BackgroundLimited information has been published regarding standard quality assurance (QA) procedures for stroke registries. We share our experience regarding the establishment of enhanced QA procedures for the University of Texas Houston Stroke Registry (UTHSR) and evaluate whether these QA procedures have improved data quality in UTHSR.MethodsAll 5093 patient records that were abstracted and entered in UTHSR, between January 1, 2008 and December 31, 2011, were considered in this study. We conducted reliability and validity studies. For reliability and validity of data captured by abstractors, a random subset of 30 records was used for re-abstraction of select key variables by two abstractors. These 30 records were re-abstracted by a team of experts that included a vascular neurologist clinician as the “gold standard”. We assessed inter-rater reliability (IRR) between the two abstractors as well as validity of each abstractor with the “gold standard”. Depending on the scale of variables, IRR was assessed with Kappa or intra-class correlations (ICC) using a 2-way, random effects ANOVA. For assessment of validity of data in UTHSR we re-abstracted another set of 85 patient records for which all discrepant entries were adjudicated by a vascular neurology fellow clinician and added to the set of our “gold standard”. We assessed level of agreement between the registry data and the “gold standard” as well as sensitivity and specificity. We used logistic regression to compare error rates for different years to assess whether a significant improvement in data quality has been achieved during 2008–2011.ResultsThe error rate dropped significantly, from 4.8% in 2008 to 2.2% in 2011 (P < 0.001). The two abstractors had an excellent IRR (Kappa or ICC ≥ 0.75) on almost all key variables checked. Agreement between data in UTHSR and the “gold standard” was excellent for almost all categorical and continuous variables.ConclusionsEstablishment of a rigorous data quality assurance for our UTHSR has helped to improve the validity of data. We observed an excellent IRR between the two abstractors. We recommend training of chart abstractors and systematic assessment of IRR between abstractors and validity of the abstracted data in stroke registries.

IntroductionThe Lone Star Stroke Consortium Telestroke Registry (LeSteR) currently consisting of 3 academic hub centres and 27 partner spokes is a statewide initiative organised by leading academic health centres in the State of Texas to understand practice patterns of acute stroke management via telestroke (TS) in Texas, a state with one of the largest rural populations in the USA.Methods and analysisAll patients who had presumed stroke for whom a TS consultation has been obtained in the network are entered into a web-based, Health Insurance Portability and Accountability Act-compliant database from September 2013 to present. Spokes were enrolled into LeSteR in a staggered approach in two data collection phases: a retrospective phase and a prospective phase. Basic clinical, demographic data and relevant time metrics are collected in the retrospective phase. Starting 1 September 2015, additional outcome data including 90-day modified Rankin score, readmission and 90-day disposition are obtained by a standard phone interview. From the registry initiation to 31 December 2017, there are 8089 patients who had suspected stroke in the registry. Over 60% of patients enrolled after 1 September 2015 have reported outcome data. Enrolment is still active for this registry.Ethics and disseminationLeSteR is a statewide TS registry organised by academic health centres that will provide significant insight regarding the impact of TS in the State of Texas. Findings from LeSteR will provide data that can be analysed to improve the allocation of healthcare resources using TS to treat stroke in a state with one of the largest rural populations.

Background and Purpose: Telemedicine (TM) is increasingly utilized for intravenous tissue plasminogen activase (tPA) delivery. The comparative safety of leaving tPA-treated patients at a presenting (spoke) hospital (drip and stay) or transferring patients to a central treating (hub) hospital (drip and ship) is not established. We sought to compare outcomes between drip and ship and drip and stay patients treated with tPA via TM. We hypothesized that there would be no differences in short-term outcomes of in-hospital mortality, length of stay, or discharge disposition or in 90-day outcomes between groups. Methods: We retrospectively identified patients treated with tPA at 17 spoke hospitals between September 2015 and December 2016. Demographic, clinical, and outcome data were obtained from a prospective telemedicine registry. We used negative binomial, multinomial, and logistic regression analyses to evaluate length of stay (LOS), discharge disposition, and inpatient mortality, respectively. We compared the proportion of patients with 90-day modified rankin score (mRS) less than 2 by group. Results: Among 430 tPA-treated patients, 232 (53.9%) were transferred to the hub after treatment. The median arrival NIHSS was higher for drip and ship (10; IQR 5,18) compared to drip and stay patients (6; IQR 4,10; p < 0.001). Unadjusted LOS was longer in drip and stay patients (IRR 0.82, 95% CI 0.71, 0.95). There were no significant differences in adjusted LOS, hospital mortality, or discharge disposition. Among the 64% of patients with complete 90-day mRs, the proportion with good outcomes (mRS < 2) did not differ between groups.

IntroductionTissue plasminogen activator (tPA) refusal is 4%–6% for acute ischemic stroke (AIS) in the emergency room. Telestroke (TS) has increased the use of tPA for AIS, but is accompanied by barriers in communication that can affect tPA consent. We characterized the incidence of tPA refusal in our TS network and its associated reasons.MethodsPatients with AIS who were offered tPA within 4.5 hours from symptom onset according to American Heart Association guidelines were identified within our Lone Star Stroke Consortium Telestroke Registry from September 2015 to December 2018. We compared baseline characteristics and clinical outcomes between patients who refused tPA and patients who accepted tPA.ResultsAmong the 1242 patients who qualified for tPA and were offered treatment, 8% refused tPA. Female and non-Hispanic black patients and patients with prior history of stroke were more likely to decline tPA. Patients who refused tPA presented with a lower NIHSS and was associated with a final diagnosis of stroke mimic (odds ratio [0.23]; 95% confidence interval [CI] 0.15–0.36). Good outcome (90 days modified Rankin Scale 0–2) was the same among patients who received tPA and those who refused (OR 0.80; 95% CI 0.42–1.54). The most common reasons for refusal were rapidly improving and mild/non-disabling symptoms and concern for potential side effects.ConclusiontPA refusal over TS is comparable to previously reported rates; there was no difference in outcomes among patients who received tPA compared to those who refused. Sex and racial differences associated with an increase tPA refusal warrant further investigation in efforts to achieve equity/parity in tPA decisions.