Department of Neurology

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Does Inclusion of Stroke Severity in a 30-day Mortality Model Change Standardized Mortality Rates at VA Hospitals?
(2012-07) Keyhani, Salomeh; Cheng, Eric M.; Arling, Greg; Li, Xinli; Myers, Laura J.; Ofner, Susan; Williams, Linda S.; Phipps, Michael S.; Ordin, Diana L.; Bravata, Dawn M.
Background—The Centers for Medicare and Medicaid Services is considering developing a 30-day ischemic stroke hospital-level mortality model using administrative data. We examined whether inclusion of the National Institutes of Health Stroke Scale (NIHSS), a measure of stroke severity not included in administrative data, would alter 30-day mortality rates in the Veterans Health Administration. Methods and Results—A total of 2562 veterans admitted with ischemic stroke to 64 Veterans Health Administration Hospitals in the fiscal year 2007 were included. First, we examined the distribution of unadjusted mortality rates across the Veterans Health Administration. Second, we estimated 30-day all-cause, risk standardized mortality rates (RSMRs) for each hospital by adjusting for age, sex, and comorbid conditions using hierarchical models with and without the inclusion of the NIHSS. Finally, we examined whether adjustment for the NIHSS significantly changed RSMRs for each hospital compared with other hospitals. The median unadjusted mortality rate was 3.6%. The RSMR interquartile range without the NIHSS ranged from 5.1% to 5.6%. Adjustment with the NIHSS did not change the RSMR interquartile range (5.1%–5.6%). Among veterans ≥65 years, the RSMR interquartile range without the NIHSS ranged from 9.2% to 10.3%. With adjustment for the NIHSS, the RSMR interquartile range changed from 9.4% to 10.0%. The plot of 30-day RSMRs estimated with and without the inclusion of the NIHSS in the model demonstrated overlapping 95% confidence intervals across all hospitals, with no hospital significantly below or above the mean-unadjusted 30-day mortality rate. The 30-day mortality measure did not discriminate well among hospitals. Conclusions—The impact of the NIHSS on RSMRs was limited. The small number of stroke admissions and the narrow range of 30-day stroke mortality rates at the facility level in the Veterans Health Administration cast doubt on the value of using 30-day RSMRs as a means of identifying outlier hospitals based on their stroke care quality.
Depression and Stroke: Cause or Consequence?
(2005) Williams, Linda S.
Depression after stroke is common. Although different opinions exist about the definition, diagnosis, and measurement of outcomes related to depression after stroke, there is little debate about the prevalence of depression symptoms and their impact on stroke survivors and their families. Depression after stroke has long been recognized as a common condition with many negative effects in the poststroke period, but more recently depression has also been identified as an independent stroke risk factor. Given that there are at least 500,000 new ischemic strokes yearly in the United States, a conservative estimate is that 150,000 U.S. stroke survivors develop poststroke depression each year. Because effective treatments exist but are likely underutilized for depression, this is an important example of an evidence-practice gap to which increased efforts to improve care should be made. Such efforts would likely improve not only patient symptoms but may also decrease stroke risk, influence stroke functional recovery, decrease mortality, and reduce poststroke health care utilization. This article provides an overview of depression diagnosis in stroke, reviews the epidemiology of poststroke depression and its associated morbidity and mortality, and reviews existing evidence on the treatment and prevention of poststroke depression.
Post-Stroke Depression: Focus on Diagnosis and Management during Stroke Rehabilitation
(2007-09) Johnson, Elizabeth A; Bakas, Tamilyn; Williams, Linda S.
Post-Stroke Depression: Focus on Diagnosis and Management during Stroke Rehabilitation. Geriatrics & Aging. 10(8):492–6.
Using Administrative Databases to Calculate Framingham Scores within a Large Healthcare Organization
(2011-07) Ekundayo, O James; Vassar, Stefanie D; Williams, Linda S.; Bravata, Dawn M.; Cheng, Eric M.
Background and Purpose—Framingham calculators are typically implemented in 1-on-1 settings to determine if a patient is at high risk for development of cardiovascular disease in the next 10 years. Because health care administrative datasets are including more clinical information, we explored how well administrative data-derived Framingham scores could identify persons who would have stroke develop in the next year. Methods—Using a nested case-control design, we compared all 313 persons who had a first-time stroke at 5 Veterans Administration Medical Centers with a random sample of 25 361 persons who did not have a first-time stroke in 2008. We compared Framingham scores and risk using administrative data available at the end of 2007. Results—Stroke patients had higher risk profile than controls: older age, higher systolic blood pressure and total cholesterol, more likely to have diabetes, cardiovascular disease, left ventricular hypertrophy, and more likely to use treatment for blood pressure (P<0.05). The mean Framingham generalized cardiovascular disease score (18.0 versus 14.5) as well as the mean Framingham stroke-specific score (13.2 versus 10.2) was higher for stroke cases than controls (both P<0.0001). The c-statistic for the generalized cardiovascular disease score was 0.68 (95% CI, 0.65–0.70) and for the stroke score was 0.64 (95% CI, 0.62–0.67). Conclusions—Persons who had a stroke develop in the next year had a worse Framingham risk profile, as determined by administrative data. Future studies should examine how to improve the stroke predictive tools and to identify the appropriate populations and uses for applying stroke risk predictive tools.
