Professional Documents
Culture Documents
Monique Bueno Alves, RN, MsC,*, Gisele Sampaio Silva, MD, MPH, PhD,*,
Renata Carolina Acri Miranda, RN, Rodrigo Meireles Massaud, MD,
Andreia Maria Heins Vaccari, RN, Miguel Cendoroglo-Neto, MD, PhD,*, and
Solange Diccini, RN, PhD*
ARTICLE IN PRESS
Variable (n = 83) (n = 105) (n = 115) (n = 119) (n = 128) (n = 551) P Value
Age 77.0 (64.0-83.0) 77.0 (66.0-84.50) 75.0 (63.0-82.0) 78.0 (63.0-84.0) 80.0 (62.0-87.0) 77.0 (64.0-84.0) .600
Gender (male) (%) 57.8 61.9 57.4 54.6 60.5 58.4 .824
Median time from symptom onset 530.0 (87.0-1500.0) 420.0 (85.0-1301.0) 205.0 (102.0-655.0) 390.0 (110.0-1440.0) 465.0 (115.5-1440.0) 345.0 (104.5-1417.5) .137
to hospital admission (min)
Mean NIHSS score at admission 16.8 6.2 15.5 7.1 13.3 7.7 12.4 7.0 14.3 8.5 14.2 7.5 .242
Hypertension (%) 51.8 65.7 66.1 53.8 62.0 60.3 .105
Dyslipidemia (%) 27.7 27.6 27.8 31.1 34.9 30.1 .686
Diabetes (%) 31.3 33.3 27.8 26.9 36.4 31.2 .477
Smoking (%) 20.5 11.4 16.5 10.9 9.3 13.2 .113
Alcohol abuse (%) 10.8 5.7 1.7 .2 1.6 4.0 .004
CAD (%) 10.8 12.4 9.6 21.8 14.7 14.2 .065
Atrial fibrillation (%) 22.9 13.3 13.0 16.8 15.6 16.0 .350
Previous stroke or TIA (%) 25.3 39.0 21.7 28.6 22.5 27.2 .028
Length of stay (d) 7.0 (3.0-13.0) 9.0 (5.0-15.0) 7.0 (3.0-14.0) 8.0 (5.0-14.0) 7.0 (4.0-15.5) 8.0 (4.0-14.0) .376
In-hospital mortality (%) 6.0 10.4 13.0 3.3 9.3 8.5 <.001
Abbreviations: CAD, coronary artery disease; NIHSS, National Institutes of Health Stroke Scale; TIA, transient ischemic attack.
Treatment with reperfusion therapy (%) 12.0 16.2 17.4 13.4 13.5 17.1 .806
IV rtPA (%) 70.0 64.7 65.0 43.8 47.1 57.5 .513
IA therapy (%) 10.0 29.4 35.0 50.0 29.4 33.8
Combined therapy (%) 20.0 5.9 .0 6.3 23.5 8.8
Abbreviations: IA, intra-arterial; IV, intravenous; rtPA, recombinant tissue plasminogen activator.
Combined therapy includes an IV therapy followed by an IA procedure.
Abbreviations: AF, atrial fibrillation; CT, computerized tomography; DVT, deep vein thrombosis; IV, intravenous; ns, not significant; rtPA,
recombinant tissue plasminogen activator.
*P < .05 in the chi-square trend test.
was performed in 33.8%, and combined therapy was 2.03, CI 1.36-3.02, P < .01), and discharge in a JCI year of
performed in 8.8% of the patients (Table 2). There was visit (OR 1.8, CI 1.29-2.65, P < .01) remained in the model
no difference among years in the following measures: IV as predictors of higher perfect care index (Table 4).
