Hospital personnel often overestimate facility performance in delivering stroke care

Fewer than one-third of hospital staff members accurately identified the percentage of patients who received intravenous tissue plasminogen activator (tPA) within 60 minutes of arriving at the institutions, according to an analysis of a national stroke registry. Personnel at low-performing hospitals tended to overestimate their performance in stroke care compared with other hospitals.

Lead researcher Cheryl B. Lin, MD, of Tufts Medical Center in Boston, and colleagues surveyed 141 institutions that participated in the Get With The Guidelines (GWTG)–Stroke registry. The program is an initiative of the American Heart Association and American Stroke Association intended to improve the care and outcomes of patients with strokes and transient ischemic attacks.

In this analysis, the researchers asked hospitals to quantify their tPA administration rate and rank themselves as below-average, average or top performer in terms of their stroke response on a national level. They published their results in the July issue of the Journal of the American Heart Association.

Bimal R. Shah, MD, a study author from Duke University Medical Center, said guidelines recommend patients should typically receive tPA within three hours of the onset of stroke symptoms. However, there are some contraindications with tPA, including high, uncontrolled blood pressure and recent bleeding or surgery.

As part of the GWTG-Stroke program, hospitals receive feedback reports on their relative performance to their peers in a number of areas, including tPA administration. Hospitals volunteer and pay to participate in the program.

“This tells us that maybe those reports aren’t communicated as widely to the whole team that are involved in the care of these patients as they need to be,” Shah told Cardiovascular Business. “If they are, people may not be paying attention to them. It also probably speaks to some system issues, how much is the healthcare system actually paying attention to and providing support to help the teams actually achieve guideline-based care?”

The researchers identified 300 hospitals and chose the 100 highest and 100 lowest performing hospitals based on their door-to-needle performance. They then selected 50 hospitals above and below the median door-to-needle performance and considered them as the middle-performing group. Of the 300 hospitals, 157 responded. The final sample included 141 hospitals that treated a total of 48,201 stroke patients during the study.

Between January 2011 and July 2011, the researchers conducted 15-minute telephone interviews with representatives from the 141 hospitals who were familiar with the hospitals’ tPA administration process. The interview subjects included stroke neurologists, stroke coordinators and hospital-based quality improvement staff members.

Of the 141 hospitals, 49 were considered top performers, 52 were middle performers and 40 were low performers. Of those who were interviewed, 85 percent were part of the nursing staff.

The researchers found that 29.1 percent of staff members accurately identified their tPA performance. Among the middle and low performers, 60.9 percent overestimated their performance. Hospitals that overestimated their performance tended to have lower annual volumes of tPA administration, smaller percentages of eligible patients receiving tPA and smaller percentages of door-to-needle times within 60 minutes among treated patients.

As of now, hospitals are not penalized for underperforming with regards to tPA administration, although Shah said the Centers for Medicare & Medicaid Services (CMS) and other payers may hold them responsible in the future.

“The thought process is that, as hospitals take on more risk and they start to look more like health plans and integrated delivery networks or enter into value-based contracting arrangements with CMS or commercial providers, that they’re going to take on the long-term financial risk on these patients,” Shah said. “If you can reverse the effects of acute ischemic injury in the brain and give someone better functional status and quality of life and presumably less time in the rehab facility, all of those things are going to be positive benefits with regards to the cost during that episode of care.”