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Katzan IL, Spertus J, Bettger JP, Bravata DM, Reeves MJ, Smith EE, Bushnell C, Higashida RT, Hinchey JA, Holloway RG, Howard G, King RB, Krumholz HM, Lutz BJ, Yeh RW. Risk adjustment of ischemic stroke outcomes for comparing hospital performance: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:918-44. [PMID: 24457296 DOI: 10.1161/01.str.0000441948.35804.77] [Citation(s) in RCA: 81] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND AND PURPOSE Stroke is the fourth-leading cause of death and a leading cause of long-term major disability in the United States. Measuring outcomes after stroke has important policy implications. The primary goals of this consensus statement are to (1) review statistical considerations when evaluating models that define hospital performance in providing stroke care; (2) discuss the benefits, limitations, and potential unintended consequences of using various outcome measures when evaluating the quality of ischemic stroke care at the hospital level; (3) summarize the evidence on the role of specific clinical and administrative variables, including patient preferences, in risk-adjusted models of ischemic stroke outcomes; (4) provide recommendations on the minimum list of variables that should be included in risk adjustment of ischemic stroke outcomes for comparisons of quality at the hospital level; and (5) provide recommendations for further research. METHODS AND RESULTS This statement gives an overview of statistical considerations for the evaluation of hospital-level outcomes after stroke and provides a systematic review of the literature for the following outcome measures for ischemic stroke at 30 days: functional outcomes, mortality, and readmissions. Data on outcomes after stroke have primarily involved studies conducted at an individual patient level rather than a hospital level. On the basis of the available information, the following factors should be included in all hospital-level risk-adjustment models: age, sex, stroke severity, comorbid conditions, and vascular risk factors. Because stroke severity is the most important prognostic factor for individual patients and appears to be a significant predictor of hospital-level performance for 30-day mortality, inclusion of a stroke severity measure in risk-adjustment models for 30-day outcome measures is recommended. Risk-adjustment models that do not include stroke severity or other recommended variables must provide comparable classification of hospital performance as models that include these variables. Stroke severity and other variables that are included in risk-adjustment models should be standardized across sites, so that their reliability and accuracy are equivalent. There is a pressing need for research in multiple areas to better identify methods and metrics to evaluate outcomes of stroke care. CONCLUSIONS There are a number of important methodological challenges in undertaking risk-adjusted outcome comparisons to assess the quality of stroke care in different hospitals. It is important for stakeholders to recognize these challenges and for there to be a concerted approach to improving the methods for quality assessment and improvement.
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Myint PK, Clark AB, Kwok CS, Davis J, Durairaj R, Dixit AK, Sharma AK, Ford GA, Potter JF. The SOAR (Stroke subtype, Oxford Community Stroke Project classification, Age, prestroke modified Rankin) score strongly predicts early outcomes in acute stroke. Int J Stroke 2013; 9:278-83. [PMID: 23834262 DOI: 10.1111/ijs.12088] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2012] [Accepted: 11/06/2012] [Indexed: 10/26/2022]
Abstract
BACKGROUND Previous prognostic scoring systems in predicting stroke mortality are complex, require multiple measures that vary with time and failed to produce a simple scoring system. AIMS/HYPOTHESIS The study aims to derive and internally validate a stroke prognostic scoring system to predict early mortality and hospital length of stay. METHODS Data from a U.K. multicenter stroke register were examined (1997-2010). Using a prior hypothesis based on our and others observations, we selected five patient-related factors (age, gender, stroke subtype, clinical classification, and prestroke disability) as candidate prognostic indicators. An 8-point score was derived based on multiple logistic regression model using four out of five variables. Performance of the model was assessed by plotting the estimated probability of in-hospital death against the actual probability by testing for overfitting (calibration) and area under the curve methods (discrimination). RESULTS The total sample consisted of 12,355 acute stroke patients (ischemic stroke 91.0%). The score predicted both in-patient and seven-day mortality. The crude in-patient mortality were 1.57%, 4.02%, 10.65%, 21.41%, 46.60%, 62.72%, and 75.81% for those who scored 0, 1, 2, 3, 4, 5, and 6, respectively. The calibration of the model revealed no evidence of overfitting (estimated overfitting 0.001). The area under the curve values for both in-hospital and seven-day mortality were 0.79. The score predicted length of stay with a higher score was associated with longer median length of stay in those discharged alive and shorter median length of stay in those who died (P for both <0.001). CONCLUSIONS A simple 8-point clinical score is highly predictive of acute stroke mortality and length of hospital stay. It could be used as prognostic tool in service planning and also to risk-stratify patients to use these outcomes as markers of stroke care quality across institutions.