rtPA (3 hours), DVT prophylaxis, antithrombotics in the The quality indicator DVT prophylaxis was significantly
first 24 hours of admission, anticoagulation therapy for better at the tertiary hospital when compared with the
AF, door-to-CT read time, and door-to-needle time. Table 3
shows the performance measures according to the discharge
year. Table 4. Factors associated with compliance to the adherence
The quality indicators that improved along the years index on a multivariate logistic regression model
were cholesterol-lowering therapy (range 69.2%-88.0%,
P = .02) and stroke education (range 73.1%-90.6%, P = .04) 95 % CI
for exp (B)
(Table 3). The median composite perfect care was different
(range 83.0 18.9 to 92.6 11.4, P < .001) but did not con- Exp Lower Upper
sistently improve along the years (P = .13 in the chi-square Variable Sig. (B) CI CI
trend test). The highest scores were obtained in 2010 and
2013 (Table 3). Age .297 1.006 .995 1.017
In the univariate analysis, being discharged in a JCI Female sex .049 .703 .495 .999
visit year (odds ratio [OR] 1.84, confidence interval [CI] Thrombolytic treatment <0.01 2.06 1.21 3.51
Discharged in a joint <0.01 1.834 1.285 2.617
1.29-2.61, P < .01), female gender (OR .68, CI .48-.96, P = .03),
commissions year
dyslipidemia (OR 1.95, CI 1.33-2.88, P < .01), and undergoing
Dyslipidemia <0.01 2.03 1.36 3.02
thrombolytic treatment (OR 1.81, CI 1.08-3.02, P = .02) were Length of stay .996 1.000 .896 1.004
found to be associated with a perfect care index of 85% or Constant .514 .753
higher. After the multivariable adjustment, only thrombolytic
treatment (OR 2.06, CI 1.21-3.51, P < .01), dyslipidemia (OR Abbreviations: CI, confidence interval; sig., significance.
ARTICLE IN PRESS
6 M.B. ALVES ET AL.
community hospital (100% versus 84.6%, P < .01). Con- predictor of a higher adherenceeligibility index. Physi-
versely, antithrombotics at discharge were more frequently cians might be more concerned with patients who could
prescribed at the community hospital (100% versus 90%, achieve more favorable functional outcomes and there-
P < .01). The quality indicators with worse performance (an- fore could be more compliant with treatment measures.
ticoagulation for AF and cholesterol reduction) were similar Finally, the finding of a higher perfect care index in the
in the tertiary and secondary community hospitals (Fig 2). years of JCI visits points out to the importance of a more
continuous evaluation of the quality indicators by the ac-
creditation process using methods like unannounced surveys
Discussion
or periodic data reports. Audit and feedback, as used in
We found a significant improvement across the years the JCI evaluation process, is a common approach to
in 2 quality indicators (cholesterol reduction and stroke promote the implementation of evidence-based practices.
education) in a PSC located in Brazil. The overall perfect Overall, one quarter of the audit and feedback interven-
care measure did not consistently improve over time and tions have a large positive effect on quality of care. The
was influenced by being discharged in a JCI visit year, identification of factors that distinguish more and less suc-
having dyslipidemia, and undergoing thrombolytic treat- cessful interventions, including the frequency of visits and
ment. The GWTG-Stroke program has improved the quality the adaptation of the quality evaluation process to each
of stroke care in U.S. academic and community hospi- country reality, constitutes a real challenge.15,16
tals, with important implications for the entire country. Our higher adherence mean rates were for IV rtPA use,
The generalizability of GWTG-Stroke across distinct na- early antithrombotics, DVT prophylaxis, and antithrombotics
tional and economic realities remains unanswered.8,10 at discharge across the years. Smoking cessation counsel-
Our hospital was the first institution outside the United ing, anticoagulation at discharge for patients with AF, and
States to be accredited by the JCI in 1999, when the in- cholesterol reduction had lower rates above the target of
ternational program was launched. In June 2007, Albert 85%. Interestingly, in a GWTG cohort, these 3 measures
Einstein Hospital became the first institution in Latin also had the lowest compliance and major improvement
America and one of only three worldwide to have a PSP across the period of 4 years evaluated.8
certified by JCI.4 Therefore, it is expected that the find- In the United States, being treated in a PSC increases
ings from our study likely reflect better performance in the chance of undergoing IV thrombolysis.17,18 The rates
acute stroke treatment than the overall national perfor- of thrombolysis treatment in Brazilian studies vary from
mance data.12 Actually, data evaluating quality of care 1.1% to 11.2%.4,14,19,20 A study in Massachusetts concluded
indicators in Brazilian stroke centers are largely unavail- that the PSC designation program improved the throm-
able. A previous study assessed the quality of hospital bolysis rates in early admissions.21 Our overall rate of use
care for acute IS in the Brazilian Unified National Health of reperfusion therapies was 17.1%.
System, but none of the quality indicators suggested by Early admissions were not related to higher perfect care
the GWTG stroke program were reported. Another study scores, and their frequencies did not change across the study
evaluating patients at the northeast region of the country period. At least 25% of our patients arrived in a therapeutic
reported a mean door-to-CT time of 75.6 minutes, but time window for IV rtPA. The finding of a stable propor-
data on other quality indicators were also not available.13,14 tion of patients arriving in a therapeutic time window was
In our series, the presence of certain risk factors might also reported in a previous international study from the
have triggered the clinician to be more attentive to the treat- GWTG Stroke Program.22 Albert Einstein Hospital is a
ment measures, it could be observed in patients with private institution in So Paulo, a city with 11.3 million
dyslipidemia with better perfect care. Likely for similar inhabitants. Around 1.5 million people have potential access
reasons, thrombolysis treatment was also an independent to our hospital. It is possible that the high socioeconomic
ARTICLE IN PRESS
PATTERNS OF CARE IN ISCHEMIC STROKE: A BRAZILIAN PERSPECTIVE 7
and educational levels of the patients who have access to to guidelines-based care and should result in a signifi-
Albert Einstein explain at least in part the high frequen- cant improvement in patient outcomes.10,12,26 Quality
cy of early arrivals observed in our series. programs facilitate the implementation of improvement
We found an interesting difference in in-hospital mor- efforts, certainly influencing the time-dependent process
tality between the 5 years (ranging from 3.3% in 2012 such as neuroimaging, laboratory analysis, and in-
to 13% in 2011). The overall mortality rate for the 5 years hospital transportation, and could possibly decrease time-
was 8.5%, which was similar to other national and in- dependent measures.12
ternational stroke series. We could not find a good reason The present study has several limitations. First, we report
to explain such differences, except for the slightly low data from a single center, with predominantly white pa-
NIHSS scores in 2012. It is possible that differences in tients and no concurrent controls; therefore, our findings
stroke mortality could be attributable to some unmea- might not be generalizable to all Brazilian stroke centers.
sured factors such as previous modified stroke scale Despite this limitation, our comparison with the quality
differences and clinical complications such as pneumonia. indicators available for the first year of the study from a
Brazil is a country of great social inequalities; there- secondary public community hospital suggests that there
fore, it is not simple to apply international data to our are similarities between the public and the private systems,
reality. Fortunately in the last decade, Brazil had a great and that indeed the poor performances on some specific
evolution in stroke care. From 2008 to 2012, the number quality indicators might reflect cultural aspects of adher-
of stroke centers increased from 35 to 82. In 2012, the ence to protocols that might indeed be generalizable for
Brazilian national stroke policy was published.23 The policy the whole country. Second, data were prospectively col-
includes definitions for stroke centers by level, reim- lected in a period when the certification was already
bursement values, telemedicine, rehabilitation and training achieved; therefore, trends in improvement could not be
funding, population awareness, and establishment of a observed in all quality measures as in 2009 several actions
stroke care program integrating available resources from have already been implemented. Moreover, our final sample
other health programs. A National Stroke Registry was size was relatively small and probably not sufficiently
initiated linked to the Ministry of Health to improve quality, powered to detect what could still be considered a clin-
and hospitals were invited to participate. Data from this ically meaningful change over time, particularly for indicators
registry are not yet published.24 In 2015, the Brazilian with low eligibility numbers. However, at least for the perfect
Academy of Neurology launched an important survey care score, our main outcome measure, we had a power
evaluating the medical perception of stroke treatment in of 98% to detect an annual change of 5%. Finally, data from
the country. In a structured questionnaire, several dif- patients with TIA were excluded from the present anal-
ferences from the public and private services were ysis mostly because benchmarks from the literature regarding
highlighted, with a focus on triage, infrastructure, and quality indicators in the care for such patients are largely
human resources. The survey is still ongoing and its results lacking. This finding could be explained by the fact that
will be of utmost importance for understanding stroke TIA patients have a shorter length of stay at hospitals or
gaps in the country.25 can be treated in outpatient clinics, such as TIA clinics.
In the United States, a study comparing PSC with non- In conclusion, the predictors of adherence to stroke care
PSCs found that all quality measures in stroke care were protocols in a Brazilian hospital appear to be similar to
significantly higher in certified centers.12 In our series, in those described in international series, and some quality
the first year reported (2009), we had already estab- indicators tend to improve over the years when moni-
lished the improvement plan needed for the certification; tored through a quality control program. If the existence
therefore, we do not have a real-life baseline performance of such protocols has proven important, their implemen-
to compare to evaluate the real progress of our program. tation across the country would be of utmost importance.
Although there are several cultural differences between Whether our results could be further reproduced by the
Brazil and the United States, having a PSC certification design of a national stroke quality improvement program
seems to be important in quality indicators in stroke care addressing the specific national challenges for Brazil
improvement. However, certification or award recognition remains to be evaluated.
programs alone may be insufficient to improve quality. They
should be accompanied by critical analysis, accountabili-
ty, and frequent reports of the measures.10,12 The evolution References
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