Processes of Care Associated with Risk of Mortality and Recurrent Stroke among Patients with Transient Ischemic Attack and Nonsevere Ischemic Stroke

Dawn M. Bravata, Laura J. Myers, Mathew Reeves, Eric M. Cheng, Fitsum Baye, Susan Ofner, Edward J. Miech, Teresa Damush, Jason J. Sico, Alan Zillich, Michael Phipps, Linda S. Williams, Seemant Chaturvedi, Jason Johanning, Zhangsheng Yu, Anthony J. Perkins, Ying Zhang, Greg Arling

Research output: Contribution to journalArticle

Abstract

Importance: Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. Objective: To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. Design, Setting, and Participants: This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. Main Outcomes and Measures: Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. Results: Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk. Conclusions and Relevance: Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible.

Original languageEnglish (US)
Article numbere196716
JournalJAMA Network Open
Volume2
Issue number7
DOIs
StatePublished - Jul 5 2019

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Transient Ischemic Attack
Stroke
Odds Ratio
Mortality
Hydroxymethylglutaryl-CoA Reductase Inhibitors
Guidelines
Carotid Arteries
Atrial Fibrillation
Lipids

ASJC Scopus subject areas

  • Medicine(all)

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Processes of Care Associated with Risk of Mortality and Recurrent Stroke among Patients with Transient Ischemic Attack and Nonsevere Ischemic Stroke. / Bravata, Dawn M.; Myers, Laura J.; Reeves, Mathew; Cheng, Eric M.; Baye, Fitsum; Ofner, Susan; Miech, Edward J.; Damush, Teresa; Sico, Jason J.; Zillich, Alan; Phipps, Michael; Williams, Linda S.; Chaturvedi, Seemant; Johanning, Jason; Yu, Zhangsheng; Perkins, Anthony J.; Zhang, Ying; Arling, Greg.

In: JAMA Network Open, Vol. 2, No. 7, e196716, 05.07.2019.

Research output: Contribution to journalArticle

Bravata, DM, Myers, LJ, Reeves, M, Cheng, EM, Baye, F, Ofner, S, Miech, EJ, Damush, T, Sico, JJ, Zillich, A, Phipps, M, Williams, LS, Chaturvedi, S, Johanning, J, Yu, Z, Perkins, AJ, Zhang, Y & Arling, G 2019, 'Processes of Care Associated with Risk of Mortality and Recurrent Stroke among Patients with Transient Ischemic Attack and Nonsevere Ischemic Stroke', JAMA Network Open, vol. 2, no. 7, e196716. https://doi.org/10.1001/jamanetworkopen.2019.6716
Bravata, Dawn M. ; Myers, Laura J. ; Reeves, Mathew ; Cheng, Eric M. ; Baye, Fitsum ; Ofner, Susan ; Miech, Edward J. ; Damush, Teresa ; Sico, Jason J. ; Zillich, Alan ; Phipps, Michael ; Williams, Linda S. ; Chaturvedi, Seemant ; Johanning, Jason ; Yu, Zhangsheng ; Perkins, Anthony J. ; Zhang, Ying ; Arling, Greg. / Processes of Care Associated with Risk of Mortality and Recurrent Stroke among Patients with Transient Ischemic Attack and Nonsevere Ischemic Stroke. In: JAMA Network Open. 2019 ; Vol. 2, No. 7.
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title = "Processes of Care Associated with Risk of Mortality and Recurrent Stroke among Patients with Transient Ischemic Attack and Nonsevere Ischemic Stroke",
abstract = "Importance: Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. Objective: To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. Design, Setting, and Participants: This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. Main Outcomes and Measures: Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. Results: Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0{\%}) were men, 5929 (73.4{\%}) were white, 474 (6.1{\%}) had a recurrent ischemic stroke within 90 days, 793 (10.7{\%}) had a recurrent ischemic stroke within 1 year, 320 (4.0{\%}) died within 90 days, and 814 (10.1{\%}) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95{\%} CI, 0.38-0.63; 1-year aOR, 0.61; 95{\%} CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95{\%} CI, 0.45-0.74; 1-year aOR, 0.70; 95{\%} CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95{\%} CI, 0.51-0.90; 1-year aOR, 0.64; 95{\%} CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95{\%} CI, 0.33-0.65; 1-year aOR, 0.67; 95{\%} CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95{\%} CI, 0.36-0.73; 1-year aOR, 0.70; 95{\%} CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95{\%} CI, 0.26-0.83; 1-year aOR, 0.56; 95{\%} CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95{\%} CI, 0.40-0.79; 1-year aOR, 0.69; 95{\%} CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95{\%} CI, 0.41-0.86; 1-year aOR, 0.69; 95{\%} CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95{\%} CI, 0.52-0.87; 1-year aOR, 0.74; 95{\%} CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95{\%} CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3{\%}; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2{\%} lower odds of 1-year mortality (aOR, 0.69; 95{\%} CI, 0.55-0.87) but was not independently associated with stroke risk. Conclusions and Relevance: Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible.",
author = "Bravata, {Dawn M.} and Myers, {Laura J.} and Mathew Reeves and Cheng, {Eric M.} and Fitsum Baye and Susan Ofner and Miech, {Edward J.} and Teresa Damush and Sico, {Jason J.} and Alan Zillich and Michael Phipps and Williams, {Linda S.} and Seemant Chaturvedi and Jason Johanning and Zhangsheng Yu and Perkins, {Anthony J.} and Ying Zhang and Greg Arling",
year = "2019",
month = "7",
day = "5",
doi = "10.1001/jamanetworkopen.2019.6716",
language = "English (US)",
volume = "2",
journal = "JAMA network open",
issn = "2574-3805",
publisher = "American Medical Association",
number = "7",

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TY - JOUR

T1 - Processes of Care Associated with Risk of Mortality and Recurrent Stroke among Patients with Transient Ischemic Attack and Nonsevere Ischemic Stroke

AU - Bravata, Dawn M.

AU - Myers, Laura J.

AU - Reeves, Mathew

AU - Cheng, Eric M.

AU - Baye, Fitsum

AU - Ofner, Susan

AU - Miech, Edward J.

AU - Damush, Teresa

AU - Sico, Jason J.

AU - Zillich, Alan

AU - Phipps, Michael

AU - Williams, Linda S.

AU - Chaturvedi, Seemant

AU - Johanning, Jason

AU - Yu, Zhangsheng

AU - Perkins, Anthony J.

AU - Zhang, Ying

AU - Arling, Greg

PY - 2019/7/5

Y1 - 2019/7/5

N2 - Importance: Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. Objective: To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. Design, Setting, and Participants: This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. Main Outcomes and Measures: Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. Results: Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk. Conclusions and Relevance: Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible.

AB - Importance: Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. Objective: To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. Design, Setting, and Participants: This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. Main Outcomes and Measures: Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. Results: Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk. Conclusions and Relevance: Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible.

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