Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke
Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. This cohort study included a...
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| Veröffentlicht in: | JAMA network open 2019-07, Vol.2 (7), p.e196716-e196716 |
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| creator | 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 |
| description | Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes.
To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke.
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.
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.
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 |
| doi_str_mv | 10.1001/jamanetworkopen.2019.6716 |
| format | Article |
| fullrecord | <record><control><sourceid>proquest_pubme</sourceid><recordid>TN_cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_6613337</recordid><sourceformat>XML</sourceformat><sourcesystem>PC</sourcesystem><sourcerecordid>2251696808</sourcerecordid><originalsourceid>FETCH-LOGICAL-a470t-77a0485559bd37e4312505845c8ac9a1ec00969c729fc74c71efd8a4515795053</originalsourceid><addsrcrecordid>eNpdUctuEzEUtRCIVqG_gIzYsEmwx2N7vEGKIh6VClSliKXleu40TmbsYHuK-h_94HpIiUpXfpzHvUcHoTeULCgh9P3GDMZD_hPiNuzALypC1UJIKp6h44rLes4awp8_uh-hk5Q2hJDCZErwl-iI0Uo0vGbH6O48BgspQcKhwysTAS9TCtaZDC3-5fIaX7i0ncCvIWbTu3yLjW_xBdgxRvAZ_8gxbItsCP4an5vsymfaSy-j8Wl649Nk1zA4i5c5G7v9a_Et-AQ3UEYe0L3XK_SiM32Ck4dzhn5--ni5-jI_-_75dLU8m5takjyX0pC64Zyrq5ZJqEsqTnhTc9sYqwwFS4gSyspKdVbWVlLo2sbUnHKpCpPN0Ie97268GqC1ZdFoer2LbjDxVgfj9P-Id2t9HW60EJQxJovBuweDGH6PkLIeXLLQ96WhMCZdVZwKJRrSFOrbJ9RNGKMv8XQlRFMxyorpDKk9y8aQUoTusAwleqpfP6lfT_Xrqf6iff04zUH5r2x2D1gyspw</addsrcrecordid><sourcetype>Open Access Repository</sourcetype><iscdi>true</iscdi><recordtype>article</recordtype><pqid>2668231361</pqid></control><display><type>article</type><title>Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke</title><source>DOAJ Directory of Open Access Journals</source><source>EZB-FREE-00999 freely available EZB journals</source><source>Alma/SFX Local Collection</source><creator>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</creator><creatorcontrib>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</creatorcontrib><description>Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes.
To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke.
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.
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.
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.
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.</description><identifier>ISSN: 2574-3805</identifier><identifier>EISSN: 2574-3805</identifier><identifier>DOI: 10.1001/jamanetworkopen.2019.6716</identifier><identifier>PMID: 31268543</identifier><language>eng</language><publisher>United States: American Medical Association</publisher><subject>Cardiac arrhythmia ; Carotid arteries ; Health Policy ; Mortality ; Online Only ; Original Investigation ; Stroke ; Transient ischemic attack</subject><ispartof>JAMA network open, 2019-07, Vol.2 (7), p.e196716-e196716</ispartof><rights>2019. This work is published under https://creativecommons.org/licenses/by/4.0/ (the “License”). Notwithstanding the ProQuest Terms and Conditions, you may use this content in accordance with the terms of the License.</rights><rights>Copyright 2019 Bravata DM et al. .</rights><lds50>peer_reviewed</lds50><oa>free_for_read</oa><woscitedreferencessubscribed>false</woscitedreferencessubscribed><citedby>FETCH-LOGICAL-a470t-77a0485559bd37e4312505845c8ac9a1ec00969c729fc74c71efd8a4515795053</citedby><cites>FETCH-LOGICAL-a470t-77a0485559bd37e4312505845c8ac9a1ec00969c729fc74c71efd8a4515795053</cites></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>230,314,776,780,860,881,27901,27902</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/31268543$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Bravata, Dawn M</creatorcontrib><creatorcontrib>Myers, Laura J</creatorcontrib><creatorcontrib>Reeves, Mathew</creatorcontrib><creatorcontrib>Cheng, Eric M</creatorcontrib><creatorcontrib>Baye, Fitsum</creatorcontrib><creatorcontrib>Ofner, Susan</creatorcontrib><creatorcontrib>Miech, Edward J</creatorcontrib><creatorcontrib>Damush, Teresa</creatorcontrib><creatorcontrib>Sico, Jason J</creatorcontrib><creatorcontrib>Zillich, Alan</creatorcontrib><creatorcontrib>Phipps, Michael</creatorcontrib><creatorcontrib>Williams, Linda S</creatorcontrib><creatorcontrib>Chaturvedi, Seemant</creatorcontrib><creatorcontrib>Johanning, Jason</creatorcontrib><creatorcontrib>Yu, Zhangsheng</creatorcontrib><creatorcontrib>Perkins, Anthony J</creatorcontrib><creatorcontrib>Zhang, Ying</creatorcontrib><creatorcontrib>Arling, Greg</creatorcontrib><title>Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke</title><title>JAMA network open</title><addtitle>JAMA Netw Open</addtitle><description>Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes.
