Quality of hospital care for African American and white patients with acute ischemic stroke and TIA was similar in many respects. However, African Americans were less likely to receive a CT within 25 minutes of arrival, cardiac monitoring, dysphagia screening, and smoking cessation counseling.

Background-Interhospital transfer of acute stroke patients is becoming increasingly important as regional stroke systems of care continue to evolve. We describe the characteristics and outcomes of stroke cases transferred to hospitals participating in the Michigan Coverdell Stroke Registry. Methods and Results-Thirty-six hospitals participated in the Michigan registry during 2009 to 2011. Transfer patients were transferred from another hospital either acutely or after admission. Multivariable logistic regression was used to determine predictors of transfer and the independent association between transfer and in-hospital mortality and complications. Of 16 202 acute stroke admissions, 19.1% were transferred. Independent predictors of being transferred included younger age, hemorrhagic stroke, and higher stroke severity, but having a past history of stroke decreased the likelihood of being transferred. Transferred cases had higher in-hospital mortality (12.0% versus 6.4%; P<0.001) compared with regular admissions and were more likely to suffer complications (18.4% versus 12.8%; P<0.001). These differences remained after adjustment for confounding variables (adjusted odds ratio for mortality =1.32, 95% confidence interval 1.12, 1.56; adjusted odds ratio for complications =1.39, 95% confidence interval 1.22, 1.58). Among ischemic stroke, elevated odds of poor outcomes among transferred patients remained after adjustment for stroke severity. Conclusions-Transferred patients represent a complex admixture of patient characteristics that result in higher risks of poor outcomes. Our results suggest that it is prudent to account for patient transfer status when comparing hospital outcomes and that stroke registries need to expand their data collection capacity to provide a better understanding of the relative benefits and risks of transferring patients. (Circ Cardiovasc Qual Outcomes. 2016;9:265-274.

ResultsThe average age of the 9609 admissions was 69.2 years; 31% were nonwhite, 62.3% had ischemic stroke, 10.3% hemorrhagic stroke, 24.1% TIA, and 3.3% stroke not specified.Background and Purpose-Stroke education, 1 of 8 endorsed stroke performance measures, consists of 5 specific subcomponents: risk factors, stroke warning signs, emergency medical service activation, physician follow-up, and discharge medications. We identified predictors of stroke education performance measure compliance in the Michigan Paul Coverdell National Acute Stroke Registry. Methods-Data were collected on 9609 acute stroke admissions to 20 registry hospitals during 2008 and 2009. Predictors of measure compliance (delivery of all 5 subcomponents) were determined using multivariable logistic regression. Results-Overall compliance with the stroke education measure was 61.8% (hospital-level compliance ranged between 16% and 93%). Compliance with individual subcomponents were risk factors (65.5%), stroke warning signs (68.9%), emergency medical service activation (66.8%), physician follow-up (92.9%), and discharge medications (91.5%). Age, gender, stroke subtype, prestroke ambulation, discharge destination, and hospital size were all significant independent predictors of compliance. Stroke education was delivered less often to patients who were ≥70 years of age, nonambulatory prestroke, not discharged to home, had transient ischemic attack, or hemorrhagic stroke. Conclusions-Only 60% of patients received stroke education consistent with the endorsed performance measures.Strategies to increase stroke education, including the impact of incorporating stroke-specific education measures into hospital care protocols, should be explored. (Stroke. 2013;44:1459-1462.)

The MSR collects information on the quality of acute stroke care as part of the Centers for Disease Control and Prevention Paul Coverdell National Acute Stroke Registry.3 Hospitals were selected through a stratified complex sampling scheme (based on geography, urban versus rural setting, and minority status [black versus white]) to obtain a representative statewide sample of hospitals providing acute stroke care. Human subjects' approval was obtained from the Michigan Department of Community Health institutional review board. Each hospital was responsible for complying with its own institutional review board process before starting data collection. Because of the quality improvement focus of the project, the requirement for individual patient consent was waived. Databases were linked using hospital, age, sex, and admission date. The MIDB was regarded as the gold standard. To assess completeness, we calculated the percent difference between the number of cases entered in the registry relative to the MIDB. To quantify accuracy, we defined sensitivity as the proportion of cases identified in the MIDB that were matched to the registry and positive predictive value as the proportion of cases identified in the registry that were matched to the MIDB. Before data linkage, 4 hospitals were known to be using a case sampling approach. The remaining 26 registry hospitals submitted 21% fewer cases (n=3403) than were found in the MIDB (n=4340). The overall sensitivity was 68.8% (95% confidence interval, 76.4%-79.3%), and positive predictive value was 87.7% (95% confidence interval, 87.4%-89.8%). The sensitivity of case ascertainment was significantly lower in teaching hospitals and primary stroke centers but was higher in the sites that used prospective case ascertainment methods. Conclusions-Among registry hospitals, these results revealed relatively high levels of completeness and accuracy.Matching registry data to hospital discharge data identified hospitals that changed their case ascertainment method to a case sampling approach. This study illustrates the value of monitoring case ascertainment in stroke registries using external data sources. (Circ Cardiovasc Qual Outcomes. 2014;7:757-763.)