Geographic variation in poststroke depression among veterans with acute stroke
(2008) Jia, Huanguang; Ried, L Douglas; Wang, Xinping; Damush, Teresa M.; Young, Linda J; Cameon, Randi H; Williams, Linda S.
This study compared patterns of poststroke depression (PSD) detection among veterans with acute stroke in eight U.S. geographic regions. Department of Veterans Affairs (VA) medical and pharmacy data as well as Medicare data were used. International Classification of Diseases-9th Revision depression codes and antidepressant medication dispensing were applied to define patients’ PSD status 12 months poststroke. Logistic regression models were fit to compare VA PSD diagnosis and overall PSD detection between the regions. The use of VA medical data alone may underestimate the rate of PSD. Geographic variation in PSD detection depended on the data used. If VA medical data alone were used, we found no significant variation. If VA medical data were used along with Medicare and VA pharmacy data, we observed a significant variation in overall PSD detection across the regions after adjusting for potential risk factors. VA clinicians and policy makers need to consider enrollees’ use of services outside the system when conducting program evaluation. Future research on PSD among veteran patients should use VA medical data in combination with Medicare and VA pharmacy data to obtain a comprehensive understanding of patients’ PSD.
Postdischarge quality of care: Do age disparities exist among Department of Veterans Affairs ischemic stroke patients?
(2013) Chumbler, Neale R.; Jia, Huanguang; Phipps, Michael S.; Li, Xinli; Ordin, Diana L.; Williams, Linda S.; Myers, Laura J.
This study examined whether age disparities existed across postdischarge quality indicators (QIs) for veterans with ischemic stroke who received care at Department of Veterans Affairs medical centers (VAMCs). This retrospective cohort included a national sample of 3,196 veterans who were diagnosed with ischemic stroke and received acute and postdischarge stroke care at 127 VAMCs in fiscal year 2007 (10/1/06 through 9/30/07). Data included an assessment of postdischarge stroke QIs in the outpatient setting during the 6 mo postdischarge. The QIs included measurement of and goal achievement for (1) blood pressure, (2) serum international normalized ratio (INR) for all patients discharged on warfarin, (3) cholesterol (low-density lipoprotein [LDL]) levels, (4) serum glycosylated hemoglobin, and (5) depression treatment. The mean age for the 3,196 veterans included in this study was 67.2 +/– 11.3 yr. Before risk adjustment, there were age differences in (1) depression screening/treatment, (2) blood pressure goals, and (3) LDL levels. After we adjusted for patient sociodemographic, clinical, and facility-level characteristics by using hierarchical linear mixed modeling, none of these differences remained significant but INR goals for patients discharged on warfarin differed significantly by age. After we adjusted for patient and facility characteristics, fewer age differences were found in the postdischarge stroke QIs. Clinical trial registration was not required.
Stroke Caregiver Outcomes from the Telephone Assessment and Skill-Building Kit (TASK)
(2009-03) Bakas, Tamilyn; Farran, Carol J.; Austin, Joan K.; Given, Barbara A.; Johnson, Elizabeth A.; Williams, Linda S.
Purpose: Stroke caregivers often express the need for information about stroke and assistance with stroke-related care in the early discharge period. The Telephone Assessment and Skill-Building Kit (TASK) is an 8-week program that addresses caregiver needs. This study explored the efficacy of the TASK program in improving stroke caregiver outcomes. Method: Guided by a conceptual model, 6 outcomes (optimism, task difficulty, threat appraisal, depressive symptoms, life changes, general health perceptions) were measured in 40 caregivers randomized to the TASK (n = 21) or an attention control group (n = 19). Data were analyzed using analysis of covariance (ANCOVA), controlling for baseline scores and minutes spent with the nurse. Results: Significant increases in optimism at 4 weeks, 8 weeks, and 12 weeks were found, with medium effect sizes for the TASK group relative to the control group (p < .05). Significant improvements in task difficulty at 4 weeks, and threat appraisal at both 8 weeks and 12 weeks were also found (p < .05). Conclusion: Caregivers receiving the TASK intervention improved in optimism, task difficulty, and threat appraisal. Further testing of an enhanced version of the TASK program is warranted, with attention directed toward more distal stroke caregiver outcomes.
Bleeding Risk, Physical Functioning, and Non-use of Anticoagulation Among Patients with Stroke and Atrial Fibrillation
(2014-08) Schmid, Arlene A.; Ofner, Susan; Shorr, Ronald I; Williams, Linda S.; Bravata, Dawn M.
