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Background: Use of MRI with diffusion weighted imaging (DWI) can identify infarcts in 30-50% of patients with transient neurovascular symptoms. Previous guidelines have indicated that MRI-DWI is the preferred imaging modality for patients with TIA symptoms. We assessed the frequency of MRI utilization and predictors of MRI performance in a national integrated health system. Methods: A review of TIA and minor stroke patients evaluated at Veterans Affairs Hospitals (fiscal year 2011) was conducted. Administrative data was reviewed with regard to demographic factors, past medical history, use of diagnostic imaging within two days of presentation, and in hospital care variables. Detailed chart abstraction was performed in a patient subset of large volume hospitals to assess clinical variables. Results: 8427 patients with TIA or minor stroke were included in the administrative data cohort. Overall, 6817 patients (80.9%) had cranial imaging (either CT or MRI) within two days of presentation, with 3420 (50.2%) having CT without MRI and 3397 (49.8%) having MRI. 3.6% of patients with CT only had a pacemaker. Specific variables that were associated with CT performance (rather than MRI) in the administrative data cohort included the following: age>80 years, prior stroke, atrial fibrillation, dementia, and congestive heart failure (p6 hours (74% had MRI vs. 26% had CT only, p=0.0009) were associated with MRI performance. Conclusions: Within a large national health system, about 40% of patients with TIA or minor stroke had MRI performed within two days. Performance of MRI appears to be influenced by several variables, including age, nature of the symptoms, prior stroke, and neurological consultation in the ED. These data suggest that there has been partial acceptance of the previous guideline which endorsed MRI for patients with TIA.

We conducted an evaluation of the implementation of a Veteran Secondary Stroke Prevention Program at two VA medical center sites. We prospectively recruited patients hospitalized for stroke/TIA and randomized to either an intervention or a control group. Each site locally tailored the intervention. The program targeted stroke self-management and risk factors or a placebo telephone call program that mimicked the intervention schedule. The self-management program followed a standardized manual (control call simply asked how the patient was doing), and interviews were conducted at baseline during hospital visit, 3 and 6 months. To address veteran preferences, both sites implemented the ASA Sharegiver peer support program to subjects in the intervention.We assessed stroke health-related quality of life with the SS-QOL and depression with the PHQ9. Results: The final sample included 174 veteran patients with an acute stroke/TIA and were randomized to receive either a VSPP (n=87) or a control program (n=87) stratified by stroke/TIA and by receipt of inpatient rehabilitation to control for stroke severity. A random subject effect was used to correlate observations from the same subject. Subgroup analyses were run with subgroups defined as diagnosed TIA or Stroke at acute event. On the SSQoL overall score and the Language subscale, those with a TIA in the intervention group reported an improved score while those in the control group reported a declined score at 3 mos. For those with Stroke in the intervention group, improvements in the Energy subscale were reported compared to declines in the control group at 3 months. For those with TIA in the intervention reported less depression than those in the control group and this effect was maintained at 6 months. Self-efficacy increased among those with stroke in the intervention group while decreased among the control group; although not significant. Our results indicate the feasibility of delivering a local, secondary stroke prevention program. We report better stroke specific quality of life at 3 months among stroke/TIA survivors and less depression among those with TIA 6 months after the intervention suggesting that a post stroke program may enhance recovery. Funded by Veterans Health Administration HSRD IAB 05-297-2

We targeted both providers and patients for medication and lifestyle modification to reduce secondary stroke risk factors after stroke. The specific aim of this study was to: Conduct a quasi-experimental feasibility test of implementing the adapted VA stroke prevention program (VSPP) at two VA sites to evaluate the impact on medication adherence. Program sessions targeted stroke risk factor management. The key stroke risk factors of interest were: 1) hypertension, 2) diabetes, 3) hypercholesterolemia. Medication possession ratios based upon patient medication refills were calculated to evaluate medication compliance for the randomized subjects using PBM data pre (6 months prior to the acute event) and post (6 months after the event). Based upon the literature standard of 80% compliance, we used this rate to dichotomize and model the data using logistics regression. Results: The final sample included 174 veteran patients with an acute stroke/TIA who were randomized to receive either the intervention (n=87) or a control program (n=87). In the intervention group, the odds of compliance to diabetes meds post stroke were significantly larger than the odds of compliance prior to the stroke (odds ratio=3.45 (1.08, 10.96) p