To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke.
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.
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.
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.
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.</description><subject>Cardiac arrhythmia</subject><subject>Carotid arteries</subject><subject>Health Policy</subject><subject>Mortality</subject><subject>Online Only</subject><subject>Original Investigation</subject><subject>Stroke</subject><subject>Transient ischemic attack</subject><issn>2574-3805</issn><issn>2574-3805</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2019</creationdate><recordtype>article</recordtype><sourceid>BENPR</sourceid><recordid>eNpdUctuEzEUtRCIVqG_gIzYsEmwx2N7vEGKIh6VClSliKXleu40TmbsYHuK-h_94HpIiUpXfpzHvUcHoTeULCgh9P3GDMZD_hPiNuzALypC1UJIKp6h44rLes4awp8_uh-hk5Q2hJDCZErwl-iI0Uo0vGbH6O48BgspQcKhwysTAS9TCtaZDC3-5fIaX7i0ncCvIWbTu3yLjW_xBdgxRvAZ_8gxbItsCP4an5vsymfaSy-j8Wl649Nk1zA4i5c5G7v9a_Et-AQ3UEYe0L3XK_SiM32Ck4dzhn5--ni5-jI_-_75dLU8m5takjyX0pC64Zyrq5ZJqEsqTnhTc9sYqwwFS4gSyspKdVbWVlLo2sbUnHKpCpPN0Ie97268GqC1ZdFoer2LbjDxVgfj9P-Id2t9HW60EJQxJovBuweDGH6PkLIeXLLQ96WhMCZdVZwKJRrSFOrbJ9RNGKMv8XQlRFMxyorpDKk9y8aQUoTusAwleqpfP6lfT_Xrqf6iff04zUH5r2x2D1gyspw</recordid><startdate>20190703</startdate><enddate>20190703</enddate><creator>Bravata, Dawn M</creator><creator>Myers, Laura J</creator><creator>Reeves, Mathew</creator><creator>Cheng, Eric M</creator><creator>Baye, Fitsum</creator><creator>Ofner, Susan</creator><creator>Miech, Edward J</creator><creator>Damush, Teresa</creator><creator>Sico, Jason J</creator><creator>Zillich, Alan</creator><creator>Phipps, Michael</creator><creator>Williams, Linda S</creator><creator>Chaturvedi, Seemant</creator><creator>Johanning, Jason</creator><creator>Yu, Zhangsheng</creator><creator>Perkins, Anthony J</creator><creator>Zhang, Ying</creator><creator>Arling, Greg</creator><general>American Medical Association</general><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>3V.</scope><scope>7X7</scope><scope>7XB</scope><scope>8FI</scope><scope>8FJ</scope><scope>8FK</scope><scope>ABUWG</scope><scope>AFKRA</scope><scope>AZQEC</scope><scope>BENPR</scope><scope>CCPQU</scope><scope>DWQXO</scope><scope>FYUFA</scope><scope>GHDGH</scope><scope>K9.</scope><scope>M0S</scope><scope>PHGZM</scope><scope>PHGZT</scope><scope>PIMPY</scope><scope>PKEHL</scope><scope>PQEST</scope><scope>PQQKQ</scope><scope>PQUKI</scope><scope>PRINS</scope><scope>7X8</scope><scope>5PM</scope></search><sort><creationdate>20190703</creationdate><title>Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke</title><author>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</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-a470t-77a0485559bd37e4312505845c8ac9a1ec00969c729fc74c71efd8a4515795053</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2019</creationdate><topic>Cardiac arrhythmia</topic><topic>Carotid arteries</topic><topic>Health Policy</topic><topic>Mortality</topic><topic>Online Only</topic><topic>Original Investigation</topic><topic>Stroke</topic><topic>Transient ischemic attack</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Bravata, Dawn M</creatorcontrib><creatorcontrib>Myers, Laura J</creatorcontrib><creatorcontrib>Reeves, Mathew</creatorcontrib><creatorcontrib>Cheng, Eric M</creatorcontrib><creatorcontrib>Baye, Fitsum</creatorcontrib><creatorcontrib>Ofner, Susan</creatorcontrib><creatorcontrib>Miech, Edward J</creatorcontrib><creatorcontrib>Damush, Teresa</creatorcontrib><creatorcontrib>Sico, Jason J</creatorcontrib><creatorcontrib>Zillich, Alan</creatorcontrib><creatorcontrib>Phipps, Michael</creatorcontrib><creatorcontrib>Williams, Linda S</creatorcontrib><creatorcontrib>Chaturvedi, Seemant</creatorcontrib><creatorcontrib>Johanning, Jason</creatorcontrib><creatorcontrib>Yu, Zhangsheng</creatorcontrib><creatorcontrib>Perkins, Anthony J</creatorcontrib><creatorcontrib>Zhang, Ying</creatorcontrib><creatorcontrib>Arling, Greg</creatorcontrib><collection>PubMed</collection><collection>CrossRef</collection><collection>ProQuest Central (Corporate)</collection><collection>Health & Medical Collection</collection><collection>ProQuest Central (purchase pre-March 