New AHA/ASA Performance Metrics for Comprehensive Stroke Centers

Pauline Anderson

January 13, 2011

January 13, 2011 — The American Heart Association and the American Stroke Association (AHA/ASA) have developed a series of 26 standardized metrics for use by comprehensive stroke centers (CSCs) across the United States to measure and monitor quality of care.

The proposed metrics, and the research backing them, were published online January 13 and will appear in the March issue of Stroke: Journal of the American Heart Association.

Dr. Dana Leifer

CSCs represent a more intensive level of stroke care than what is available at primary stroke centers (PSCs). PSCs have standard neurosurgical capabilities or can transfer patients to a facility that offers such services, but their focus is mainly on ischemic stroke. In contrast, CSCs will have full on-site capability to perform neurosurgical procedures and endovascular procedures and have intensive care services for patients with ischemic or hemorrhagic stroke.

"This is going a step further," said the chair of the paper's writing group, Dana Leifer, MD, associate professor of neurology at Weill Cornell Medical College, New York City. "This is designating certain hospitals with more specialized and advanced methods for treating stroke patients, so patients with more complications or more complicated stroke."

Designating and Certifying Hospitals

Establishing the new metrics is part of an effort to create mechanisms for designating and certifying hospitals in the field of stroke care.

"It's similar to the idea that there are different levels of trauma centers," said Dr. Leifer. "What we are doing in this paper is essentially proposing a standardized set of metrics and other data that CSCs should collect so that the care they provide can be assessed."

In 2005, the Brain Attack Coalition, a joint effort of the AHA and ASA, proposed an infrastructure of personnel, equipment, and protocols for CSCs and called for quality improvement mechanisms and registries to record how patients should be treated. The new recommendations, developed after an extensive review of the literature, are based on experience with previous quality improvement initiatives, such as the Get With The Guidelines (GWTG) program.

CSCs will treat both ischemic and hemorrhagic strokes. For the former, they will use some of the more advanced endovascular techniques, for example, catheters to deliver intra-arterial tissue plasminogen activator or mechanically extract a clot blocking an artery, said Dr. Leifer.

"But a lot of what CSCs also do is treat hemorrhagic strokes, in particular strokes related to subarachnoid hemorrhage (SAH) and to arteriovenous malformations (AVMs)."

Some proposed metrics involve the percentage of patients who receive certain procedures, such as, for example, the number of eligible patients receiving intravenous thrombolysis within the appropriate time window, or who develop certain complications, such as the number of intravenous thrombolysis-treated patients who have a symptomatic intracranial hemorrhage (ICH) within 36 hours of treatment. Others pertain to the median time to have a particular procedure, such as the time from hospitalization to repair of blood vessels for patients with a ruptured aneurysm.

One important metric relates to the use of nimodipine in patients with SAH to prevent vasospasm, a major secondary complication of SAH. Yet another relates to complication rates for aneurysm coiling and clipping.

The metrics are organized by disease category with metrics 1 through 11 pertaining to ischemic stroke and 12 to 20 to hemorrhagic stroke (12 – 18 related to aneurysms and 19 – 20 to ICH or AVMs). Other metrics relate to the patient transfer process.

"CSCs will be taking patients who initially present to another hospital," said Dr. Leifer. "One of the things that needs to be looked at is the efficiency of the transfer process so that the right patients get there and get there in a timely fashion."

Some metrics are designated as "core," which means they have stronger evidence supporting them or have greater clinical significance.

Track Performance

Dr. Ralph Sacco

Ralph Sacco, MD, president of the AHA and chief of neurology at the University of Miami's Miller School of Medicine and Jackson Memorial Hospital in Florida, said the new recommendations can help provide the basis to monitor and track performance.

"We have consistently shown that when you track and benchmark performance, such as among our Get With the Guidelines–Stroke centers, you can raise the standard of care for many stroke patients in the US," he said in an email to Medscape Medical News.

Dr. Sacco noted that today almost 85% of the US population lives within 1 hour of a GWTG-Stroke hospital. 

The goal of the AHA is to reduce deaths from cardiovascular diseases and stroke by 20% before the year 2020, he added. "Every improvement in the performance of the way we treat strokes will help us accomplish this important goal."  

Dr. Leifer reports having received research funding from the National Institutes of Health as a site principal investigator in the MR and Recanalization of Stroke Clots Using Embolectomy and the Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis trials. Disclosures for other members of the writing committee are outlined in the document. Dr. Sacco has disclosed no relevant financial relationships.

Stroke. Published online January 13, 2011.

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