Paul Coverdell National Acute Stroke Program 2012-2015 Case Study Evaluation State Summaries

From 2012 to 2015, the Paul Coverdell National Acute Stroke Program (Coverdell Program) funded 11 state health departments to develop stroke systems of care and improve quality of care for stroke patients.

All grantees worked toward improvements in hospital stroke care and also worked in the pre-hospital setting, the post-hospital setting, or across the care continuum. The goal of the program is to develop high-quality stroke systems of care to save lives and prevent premature disability and death. Stroke systems of care improve patient care and support throughout their health care journey—from the first symptoms of stroke, EMS transport, and hospital care to follow-up with outpatient providers.

Case Studies

CDC contracted with RTI International to conduct a case study evaluation of each state grantee to describe program implementation and assess program achievements. The case studies included a thematic analysis of qualitative data sources and a quantitative analysis of secondary data. The evaluation resulted in 11 state-specific reports, one for each grantee, as well as a cross-site report that highlights common themes across all grantees.

Data Collection and Analysis

During May and June 2015, the evaluation team conducted semi-structured telephone interviews with staff and stakeholders of the 11 funded programs, representing various staff roles and stakeholder types. Qualitative data were analyzed using NVivo for coding and thematic analysis. Along with interview data, the evaluation team used other secondary data sources, such as program documents, to supplement the detailed description of each program.

The evaluation team analyzed data on intermediate outcomes of the program and coupled it with qualitative interview data. Grantee-specific trend analyses with trend P values were conducted using the program’s in-hospital quality-of-care performance measure data from 2012 to 2015 or 2013 to 2015, depending on the year when data were first available. There were 265,876 stroke patients in the analysis. Table 1 in each summary shows the program’s in-hospital quality of stroke care measures that significantly improved across the time period, with P < .05 as the significance level. Some states had one or more measures that started with at least 90% agreement with the 2012–2015 Coverdell Program in-hospital quality-of-care performance measures and thus had less room for improvement.

Lessons Learned

Although each grantee-specific report documented lessons learned from various activities, there was great variability depending on the program context and resources. A key lesson learned among all grantees was that state-level and health systems–level contextual factors that affect state health departments’ efforts to establish stroke systems of care need to be accounted for when systems are being designed. Examples of state-level contextual factors include geography, demographics, population density, and supporting legislation. Examples of health systems–level contextual factors include centralizations of EMS authority and engagement of local stroke experts and champions.

The performance measures below represent the measures that were used for the 2012–2015 Coverdell Program cooperative agreement. Some of these measures have changed since the cooperative agreement ended in June 2015. Learn more about current NQF measures.

Venous thromboembolism (VTE) prophylaxis (NQF 0434)—Ischemic and hemorrhagic stroke patients and those with stroke not otherwise specified who received VTE prophylaxis or have documentation why no VTE prophylaxis was given either the day of or the day after hospital admission.

Discharged on antithrombotic therapy (NQF 0435)—Ischemic stroke and transient ischemic attack (TIA) patients prescribed antithrombotic therapy at hospital discharge.

Anticoagulation therapy for atrial fibrillation/ flutter (NQF 0436)—Ischemic stroke and TIA patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge.

Thrombolytic therapy (NQF 0437)—Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom intravenous tPA was initiated at this hospital within 3 hours of time last known well.

Antithrombotic therapy by end of hospital day 2 (NQF 0438)—Ischemic stroke and TIA patients administered antithrombotic therapy by the end of hospital day 2.

Discharged on statin medication (NQF 0439)—Ischemic stroke and TIA patients with a low-density lipoprotein (LDL) level greater than or equal to 100 mg/dL, or whose LDL was not measured, or who were on a lipid-lowering medication prior to hospital arrival, who were prescribed a statin medication at hospital discharge.

Stroke education (NQF 0440)—Ischemic or hemorrhagic stroke patients, patients with stroke not otherwise specified, and TIA patients or their caregivers who were given educational materials during the hospital stay addressing activation of the emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke.

Assessed for rehabilitation (NQF 0441)—Ischemic or hemorrhagic stroke or stroke not otherwise specified patients who were assessed for rehabilitation services.

Smoking cessation counseling—Ischemic or hemorrhagic stroke patients or stroke not otherwise specified and TIA patients who are current smokers who receive or refuse smoking cessation counseling.

Dysphagia screening (NQF 0243)—Ischemic stroke or hemorrhagic stroke or stroke not otherwise specified who receive any food, fluids or medication by mouth (PO) for whom a dysphagia screening was performed prior to PO intake in accordance with a dysphagia screening tool approved by the institution in which the patient is receiving care.

Recording of NIHSS score (NQF 1955 – not endorsed in 2015)—Ischemic stroke with an initial National Institutes of Health Stroke Scale (NIHSS) score recorded.

Time to intravenous thrombolytic therapy (NQF 1952)—Acute ischemic stroke patients receiving intravenous tPA therapy during the hospital stay and having a time from hospital arrival to initiation of thrombolytic therapy administration (door-to-needle time) of 60 minutes or less.