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

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

About this Dissertation

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School	Laney Graduate School
Department	Epidemiology
Degree	PhD
Submission	Dissertation
Language	English
Research Field	Health Sciences, Epidemiology
Mot-clé	quality of care stroke
Committee Chair / Thesis Advisor	McClellan, William, Emory University
Committee Members	Frankel, Michael, Emory University Horan, John, CDC Klein, Mitchel, Emory University Buehler, James W, Emory University

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