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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