2016)</collection><collection>Hospital Premium Collection</collection><collection>Hospital Premium Collection (Alumni Edition)</collection><collection>ProQuest Central (Alumni) (purchase pre-March 2016)</collection><collection>ProQuest Central (Alumni Edition)</collection><collection>ProQuest Central UK/Ireland</collection><collection>ProQuest Central Essentials</collection><collection>ProQuest Central</collection><collection>ProQuest One Community College</collection><collection>ProQuest Central Korea</collection><collection>Health Research Premium Collection</collection><collection>Health Research Premium Collection (Alumni)</collection><collection>ProQuest Health & Medical Complete (Alumni)</collection><collection>Health & Medical Collection (Alumni Edition)</collection><collection>ProQuest Central (New)</collection><collection>ProQuest One Academic (New)</collection><collection>Publicly Available Content Database</collection><collection>ProQuest One Academic Middle East (New)</collection><collection>ProQuest One Academic Eastern Edition (DO NOT USE)</collection><collection>ProQuest One Academic</collection><collection>ProQuest One Academic UKI Edition</collection><collection>ProQuest Central China</collection><collection>MEDLINE - Academic</collection><collection>PubMed Central (Full Participant titles)</collection><jtitle>JAMA network open</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Bravata, Dawn M</au><au>Myers, Laura J</au><au>Reeves, Mathew</au><au>Cheng, Eric M</au><au>Baye, Fitsum</au><au>Ofner, Susan</au><au>Miech, Edward J</au><au>Damush, Teresa</au><au>Sico, Jason J</au><au>Zillich, Alan</au><au>Phipps, Michael</au><au>Williams, Linda S</au><au>Chaturvedi, Seemant</au><au>Johanning, Jason</au><au>Yu, Zhangsheng</au><au>Perkins, Anthony J</au><au>Zhang, Ying</au><au>Arling, Greg</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke</atitle><jtitle>JAMA network open</jtitle><addtitle>JAMA Netw Open</addtitle><date>2019-07-03</date><risdate>2019</risdate><volume>2</volume><issue>7</issue><spage>e196716</spage><epage>e196716</epage><pages>e196716-e196716</pages><issn>2574-3805</issn><eissn>2574-3805</eissn><abstract>Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes.
To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke.
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.
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.
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.
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.</abstract><cop>United States</cop><pub>American Medical Association</pub><pmid>31268543</pmid><doi>10.1001/jamanetworkopen.2019.6716</doi><oa>free_for_read</oa></addata></record> |
| fulltext | fulltext |
| identifier | ISSN: 2574-3805 |
| ispartof | JAMA network open, 2019-07, Vol.2 (7), p.e196716-e196716 |
| issn | 2574-3805 2574-3805 |
| language | eng |
| recordid | cdi_pubmedcentral_primary_oai_pubmedcentral_nih_gov_6613337 |
| source | DOAJ Directory of Open Access Journals; EZB-FREE-00999 freely available EZB journals; Alma/SFX Local Collection |
| subjects | Cardiac arrhythmia Carotid arteries Health Policy Mortality Online Only Original Investigation Stroke Transient ischemic attack |
| title | Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke |
| url | https://sfx.bib-bvb.de/sfx_tum?ctx_ver=Z39.88-2004&ctx_enc=info:ofi/enc:UTF-8&ctx_tim=2025-02-15T05%3A00%3A00IST&url_ver=Z39.88-2004&url_ctx_fmt=infofi/fmt:kev:mtx:ctx&rfr_id=info:sid/primo.exlibrisgroup.com:primo3-Article-proquest_pubme&rft_val_fmt=info:ofi/fmt:kev:mtx:journal&rft.genre=article&rft.atitle=Processes%20of%20Care%20Associated%20With%20Risk%20of%20Mortality%20and%20Recurrent%20Stroke%20Among%20Patients%20With%20Transient%20Ischemic%20Attack%20and%20Nonsevere%20Ischemic%20Stroke&rft.jtitle=JAMA%20network%20open&rft.au=Bravata,%20Dawn%20M&rft.date=2019-07-03&rft.volume=2&rft.issue=7&rft.spage=e196716&rft.epage=e196716&rft.pages=e196716-e196716&rft.issn=2574-3805&rft.eissn=2574-3805&rft_id=info:doi/10.1001/jamanetworkopen.2019.6716&rft_dat=%3Cproquest_pubme%3E2251696808%3C/proquest_pubme%3E%3Curl%3E%3C/url%3E&disable_directlink=true&sfx.directlink=off&sfx.report_link=0&rft_id=info:oai/&rft_pqid=2668231361&rft_id=info:pmid/31268543&rfr_iscdi=true |