Clinical Trial URL: http://clinicaltrials.gov/ct2/show/NCT00328640; identification number: NCT00328640.
Standardized discharge orders after stroke: Results of the quality improvement in stroke prevention (QUISP) cluster randomized trial†
Article first published online: 15 MAR 2010
Copyright © 2010 American Neurological Association
Annals of Neurology
Volume 67, Issue 5, pages 579–589, May 2010
How to Cite
Johnston, S. C., Sidney, S., Hills, N. K., Grosvenor, D., Klingman, J. G., Bernstein, A. and Levin, E. (2010), Standardized discharge orders after stroke: Results of the quality improvement in stroke prevention (QUISP) cluster randomized trial. Ann Neurol., 67: 579–589. doi: 10.1002/ana.22019
- Issue published online: 26 APR 2010
- Article first published online: 15 MAR 2010
- Manuscript Accepted: 2 MAR 2010
- Manuscript Revised: 19 FEB 2010
- Manuscript Received: 21 SEP 2009
- Centers for Disease Control and Prevention, administered through the Association of American Medical Colleges
Proven strategies to reduce risk of stroke recurrence are under-utilized. We sought to evaluate the impact of standardized stroke discharge orders on treatment practices in a cluster-randomized trial.
The Quality Improvement in Stroke Prevention (QUISP) trial randomized 12 hospitals to continue usual care or to receive assistance in the development and implementation of standardized stroke discharge orders. All patients with ischemic stroke were identified during a 12-month period prior to implementation and for 12 months afterward, and were followed for 6 months after discharge. The primary outcome was optimal treatment at 6 months, defined as taking a statin, having blood pressure <140/90mmHg, and receiving anticoagulation if atrial fibrillation was diagnosed. The primary analysis treated the hospital as the unit of analysis, comparing optimal treatment rates—adjusted for race, age, dementia, atrial fibrillation, and history of bleeding—between intervention and non-intervention hospitals using a paired t test.
In the primary analysis with hospital as the unit of analysis, the odds of optimal treatment was not significantly increased at intervention compared to non-intervention hospitals (odds ratio, 1.39; 95% confidence interval, 0.71–2.76; p = 0.27). However, in analyses conducted at the level of the individual patients (N = 3,361), rates of optimal treatment increased from 37% to 45% in the intervention hospitals (p = 0.001) and did not change significantly in the non-intervention hospitals (39% to 40%; p = 0.27).
Implementation of standardized discharge orders after stroke was associated with increased rates of optimal secondary prevention; this improvement was not significant in the primary analysis at the hospital level. ANN NEUROL 2010;67:579–589