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Affiliation(s)
- Phyo Kyaw Myint
- Norwich Medical School, Faculty of Medicine and Health Sciences, University of East Anglia, Norwich, Norfolk, UK; Stroke Research Group, Norfolk and Norwich University Hospital, Norwich, Norfolk, UK; Clinical Gerontology Unit, University of Cambridge, Cambridge, Cambridgeshire, UK
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Smith EE, Shobha N, Dai D, Olson DM, Reeves MJ, Saver JL, Hernandez AF, Peterson ED, Fonarow GC, Schwamm LH. A risk score for in-hospital death in patients admitted with ischemic or hemorrhagic stroke. J Am Heart Assoc 2013; 2:e005207. [PMID: 23525444 PMCID: PMC3603253 DOI: 10.1161/jaha.112.005207] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We aimed to derive and validate a single risk score for predicting death from ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH). METHODS AND RESULTS Data from 333 865 stroke patients (IS, 82.4%; ICH, 11.2%; SAH, 2.6%; uncertain type, 3.8%) in the Get With The Guidelines-Stroke database were used. In-hospital mortality varied greatly according to stroke type (IS, 5.5%; ICH, 27.2%; SAH, 25.1%; unknown type, 6.0%; P<0.001). The patients were randomly divided into derivation (60%) and validation (40%) samples. Logistic regression was used to determine the independent predictors of mortality and to assign point scores for a prediction model in the overall population and in the subset with the National Institutes of Health Stroke Scale (NIHSS) recorded (37.1%). The c statistic, a measure of how well the models discriminate the risk of death, was 0.78 in the overall validation sample and 0.86 in the model including NIHSS. The model with NIHSS performed nearly as well in each stroke type as in the overall model including all types (c statistics for IS alone, 0.85; for ICH alone, 0.83; for SAH alone, 0.83; uncertain type alone, 0.86). The calibration of the model was excellent, as demonstrated by plots of observed versus predicted mortality. CONCLUSIONS A single prediction score for all stroke types can be used to predict risk of in-hospital death following stroke admission. Incorporation of NIHSS information substantially improves this predictive accuracy.
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Affiliation(s)
- Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
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Affiliation(s)
- Carol Parker
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Lee H. Schwamm
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Gregg C. Fonarow
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Eric E. Smith
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Mathew J. Reeves
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
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Smith EE, Shobha N, Dai D, Olson DM, Reeves MJ, Saver JL, Hernandez AF, Peterson ED, Fonarow GC, Schwamm LH. Risk Score for In-Hospital Ischemic Stroke Mortality Derived and Validated Within the Get With The Guidelines–Stroke Program. Circulation 2010; 122:1496-504. [DOI: 10.1161/circulationaha.109.932822] [Citation(s) in RCA: 187] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
There are few validated models for prediction of in-hospital mortality after ischemic stroke. We used Get With the Guidelines–Stroke Program data to derive and validate prediction models for a patient's risk of in-hospital ischemic stroke mortality.
