purpose: Quality of care delivered in the inpatient and ambulatory settings may be correlated within an integrated health system such as the Veterans Health Administration. We examined the correlation between stroke care quality at hospital discharge and within 6 months postdischarge.

Methods: We conducted a cross-sectional hospital-level correlation analyses of chart-abstracted data for 3467 veterans discharged alive after an acute ischemic stroke from 108 Veterans Health Administration medical centers and 2380 veterans with postdischarge follow-up within 6 months in fiscal year 2007. Four risk-standardized processes of care represented discharge care quality: prescription of antithrombotic and antilipidmic therapy, anticoagulation for atrial fibrillation, and tobacco cessation counseling along with a composite measure of defect-free care. Five risk-standardized intermediate outcomes represented postdischarge care quality: achievement of blood pressure, low-density lipoprotein, international normalized ratio, and glycosylated hemoglobin target levels, and delivery of appropriate treatment for poststroke depression along with a composite measure of achieved outcomes.

Results: Median risk-standardized composite rate of defect-free care at discharge was 79%. Median risk-standardized postdischarge rates of achieving goal were 56% for blood pressure, 36% for low-density lipoprotein, 41% for international normalized ratio, 40% for glycosylated hemoglobin, and 39% for depression management and the median risk-standardized composite 6-month outcome rate was 44%. The hospital composite rate of defect-free care at discharge was correlated with meeting the low-density lipoprotein goal (r=0.31; P=0.007) and depression management (r=0.27; P=0.03) goal but was not correlated with blood pressure, international normalized ratio, glycosylated hemoglobin goals, nor with the composite measure of achieved postdischarge outcomes (probability values >0.13).

Conclusions: Hospital discharge care quality was not consistently correlated with ambulatory care quality.

Figure 1

Study sample inclusion and exclusion flow chart. Note: VAMC=Veterans Affairs Medical Center. * Exclusion categories are not mutually exclusive.

Figure 2

Correlation between hospital rates of delivering care to ischemic stroke patients at discharge and 6 month post-discharge outcomes, specifically achieving target A) blood pressure, B) serum low-density lipoprotein, C) serum international normalized ratio, and D) serum glycosylated hemoglobin.

Figure 2

Correlation between hospital rates of delivering care to ischemic stroke patients at discharge and 6 month post-discharge outcomes, specifically achieving target A) blood pressure, B) serum low-density lipoprotein, C) serum international normalized ratio, and D) serum glycosylated hemoglobin.

Figure 2

Correlation between hospital rates of delivering care to ischemic stroke patients at discharge and 6 month post-discharge outcomes, specifically achieving target A) blood pressure, B) serum low-density lipoprotein, C) serum international normalized ratio, and D) serum glycosylated hemoglobin.

Figure 2

Correlation between hospital rates of delivering care to ischemic stroke patients at discharge and 6 month post-discharge outcomes, specifically achieving target A) blood pressure, B) serum low-density lipoprotein, C) serum international normalized ratio, and D) serum glycosylated hemoglobin.

Figure 3

Correlation between hospital rates of delivering care to ischemic stroke patients at discharge and 6 month post-discharge outcomes, specifically A) post-stroke depression screening and management and B) composite achievement of outcomes.

Figure 3

Correlation between hospital rates of delivering care to ischemic stroke patients at discharge and 6 month post-discharge outcomes, specifically A) post-stroke depression screening and management and B) composite achievement of outcomes.