Data to Real-World Impact: GWTG-Stroke Driving Two Decades of Sustained Improvement in Clinical Stroke Care

 

This is the whole problem in stroke enumerated in one word; 'care'; NOT RECOVERY!

YOU have to get involved and change this failure mindset of 'care' to 100% RECOVERY! Survivors want RECOVERY, NOT 'CARE'!

ASK SURVIVORS WHAT THEY WANT, THEY'LL NEVER RESPOND 'CARE'! This tyranny of low expectations has to be completely rooted out of any stroke conversation!

RECOVERY IS THE ONLY GOAL IN STROKE! GET THERE!

Data to Real-World Impact: GWTG-Stroke Driving Two Decades of Sustained Improvement in Clinical Stroke Care

• Chloe Mutimer , MD, BBMed , @drchloemutimer

Xian Y, Li S, Jiang T, Beon CD, Poudel R, Thomas K, Reeves MJ, Smith EE, Saver JL, Sheth KN, et al. Twenty Years of Sustained Improvement in Quality of Care and Outcomes for Patients Hospitalized With Stroke or Transient Ischemic Attack: Data From The Get With The Guidelines-Stroke Program. Stroke. 2024;55:2599–2610.

The Get With The Guidelines (GWTG)-Stroke program was established by the American Heart Association/American Stroke Association in 2003, to address the gap between evidence-based treatments and clinical practice. With now over >2800 participating sites, this dataset captures >75% of incident stroke in the United States. The GWTG-Stroke program has led to sustained improvements in quality care, leading to improved compliance with guidelines, the development of a nationwide stroke systems-of-care model, and promotion of local, national, and international quality improvement programs.¹ In a review by Xian et al. of the last two decades of data, they aimed to assess performance measures and clinical outcomes of patients who were admitted to participating sites with acute stroke (ischemic or hemorrhagic), subarachnoid hemorrhage, or transient ischemic attacks over the timeframe of the project. Data was reviewed from 7,837,849 patient records from hospitals who participate in the GTWG-Stroke program from April 2003 to December 2022. Several hyperacute, acute, and discharge quality metrics were assessed.

The impact of the GWTG-Stroke program on outcomes in ischemic stroke is summarized in Figure 2 of the article. The increasing adoption of thrombolysis as standard of care for eligible patients presenting in the hyperacute period (within 3.5 hours from symptom onset) was seen with rates increasing from 15.2% in 2003 to 92.9% in 2022. The time from presentation to thrombolysis administration also significantly improved with door-to-needle times of less than 60 minutes achieved in over 75% of patients in 2022. Since the advent of endovascular thrombectomy, data has been collected about door-to-puncture and door-to-reperfusion times since 2016. Modest improvements in door-to-puncture times over time were seen (54.7% in 2016 compared to 62.8% in 2022, aOR 1.03 [95%CI 1.01-1.05]) with significant improvement in time to reperfusion (aOR 1.19 [95%CI 1.14-1.24]). Rates of substantial reperfusion (defined as TICI2b-3) were also modestly improved (aOR 1.03 [95%CI 1.02-1.05]). Change in this rate likely reflects the expansion of thrombectomy criteria over time (up to 24 hours after 2018) and thus the complexity of the procedure.² Similarly, improvement in acute prescription of secondary prevention medication and strategies (antithrombotic or anticoagulation if atrial fibrillation detected, intensive statin therapy and smoking cessation advice) during admission was also seen (Supplementary Table S2). Despite significant improvement in hyperacute time metrics and subsequent acute care, a composite of in-hospital mortality and discharge to hospice remained relatively constant over time (aOR 1.01 [95%CI 1.00-1.01]). The authors attributed this to hyperacute therapies predominantly reducing disability, rather than necessarily improving mortality.

Figure 2. Temporal trends in acute ischemic stroke care over time.

For patients presenting with a transient ischemic attack, there was significant improvement in the use of early antithrombotic therapy, as well as discharge intensive statin therapy, smoking cessation and stroke education on discharge. Prescription of antithrombotic therapy at discharge remained similar over time, reflecting already high levels of compliance (>93%). The impact of these measures is difficult to ascertain from this dataset given the lack of long-term outcomes, such as recurrent event, reported.

No specific intervention for management of intracerebral or subarachnoid hemorrhage was reported, likely due to the lag in a strong evidence base for hyperacute management of these conditions. However, important safety measures were improved for both conditions, including rates of VTE prophylaxis and dysphagia screening, as well as access to rehabilitation. This was reflected in the in-hospital mortality rate for these conditions, which was reduced from 2003 to 2022.

This data supports the use of GTWG-Stroke as a nationwide quality improvement strategy that results in not only substantial improvement to patient care, but also sustained improvements over time. This study has shown that improvements in these quality metrics have translated to short-term benefit in patients in regard to length of stay and in-hospital mortality. While a limitation of this study is that it cannot exclude the influence of other quality improvement strategies on patient outcomes, it is unlikely that local or regional strategies would be able to influence care across the entirety of the US.

As outlined, GTWG-Stroke is an important nationwide registry and quality improvement project that helps support participating sites in the USA with access to up-to-date research, education opportunities, and quality improvement resources. However, as the landscape of stroke care continues to evolve, there are opportunities to further refine and expand the program’s scope to enhance its impact.

One key area for improvement is the inclusion of more comprehensive data collection for hemorrhagic stroke, particularly intracerebral hemorrhage and subarachnoid hemorrhage. There is a growing body of evidence to support disease-specific interventions — such as blood pressure control and anticoagulation reversal in ICH — and integrating these metrics could provide valuable insight into real-world application of these practices. For subarachnoid hemorrhages, rates of intervention (endovascular or neurosurgical) and complications such as delayed cerebral ischemia would enhance the program’s ability to inform best practice for this patient population.

Another important addition would be the inclusion of long-term patient outcomes. Understanding the impact of GWTG-Stroke beyond in-hospital care would provide a more complete picture of how these benefits translate into real-world benefit for stroke patients, as well as identify gaps where further intervention may be needed.