Methods and Results—
Between October 2001 and December 2007, there were 1036 hospitals that contributed 274 988 ischemic stroke patients to this study. The sample was randomly divided into a derivation (60%) and validation (40%) sample. Logistic regression was used to determine the independent predictors of mortality and to assign point scores for a prediction model. We also separately derived and validated a model in the 109 187 patients (39.7%) with a National Institutes of Health Stroke Scale (NIHSS) score recorded. Model discrimination was quantified by calculating the C statistic from the validation sample. In-hospital mortality was 5.5% overall and 5.2% in the subset in which NIHSS score was recorded. Characteristics associated with in-hospital mortality were age, arrival mode (eg, via ambulance versus other mode), history of atrial fibrillation, previous stroke, previous myocardial infarction, carotid stenosis, diabetes mellitus, peripheral vascular disease, hypertension, history of dyslipidemia, current smoking, and weekend or night admission. The C statistic was 0.72 in the overall validation sample and 0.85 in the model that included NIHSS score. A model with NIHSS score alone provided nearly as good discrimination (C statistic 0.83). Plots of observed versus predicted mortality showed excellent model calibration in the validation sample.
Conclusions—
The Get With the Guidelines–Stroke risk model provides clinicians with a well-validated, practical bedside tool for mortality risk stratification. The NIHSS score provides substantial incremental information on a patient's short-term mortality risk and is the strongest predictor of mortality.
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Affiliation(s)
- Eric E. Smith
- From the Calgary Stroke Program (E.E.S., N.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute (D.D., D.M.O., A.F.H., E.D.P.), Durham, NC; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Stroke Service (L.H.S.), Massachusetts General Hospital, Boston, Mass
| | - Nandavar Shobha
- From the Calgary Stroke Program (E.E.S., N.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute (D.D., D.M.O., A.F.H., E.D.P.), Durham, NC; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Stroke Service (L.H.S.), Massachusetts General Hospital, Boston, Mass
| | - David Dai
- From the Calgary Stroke Program (E.E.S., N.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute (D.D., D.M.O., A.F.H., E.D.P.), Durham, NC; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Stroke Service (L.H.S.), Massachusetts General Hospital, Boston, Mass
| | - DaiWai M. Olson
- From the Calgary Stroke Program (E.E.S., N.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute (D.D., D.M.O., A.F.H., E.D.P.), Durham, NC; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Stroke Service (L.H.S.), Massachusetts General Hospital, Boston, Mass
| | - Mathew J. Reeves
- From the Calgary Stroke Program (E.E.S., N.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute (D.D., D.M.O., A.F.H., E.D.P.), Durham, NC; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Stroke Service (L.H.S.), Massachusetts General Hospital, Boston, Mass
| | - Jeffrey L. Saver
- From the Calgary Stroke Program (E.E.S., N.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute (D.D., D.M.O., A.F.H., E.D.P.), Durham, NC; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Stroke Service (L.H.S.), Massachusetts General Hospital, Boston, Mass
| | - Adrian F. Hernandez
- From the Calgary Stroke Program (E.E.S., N.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute (D.D., D.M.O., A.F.H., E.D.P.), Durham, NC; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Stroke Service (L.H.S.), Massachusetts General Hospital, Boston, Mass
| | - Eric D. Peterson
- From the Calgary Stroke Program (E.E.S., N.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute (D.D., D.M.O., A.F.H., E.D.P.), Durham, NC; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Stroke Service (L.H.S.), Massachusetts General Hospital, Boston, Mass
| | - Gregg C. Fonarow
- From the Calgary Stroke Program (E.E.S., N.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute (D.D., D.M.O., A.F.H., E.D.P.), Durham, NC; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Stroke Service (L.H.S.), Massachusetts General Hospital, Boston, Mass
| | - Lee H. Schwamm
- From the Calgary Stroke Program (E.E.S., N.S.), Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada; Duke Clinical Research Institute (D.D., D.M.O., A.F.H., E.D.P.), Durham, NC; Department of Epidemiology (M.J.R.), Michigan State University, East Lansing; Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.), University of California, Los Angeles; and Stroke Service (L.H.S.), Massachusetts General Hospital, Boston, Mass
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