Impact of Increased Early Statin Administration on Ischemic Stroke Outcomes: A Multicenter Electronic Medical Record Intervention

Abstract

Background: Statin administration early in ischemic stroke may influence outcomes. Our aim was to determine the clinical impact of increasing statin administration early in ischemic stroke hospitalization.

Methods and results: This is a retrospective analysis of a multicenter electronic medical record (EMR) intervention to increase early statin administration in ischemic stroke across all 20 hospitals of an integrated healthcare delivery system. A stroke EMR order set was modified from an "opt-in" to "opt-out" mode of statin ordering. Outcomes were mortality by 90 days, discharge disposition, and increase in stroke severity. We examined the relationship between intervention and outcome using autoregressive integrated moving average (ARIMA) time-series modeling. The EMR intervention increased both overall in-hospital statin administration (from 87.2% to 90.7%, P<0.001) and early statin administration (from 16.9% to 26.3%, P<0.001). ARIMA models showed a small increase in the rate of survival (difference in probability [Pdiff]=0.02, P=0.016) and discharge to home or rehabilitation facility (Pdiff=0.04, P=0.034) associated with the intervention. The increase in statin administration <8 hours was associated with much larger increases in survival (Pdiff=0.17, P=0.033) and rate of discharge to home or rehabilitation (Pdiff=0.29, P=0.011), as well as a decreased rate of neurological deterioration in-hospital (Pdiff=-0.14, P=0.026).

Conclusions: A simple EMR change increased early statin administration in ischemic stroke and was associated with improved clinical outcomes. This is, to our knowledge, the first EMR intervention study to show that a modification of an electronic order set resulted in improved clinical outcomes.

Keywords: electronic medical record intervention; ischemic stroke; order sets; outcome; statin intervention.

Figure 1

Month‐by‐month statin administration according to study period. For both panels, the first 26 months represent the “before” period with an opt‐in ordering mode for statin prescription, and the second 25 months represent the “after” period with an opt‐out ordering mode for statin prescription. Arrowhead and solid black vertical line indicate timing of transition from opt‐in to opt‐out ordering mode. Solid black horizontal line represents the mean, and dotted black horizontal lines represent the bounds for ±2 SD of the mean. A, Percentage of patients in each month (vertical gray bars) administered a statin at any time during hospitalization. B, Percentage of patients in each month (vertical gray bars) administered a statin within 8 hours of ER triage time.

Figure 2

ARIMA time series models relating the order set change to clinical outcomes. For both panels, the difference in probability (P _diff) for each outcome is plotted along the X axis, with a solid symbol representing the point estimate for P _diff, and horizontal error bars representing the 95% CI of the estimate. Three separate models are presented in each panel, modeling the outcomes of alive at 90 days poststroke, discharge to home or inpatient rehabilitation center, and neurological deterioration (increase in mNIHSS by 4 or more points). A, ARIMA time series models examining the impact of the opt‐out vs opt‐in periods on clinical outcomes. B, ARIMA time series models examining the impact of early statin administration (within 8 hours of initial ER triage time) in opt‐out vs opt‐in periods on clinical outcomes. ARIMA indicates autoregressive integrated moving average; ER, emergency room; mNIHSS, modified National Institutes of Health Stroke Scale.

Figure 3

Time in hours to first statin administration and clinical outcomes. For all 3 panels, multivariable model‐derived estimates of clinical outcomes are plotted (solid lines with flanking dashed lines representing 95% CI for the estimates) corresponding to time in hours to administration of first statin dose. Underlying multivariable logistic regression models control for age, mNIHSS, Charlson comorbidity index, and presence of dysphagia. A, Model‐estimated percentage of patients alive at 90 days poststroke as a function of time to first statin dose in hours. B, Model‐estimated percentage of patients discharged to home or inpatient rehabilitation facility after any duration of hospitalization as a function of time to first statin dose in hours. C, Model‐estimated percentage of patients with in‐hospital neurological deterioration (defined as an increase in mNIHSS by 4 or more points) as a function of time to first statin dose in hours. mNIHSS, modified National Institutes of Health Stroke Scale.