QUERI – Quality Enhancement Research Initiative

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Acute Ischemic Stroke Care for Veterans

Stroke is the fourth leading cause of death in the United States, accounting for more than 1 out of every 18 deaths. Approximately 6,000 VA admissions are for Veterans with acute ischemic stroke, with new strokes costing an estimated $111 million for acute inpatient care, $75 million for post-acute inpatient care, and $88 million for follow-up care in the first six months post-stroke.1

Partnering to Improve Guidelines and Standards for Acute Stroke Care

Standards for acute stroke care have changed due to evidence that early thrombolytic therapy can improve outcomes in ischemic stroke. In 2009, the state of VA acute and inpatient stroke care was evaluated, and, as a result, the VA Stroke Taskforce was organized. Members of this national taskforce included leadership from VA/HSR&D's Stroke Quality Enhancement Research Initiative ( Stroke-QUERI), who guided the development of national VA Acute Ischemic Stroke (AIS) guidelines and standards to improve access to emergency care for Veterans, as well as the quality of emergency AIS stroke care.

The Treatment of Acute Ischemic Stroke, VHA Directive 2011-038, was disseminated to VISN (Veterans Integrated Service Network) leadership in November 2011, and is based onAmerican Heart Association/American Stroke Association Guidelines and a major stroke study from NINDS (National Institute of Neurological Disorders and Stroke). The AIS Directive mandated that all VA medical centers with inpatient acute care have a written policy to deliver appropriate AIS care by January 1, 2012, and that it must be implemented by June 1, 2012.

Developing a Comprehensive Acute Stroke Care System

VA is in the process of developing a comprehensive system to provide optimal acute stroke care to all eligible Veterans. Each VAMC is to be designated as one of three levels of stroke-capable hospitals and will organize their local stroke care and training based on this designation, including developing a plan to use community resources where VA capacity is absent. Due to the short window for thrombolytic therapy after stroke, travel time to the nearest VA hospital is critical. To evaluate the adequacy of the VA healthcare system for acute stroke care, Stroke-QUERI investigators are using geo-tagged (adding geographical information) data for enrolled Veterans and Veterans at high risk for acute stroke (due to a history of prior stroke), in order to examine access to acute stroke care within the network of VA hospitals.

The map below illustrates the catchment area of every VA facility by ground travel time from 15 to 60 minutes, in 15 minute increments, for all Veterans with a history of a stroke diagnosis as of fiscal year 2008. All told, about 70% of these Veterans can reach their nearest VA within 60 minutes. However, access varies considerably from one region to another.

VHA Stroke Patients FY08, All Complexity Level VHA Hospitals

Maps and statistics have been computed for each of the VA�s 21 Veterans Integrated Service Networks (VISNs), and these data are available to VA Medical Center, VISN, and national administration and leadership to inform the development of a national stroke plan that will best meet the needs of the nation�s Veterans.

Additional Stroke-QUERI Studies

Stroke-QUERI also is conducting a multi-site randomized study that aims to evaluate:

  • The effect of public reporting of stroke care data on organizational change to improve the quality of VA stroke care;
  • 12 VAMCs with the largest volume of acute ischemic stroke admissions to understand organizational barriers and facilitators in the delivery of high-quality care; and
  • System Redesign tailored intervention to improve the quality of stroke care at six of the 12 VAMCs randomly assigned to an intervention compared to six randomly assigned to quality performance feedback.

In addition, Stroke-QUERI is working on a project to determine the costs associated with provision of stroke center services across the VA healthcare system; this work will support ongoing assessment of and improvements in VA stroke care, and will assist decisions to either augment VA stroke services or enlist community resources on a facility-by-facility basis.

References:

Stroke-QUERI Fact Sheet, April 2012. VA/HSR&D Stroke Quality Enhancement Research Initiative.

Additional Resources: