Impact of Evidence‐Based Stroke Care on Patient Outcomes: A Multilevel Analysis of an International Study
Authors: Muñoz Venturelli Paula , Li Xian , Middleton Sandy , Watkins Caroline , Lavados Pablo M. , Olavarría Verónica V. , Brunser Alejandro , Pontes‐Neto Octavio , Santos Taiza E. G. , Arima Hisatomi , Billot Laurent , Hackett Maree L. , Song Lily , Robinson Thompson , Anderson Craig S. , Mead Gillian , De Silva H. Asita , Pandian Jeyaraj D. , Lin Ruey‐Tay , Lee Tsong‐Hai , Cui Liying , Peng Bin , Heritier Stephane , Lindley Richard , Jan Stephen , Boaden Elizabeth , Chen Christopher P. L. H. , Forster Anne , Billot Laurent , Woodward Mark , Rogers Kris , Scaria Anish , Lim Joyce Y. , Espinosa Natalie , McEvoy Lucy , Blackburn Lee , Richtering Sarah S. , You Shoujiang , Ladwig Simon , Merritt Gabrielle P. , Thomsen Bryce , Jenson Kerry , Gordon Penelope , Nguyen Dennis Ryan , Quan Wei Wei , Lo Tessa Pei‐Yi , Lim Jonathan , Goh Selena , Liu Leibo , Baig Mirza Ahmad , Singh Ravider , Donnelly Paul , Armenis Manuela , Zyl Marna Van , Monaghan Helen , Smith Phillipa , Glass Parisa , Zhou Fanli , Shen Yun , Lei Li , Li Di , Zhang Ting , Zhang Xiaoyan , Peng Yun , Feng Lingling , Ye Zhiping , Gregory Philip , Pandain Jeyaraj D. , Arora Deepti , Lavados Pablo M. , Gonzalez Francisca , Portales Bernardita , Pontes‐Neto Octavio , Santos‐Pontelli Taiza , Rimoli Brunna , Braga Monica , Vidal Carolina , Benadof Dafna , Rivas Rodrigo J. , Carvallo Laura , Carvallo Pamela , Miranda Rubia , Pileggi Brunna , de Silva H. Asita , Weerawardena Shalomi , Jeevarajah Thanushanthan , Dharmawardena Devaki , Ranasinghe Dumindi , Dharshana Matheesha , Nandadeva Nilesh , Nawarathna Savithri , Lin Ruey‐Tay , Lee Tsong‐Hai , Yin Jiu‐Haw , Yeh Shoou‐Jeng , Ma Ruei‐Jen , Watkins Caroline L. , Whiteley Gemma , Forshaw Denise , Lightbody Catherine Elizabeth , Cox Joanna , Fitzgerald Jane , Heney John F. , Byfield Helen , Finley Simone , Tyrer Hayley E. , Bruce Carole , Gibbon Alison , Jones Brett , Siracusa Emma , Gowda Koushik , Cowans Shahla , Forman Briana , Jacob Sherin , Caprecho Kristine , Khatri Roshan , Wan Po Yi , Lopez Maria , Vanika Sifiso , Bleeker Wilhelmina , Ireland Marinka , Jala Sheila , Day Susan , Ha Eric , Krause Martin , Passer Melissa , Giaccari Sarah , Burkolter Nadia , Braithwaite Michael , Tastula Kylie , Ghia Darshan , Musuka Tapuwa , Alvaro Anthony , Edmonds Gillian , O'Loughin Nicole , Phair Rebecca , Kaoutal Joanne , Blacker David J. , Saint Belinda L , Parrey Kim , Coad Michelle , Kinchington Matthew , Senanayake Nishantha , Alaban Johanna , Kuehne Irma , Santos‐Pontelli Taiza , Braga Monica , Rimoli Brunna , Camilo Millene , Libardi Milena , Martins Sheila , Carlos Batista , Martins Magda , Carbonera Leonardo , Almeida Andrea , Kelin Martin , Pauli Carla , Lunardi Mariana , Silveira Luciane , Chagas Olga , Souza Daily , Braga Gabriel , Ribeiro Priscila , Luvizutto Gustavo , Polin Marcia , Winckler Fernanda , Liu Jinfeng , Wang Zhenjiang , Wang Huibing , Lin Suying , Dong Jing , Zhou Junshan , Qin Suping , Zhan Hui , Xue Yongquan , Tian Dong , Yang Dan , Yin Yan , Li He , Geng Changming , Liu Jieyi , Jiang Xiaolin , Wu Yujun , Sun Wei , Yu Bingqi , Guan Yanmei , Wang Qin , Wei Bo , Wang Huirong , Wang Yan , Tai Liwen , Zhang Wenchao , Zhao Weili , Wang Xueying , Li Guoli , Ni Zhiming , Guo Fudong , Cen Lan , Lu Jun , Chen Zheng , Yin Guoming , Wang Yingchun , Zheng Jiping , Zhou Zhimin , Wang Hongquan , Zou Renlin , Xue Bin , Li Airu , Guo Jing , Guo Ying , Jiang Xingguo , Tan Xiuge , Zhang Chunpeng , Shao Bei , Niu Xiaoting , Liu Chunfeng , Chen Dongqin , Liang Ping , Zhang Xia , Zhang Chunqing , Gong Wenjie , Huang Zhichao , Liu Huihui , You Shoujiang , Huang Junying , Shi Rongfang , Wang Cuilan , Liu Ying , Wang Jinchao , Wu Guojun , Gao Zhihong , Lin Qunli , Xu Cong , Zheng Huile , Ye Xinghai , Jin Xiaoqiong , Liu Junyan , Cao Xiaoyun , Zhang Yan , Wang Jinyang , Xu Yuzhu , Li Yan , Ma Xin , Kong Qi , Hao Yanlei , Qiao Baojun , Yan Hui , Huang Zhiyong , Chang Baoqiang , Yan Jinjin , Liao Pinjun , Zhang Wei , Liu Ling , Zhu Tingting , Liu Xuehui , Li Yongping , Dong Ruifang , Chen Miao , Ge Xiaoli , Wang Hairong , Dai Lihua , Liu Jiafu , Wang Shixia , Du Jihui , Song Aixiu , Li Yunhai , Feng Jie , Yu Cheng , Feng Honglin , Sun Xiaojia , Sun Ruihong , Liu Weisong , Liu Jianfeng , Lu Xuesheng , Chen Enzhuo , Gao Wei , Liu Hui , Wang Heping , Wang Yanxia , Song Juan , Liu Dongqi , Du Wenhui , Li Guixia , Li Cuiling , Liang Yanling , Cai Xuekun , Zhang Jinli , Tao Xiaowei , An Pingshun , Tang Ranran , Qin Xu , Wang Yingling , Zhang Wenjun , Ma Rong , Huang Xiaoqiong , Liu Yonglin , Wang Yazhi , Fan Ping , Yang Hailan , Feng Lianyuan , Zhi Jianxia , Zhang Jiewen , Zhou Yao , Wu Danhong , He Haiyan , Chen Xiaohong , Hou Yongge , Su Xiaohui , Cui Liying , Peng Bin , Fan Siyuan , Suárez Luis , de Dios Polanco Juan , Sotomayor Patricio , Urzúa Ricardo , Urrutia Daniela , Conejan Nathalie , Escobar Arturo , Gonzalez Monica , Vargas Danisa , Constante Angel , Vásquez Erika , Godoy Elizabeth , Figueroa Christian , Martin Vanesa San , Vidal Nataly , Muñoz Madeleyn , Brunser Alejandro , Spencer María , Almeida Juan , Acosta Ignacio , Guerrero Rodrigo , Lozano Prudencio , Aguayo Camila , Pizarro Jimena , Soto Alvaro , Bonilla Flor , García Pía , Castillo Carolina Del , Grandjean Marcela , Von Johnn Alexis , Gutierrez Ignacio , Rivero Francisca , López Ignacio , Silva Federico , Pachón Marlen , Mendoza José , Pabón Alexander , Kate Mahesh , Akhtar Naushad , Narang Gibbsdeep S. , Deepak Ashish , Huded Vikram , De Sowza Romnesh , Sigamani Alben , Rajendran Karthikeyan , Vishwanath Anisha , K Anusha , Kumaravelu Somasundaram , Rahamath Syed , Kannneganti Sandeep , Khurana Dheeraj , Katoch Cheena , Kaur Taranpreet , Karadan Ummer , Kuriakose Anu , John Jaison , Basheer Mumthaz , Gunasekara Harsha Hemal , De Silva Gamlath Chandima Udeni , Ubeywickrama Peetagam Harshi Lakmali , Silva Kavisha Chathumali , De Silva Eshani Anuradha , Ranawaka Udaya , Mettananda Chamila , Nanayakkara Yamuna , Mendis Tharini , Fernando Gayathri , Imthikab Ahamed , Pieris Kandula , Gunatilake Saman B. , Madanayake Pamuditha M. W. , Paranavitane Shiran A. , Senanayake Bimsara , Vishwanathan Vaidhehi , Sivapalan Maathury , Murage Ruwangi U. , Chandradeva Uthpala , Lin Ruey‐Tay , Liu Yao‐Hua , Lin Chih‐Lung , Lin Hsiu‐Fen , Liu Kuan‐Ting , Chen Chien‐Fu , Wu Meng‐Ni , Tsai Su‐Hua , Chen Chi‐Ching , Chen Lan‐Yi , Lee Tsong‐Hai , Chang Chien‐Hung , Chang Yeu‐Jhy , Huang Kuo‐Lun , Chang Ting‐Yu , Liu Chi‐Hung , Seak Chen‐June , Lin Yu‐Li , Luo Jia‐Yi , Yang Hsiao‐Ying , Wang Ching‐Yi , Chan Lung , Hu Chaur‐Jong , Chi Nai‐Fang , Wu Dean , Huang Yao‐Hsien , Kuan Yi‐Chun , Hong Chien‐Tai , Chen Yi‐Chun , Sun Yu , Lin Cheng‐Huai , Lu Chien‐Jung , Chu Hai‐Jui , Lo Yi‐Chia , Chang Wen‐Hui , Lin Wan‐Jung , Su Hui‐Chen , Lin Tien‐Yu , Cho Chi‐Hsuan , Lu Shu‐Lan , Hsueh Ya‐Fang , Lai Ching‐Yi , Jarrett David , James Claire , Valentine Stacey , Whistler Clare , Butler Rebecca , Browning Simone , Watchurst Caroline , Erande Renuka , Elliott Emma , Patel Krishna , Brezitski Maria , Hogan Caroline , Banaras Asra , Crook Lucinda , Ahmed Rashidat , Potter Lindsay , Laird Rosie , Clarke Natasha , Loosemore Alison , Godber J. , Gawned Sara , Hamilton K. A. , Jones Rachael , Guyler Paul , Tysoe Sharon , Prabakaran Raji , Shah Sweni , Calver Joanne , Sztriha Laszlo K. , Fitzpatrick Maria , Drysdale Stephanie , Aeron‐Thomas John , McKenzie Emma , Chitando Belinda , Willcoxson Paul , Iveson Elizabeth , Wanklyn Peter , Dyer Natasha , Keeling Michael , Rodriguez Romina , Elliott Kerry , Porteous Mia , O'Neill Mark , Orme Sheridan , Richardson Carla , Tomlinson Janet , Hawkins Suzanne , Bester Delia , Jeffs Carol , Howard Joanne , Brown Pauline , Ward Deborah , Turfrey Jennifer , Raybould Leanne , Bates Allison , O'Connell Sue , O'Connor Margaret , Williams Samantha , Emsley Hedley C. A. , McLoughlin Alison , Raj Sonia , Gregary Bindu , Doyle Donna , Courtauld G. M. , Schofield C. , Lucas L. , Lydon A. , James A. , Saastamoinen Kari , Howaniec Laura , Daboo Premchand , Ali Ali N. , Richards Emma , Howe Joanne , Kamara Christine , Stocks Kathy , Lindert Ralf , Day Diana J. , Finlay Sarah , McGee Joanne , Mitchell Jennifer , Amis Elaine , Macey Rosemary , Tauro Suzanne , Henry Lauren , Cuddy Sarah , Steele Andrew , Mullen Kerry , Kirker Sarah , Bhattad Murudappa , Carpenter Michael , Datta Prabal , Needle Ann , Jackson Linda , Ball Julie , Beckitt Rosie , Chivers Nicola , Bowring Angela , Eddy Sara , Thorpe Kevin , Keenan Samantha , Griffin Alison , Maguire Stuart , Patterson Chris , Ramadan Hawraman , Bellfield Ruth , Hooley Michaela , Stewart Kelvin , Williams Lucy , Gurney Cara , Oliver Deborah , Gardiner Maria , Grayland Sarah , Bhandari Mohit , Collas David M. , Adesina Tolu , Sundayi Saul , Harvey Ruth , Pope Emma , Lam Audrey , Walker Elaine , Merrill Colin , Banerjee Soma , Harvey Kirsten Hannah , Mashate Sheila , Wilding Peter , Johnson Linda , Namushi Robert , Jacob Patricia , Andole Sreeman , Dunne Karen , Gadapa Naveen , King Sam , Siliuzaite Sonata , Dealing Sharon , Attwood Karen , Woods Annette , Sandhu Banher , Mamun Maam , Mahmood Afzal , Jones June , Ojo Abimbola , Carter‐Evans Denise , Liverpool Royal , Manoj Aravind , Fletcher Glyn , Lopez Paula , Greig Jill , Robinson Matthew , Jones Sarah , Jones Lorinda , West Claire , Tench Helen , Gascoyne Rachel , Whileman Amanda , Hall Emily , Wright Stephanie , Toms Julie , Tomlinson Janet , Phiri Duke , Sethuraman Sakthivel , Mohammed Niaz , Justin Frances , Tate Margaret Louise , Chauhan Meena , Haider Syed I. , Nallasivan Arumugam , Webster Tim , Leason Sandra , Seagrave Samantha , Hospital Peterborough City , Owksu‐Agyei Peter , Temple Natalie , Butterworth‐Cowin Nicola , Magezi Frederick , Infirmary Leicester Royal , Khan Shagufta , Stephens Claire , Mistri Amit , Murphy Aidan , Lam Manda , Underwood Paul , Thompson Catherine , Buckley Clare , Wood Diane , Board Sarah , Howard Linda , Ahmed Ashraf , Oates Bethany , Leonard Sara , Hospital Royal Bournemouth , Bournemouth Royal , Thavanesan Kamy , Dharmasiri Michelle , Logianathan Sathyabama , Ovington Catherine , Hann Gail , Cox Chantel , Hospital Craigavon Area , Health Southern , Trust Social Care , Douglas Catherine , Goggin Michael , Fearon Patricia , Gilpin Sara , O'Hagan Margaret , Hospital Pilgrim , Hardwick Anne , Netherton Kimberley , Quinn Judith , Bozkaplan Tulu , Jose Josin 
Published: June 2019

