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Trends in in-hospital acute stroke care processes and stroke patient outcomes observed during operation of the Georgia Coverdell Acute Stroke Registry

Winquist, Andrea Gwen (2009)
Dissertation (222 pages)
Committee Chair / Thesis Adviser: McClellan, William
Committee Members: Klein, Mitchel ; Buehler, James W ; Frankel, Michael ; Horan, John (CDC);
Research Fields: Health Sciences, Epidemiology
Keywords: stroke; quality of care
Program: Laney Graduate School, Epidemiology
Permanent url: http://pid.emory.edu/ark:/25593/50tc5

Abstract

The Georgia Coverdell Acute Stroke Registry (GCASR) seeks to monitor and improve the quality of acute stroke care in Georgia. The overall aim of this dissertation was to evaluate the impact of GCASR on stroke care processes and stroke patient outcomes in Georgia. The first study examined trends in adherence with four stroke-care quality indicators among GCASR-participating hospitals. Conditional logistic regression models were used to estimate the average monthly within-hospital change in adherence, and to assess hospital characteristics associated with the rate of improvement. The second study evaluated the impact of one registry intervention, monthly educational conference calls, and sought to separate call effects from the effects of other registry interventions. Conditional logistic regression models were used to examine within-hospital changes in adherence with three quality indicators in temporal association with calls focusing on those indicators, considering various models for change over time. The third study evaluated the association between stroke patient outcomes and the operation of the GCASR pilot registry using state-wide hospital discharge data for ischemic stroke admissions linked with death certificate data. The outcomes considered were death within 1 year of an index stroke admission, and readmission within 1 year of discharge. Intent-to-treat proportional hazards models were used to compare the hazards of these outcomes for patients admitted to hospitals randomly selected for registry participation and patients admitted to non- selected hospitals. The studies showed that GCASR operation has been associated with improvements in care processes among participating hospitals, with hospitals with lower stroke volumes showing the greatest rate of improvement. Registry-wide monthly conference calls do not appear to change care processes shortly after the call, but may have more global effects in improving quality indicator adherence. A reduction in the hazard of readmission for recurrent stroke among patients admitted to hospitals randomly selected for registry participation was seen in association with operation of the GCASR pilot registry. These studies suggest some future directions for registry recruitment and quality improvement activities. For ongoing registry evaluation, it will be important to repeat the analysis of changes in stroke patient outcomes for the current implementation phase registry.

Table of Contents

Table of Contents -- Chapter 1: Rationale and Aims of Dissertation ........................................................................................ 1 -- Chapter 2: Literature Review .............................................................................................................. 4 -- Chapter 3: Background on the Georgia Coverdell Acute Stroke Registry ..................................................... 39 -- Chapter 4: Methods ........................................................................................................................ 47 -- Chapter 5: Manuscript for Study 1 ..................................................................................................... 69 -- Chapter 6: Manuscript for Study 2 .................................................................................................... 106 -- Chapter 7: Manuscript for Study 3 .................................................................................................... 135 -- Chapter 8: Appendix on Data Quality ................................................................................................. 165 -- Chapter 9: Summary and Conclusions ................................................................................................ 191 -- Chapter 10: Implications for Further Research ..................................................................................... 197 -- References ................................................................................................................................... 199

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