Objectives: In 2009, the VHA reported inpatient stroke quality indicators based on chart abstractions of fiscal year (FY) 2007 data at all VA medical centers (VAMCs). Prior to a randomized trial of a Systems Redesign-based intervention, we re-measured VA stroke quality indicators (QIs) from 2009 data in 11 of the largest volume VAMCs. The purpose of this analysis is to examine whether any significant changes occurred in inpatient stroke care in these sites between 2007 and 2009. Methods: Data for 10 Joint Commission (JC) inpatient stroke QIs were obtained by experienced external VA chart abstractors via review of FY 2007 electronic medical records. We abstracted 2009 data at 11 sites as baseline data for a quality improvement randomized study. We calculated eligibility and passing rates for ten inpatient stroke QIs defined similarly to the 10 JC indicators from the FY 2007 study. We compared patient demographics, clinical variables, and passing rates for each QI between the FY 2007 and CY 2009 data at the 11 sites using Student’s t-test and Chi-square tests. Results: Comparing 2007 (N =750) to 2009 (N =817) data, mean age (66.3, 66.6), % male (97%, 96%), and % Black (34%, 33%) were similar but mean NIH Stroke Scale score was increased in 2009 (4.2, 5.9, p < 0.001). Three QIs were unchanged over time: DVT prophylaxis, anticoagulation for atrial fibrillation, and antithrombotic at discharge (Table). Performance on four indicators was significantly improved: dysphagia screening (16%, 45%), receipt of rehabilitation consultation (62%, 89%), stroke education (17%, 31%), and receipt of tPA (17%, 47%). Performance on three indicators was significantly reduced: antithrombotic by hospital day two (98%, 87%), cholesterol lowering medication at discharge (90%, 72%), and receipt of smoking cessation counseling (100%, 89%). Conclusions: Prior to VHA national quality improvement efforts, both positive and negative shifts in performance occurred for common inpatient stroke QIs. Future work should examine whether focusing efforts on one aspect of stroke care can lead to reduction in quality in other areas, and on whether consistent reporting of these QIs can promote maintenance of high quality stroke care across a large national healthcare system.

Objective: Clinical champions may serve as important facilitators of clinical quality improvement. We sought to understand how stroke clinical champions communicate within and between clinical services among providers of acute stroke care which spans clinical services. Methods: We conducted semi-structured, in-person baseline interviews with clinical providers of acute stroke care services and related administrators and service managers across 11 VA Medical Centers across the US. We consented the responders and audiotaped the interviews. Closed ended question responses were entered into a database and open ended question responses were transcribed and qualitatively coded. For qualitative data, we assigned at least two coders per transcript for analysis. A priori, we operationalized key constructs of stroke quality improvement and utilized these constructs as an initial coding scheme. Additionally, we coded emerging themes from the qualitative responses using Nvivo software. Coders met regularly to review and consolidate when possible the emergent themes. Results: We completed 104 interviews of which the respondents included the following service lines: neurology, emergency department, inpatient care, education, social work, quality improvement, rehabilitation. Qualitative analyses indicated that 5 of the 12 facilities had unanimously identified stroke clinical champions. These sites reported more frequent communications within neurology service and stronger communications across service lines. Respondents external to the neurology service line were more likely to identify the presence of a stroke clinical champion at VA facilities that had established acute stroke care processes across the medical center compared to facilities where no systematic acute stroke care processes currently existed. Conclusions: A stroke clinical champion may be associated with the establishment of systematic clinical processes that span interdisciplinary services within an organization. The coordination of such interdisciplinary care and the brokering of interdisciplinary relationships may need a clinical champion to foster. Impact: Understanding the development of a stroke clinical champion is crucial for organizations that seek to improve their clinical processes.