Background

The uptake of proven stroke treatments varies widely. We aimed to determine the association of evidence‐based processes of care for acute ischemic stroke (
AIS
) and clinical outcome of patients who participated in the HEADPOST (Head Positioning in Acute Stroke Trial), a multicenter cluster crossover trial of lying flat versus sitting up, head positioning in acute stroke.

Methods and Results

Use of 8
AIS
processes of care were considered: reperfusion therapy in eligible patients; acute stroke unit care; antihypertensive, antiplatelet, statin, and anticoagulation for atrial fibrillation; dysphagia assessment; and physiotherapist review. Hierarchical, mixed, logistic regression models were performed to determine associations with good outcome (modified Rankin Scale scores 0–2) at 90 days, adjusted for patient and hospital variables. Among 9485 patients with AIS, implementation of all processes of care in eligible patients, or “defect‐free” care, was associated with improved outcome (odds ratio, 1.40; 95% CI, 1.18–1.65) and better survival (odds ratio, 2.23; 95%
CI
, 1.62–3.09). Defect‐free stroke care was also significantly associated with excellent outcome (modified Rankin Scale score 0–1) (odds ratio, 1.22; 95%
CI
, 1.04–1.43). No hospital characteristic was independently predictive of outcome. Only 1445 (15%) of eligible patients with AIS received all processes of care, with significant regional variations in overall and individual rates.

Conclusions

Use of evidence‐based care is associated with improved clinical outcome in
AIS
. Strategies are required to address regional variation in the use of proven
AIS
treatments.

Clinical Trial Registration

URL
:
https://www.clinicaltrials.gov
. Unique Identifier:
NCT
02162017.