Background: Atrial fibrillation (AF) is common among people with stroke. Anticoagulation medications can be used to manage the deleterious impact of AF after stroke, however may not be prescribed due to concerns about post-stroke falls and decreased functioning. Thus, the purpose of this study was to identify, among people with stroke and AF, predictors of anticoagulation prescription at hospital discharge. Methods: This is a secondary analysis of a retrospective cohort study of data retrieved via medical records, including: National Institutes of Health Stroke Scale score; Functional Independence Measure (FIM) motor score (motor or physical function); ambulation on 2nd day of hospitalization; Morse Falls Scale (fall risk); and HAS-BLED score (Hypertension; Abnormal renal and liver function; Stroke; Bleeding; Labile INRs; Elderly > 65; and Drugs or alcohol). Data analyses included bivariate comparisons between people with and without anticoagulation at discharge. Logistic-regression modeling was used to assess predictors of discharge anti-coagulation. Results: There were 334 subjects included in the analyses, average age was 75 years old. Anticoagulation was prescribed at discharge for 235 (70%) of patients. In the adjusted regression analyses, only the FIM motor score (adjusted OR = 1.015, 95%CI 1.001-1.028) and the HAS-BLED score (adjusted OR = 0.36, 95%CI 0.22-0.58) were significantly associated with anticoagulation prescription at discharge. Conclusion: It appears that in this sample, post-stroke anti-coagulation decisions appear to be made based on clinical factors associated with bleed risk and motor deficits or physical functioning. However, opportunities may exist for improving clinician documentation of specific reasoning for non-anticoagulation prescription.
Poststroke depression and treatment effects on functional outcomes
(2011-03) Schmid, Arlene A; Kroenke, Kurt; Hendrie, H C; Bakas, Tamilyn; Williams, Linda S.
Background: Poststroke depression (PSD) is common after stroke; however, the relationship to poststroke function is inconclusive. Our objectives were to 1) determine the relationship between PSD at baseline (1 month poststroke) and function (12 weeks later) and 2) assess the impact of depression improvement on 12-week function among those with depression at baseline. Methods: We completed a secondary analysis of data from a cohort study of participants with and without PSD. We used logistic regression to identify factors associated with 12-week functional dependence for 1) all 367 participants and 2) the 174 participants with PSD. Results: In the PSD cohort, 3 characteristics were found to be independently associated with 12-week dependence: increased medical comorbidity (odds ratio [OR] 1.10, 95%confidence interval [CI] 1.02–1.22), increased stroke severity (OR 1.42, 95% CI 1.19–1.69), and increased baseline depression severity (OR 1.13, 95% CI 1.03–1.23). Depression severity was significantly different between those considered dependent and independent at 12 weeks (entire cohort, PHQ-9 7.31 vs 5.18, p = 0.008; depressed cohort, PHQ-9 9.94 vs 7.27, p = 0.019). Conclusion: Among study participants with PSD, the severity of depression symptoms at baseline was associated with dependence; however, our results are inconclusive as to whether improvement of depression is independently associated with functional recovery at 12 weeks. Even if the treatment and improvement of PSD does not directly influence functional recovery poststroke, it is essential for PSD to be identified and treated due to its high symptom burden and association with other negative health and social outcomes.
A multidisciplinary stroke clinic for outpatient care of veterans with cerebrovascular disease
(2011-04) Schmid, Arlene A.; Kapoor, John R; Miech, Edward J.; Kuehn, Deborah; Dallas, Mary I; Kerns, Robert D; Lo, Albert C.; Concato, John; Phipps, Michael S.; Couch, Cody D; Moran, Eileen; Williams, Linda S.; Goble, Layne A; Bravata, Dawn M.
Background: Managing cerebrovascular risk factors is complex and difficult. The objective of this program evaluation was to assess the effectiveness of an outpatient Multidisciplinary Stroke Clinic model for the clinical management of veterans with cerebrovascular disease or cerebrovascular risk factors. Methods: The Multidisciplinary Stroke Clinic provided care to veterans with cerebrovascular disease during a one-half day clinic visit with interdisciplinary evaluations and feedback from nursing, health psychology, rehabilitation medicine, internal medicine, and neurology. We conducted a program evaluation of the clinic by assessing clinical care outcomes, patient satisfaction, provider satisfaction, and costs. Results: We evaluated the care and outcomes of the first consecutive 162 patients who were cared for in the clinic. Patients had as many as six clinic visits. Systolic and diastolic blood pressure decreased: 137.2 ± 22.0 mm Hg versus 128.6 ± 19.8 mm Hg, P = 0.007 and 77.9 ± 14.8 mm Hg versus 72.0 ± 10.2 mm Hg, P = 0.004, respectively as did low-density lipoprotein (LDL)-cholesterol (101.9 ± 23.1 mg/dL versus 80.6 ± 25.0 mg/dL, P = 0.001). All patients had at least one major change recommended in their care management. Both patients and providers reported high satisfaction levels with the clinic. Veterans with stroke who were cared for in the clinic had similar or lower costs than veterans with stroke who were cared for elsewhere. Conclusion: A Multidisciplinary Stroke Clinic model provides incremental improvement in quality of care for complex patients with cerebrovascular disease at costs that are comparable to usual post-stroke care.

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