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Patterns of Care and Temporal Trends in Ischemic Stroke

Management: A Brazilian Perspective

Monique Bueno Alves, RN, MsC,*, Gisele Sampaio Silva, MD, MPH, PhD,*,
Renata Carolina Acri Miranda, RN, Rodrigo Meireles Massaud, MD,
Andreia Maria Heins Vaccari, RN, Miguel Cendoroglo-Neto, MD, PhD,*, and
Solange Diccini, RN, PhD*

Background and Purpose: Demonstration of an improvement process of quality

indicators in stroke care is essential to obtain certification as a primary stroke center
(PSC). Our aim was to evaluate factors that influence temporal trends in quality
indicators of ischemic stroke (IS) in a Brazilian hospital. Methods: We evaluated
patients discharged with IS from a tertiary hospital from January 2009 to Decem-
ber 2013. Ten predefined performance measures selected by the Get With the
Guidelines-Stroke program were assessed. We also compared 5 quality indica-
tors available from a secondary community hospital for the first year of the series
to those found in the tertiary hospital. Results: We evaluated 551 patients at the
tertiary stroke center (median age 77.0 years [interquartile range 64.0-84.0]; 58.4%
were men). The quality indicators that improved with time were the use of cholesterol-
lowering therapy (P = .02) and stroke education (P = .04). The median composite
perfect care did not consistently improve throughout the period (P = .13). After a
multivariable adjustment, only thrombolytic treatment (odds ratio [OR] 2.06, P < .01),
dyslipidemia (OR 2.03, P < .01), and discharge in a Joint Commission Internatio-
nals (JCI) visit year (OR 1.8, P < .01) remained as predictors of a perfect care index
of 85% or higher. The quality indicators with worse performance (anticoagula-
tion for atrial fibrillation and cholesterol reduction) were similar in the tertiary
and secondary community hospitals. Conclusions: We found a significant im-
provement in some quality indicators across the years in a PSC located in Latin
America. The overall perfect care measure did not improve and was influenced
by being discharged in a JCI visit year, having dyslipidemia, and having under-
gone thrombolytic treatment. Key Words: Strokequality indicatorsstroke
careischemic strokestroke centeroutcomes.
2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

From the *Universidade Federal de So Paulo, So Paulo, Brazil;

and Programa Integrado de Neurologia and Instituto de Ensino e
Several studies have demonstrated that better perfor-
Pesquisa, Hospital Israelita Albert Einstein, So Paulo, Brazil.
Received February 8, 2017; revision received April 16, 2017; accepted
mances are achieved in facilities with implemented quality
May 5, 2017. programs for stroke as well as for other diseases such as
Address correspondence to Monique Bueno Alves, RN, MsC, 50 heart failure and myocardial infarct. The potential con-
Ventura Ladalardo Street, Apt21B, So Paulo, So Paulo 05704-140, sequences of a higher adherence to quality indicators include
Brazil. E-mail:
lower rates of readmission and mortality based on the
1052-3057/$ - see front matter
2017 National Stroke Association. Published by Elsevier Inc. All
practice of evidence-based medicine.1,2 Quality programs,
rights reserved. such as the Get With the Guidelines (GWTG), monitor and encourage adherence to quality indicators. To obtain

Journal of Stroke and Cerebrovascular Diseases, Vol. , No. (), 2017: pp 1

and maintain the certification as a primary stroke center 2) Antithrombotic medication (antiplatelet or anti-
(PSC), for example, the demonstration of an improve- coagulant) prescribed within 48 hours of admission
ment process of quality indicators in stroke care is essential.3 (early antithrombotics)
Therefore, following temporal trends is an important part 3) Deep venous thrombosis (DVT) prophylaxis (war-
of the certification process by which hospitals can eval- farin, heparin, lowmolecular-weight heparin, other
uate and improve their performances. anticoagulants, and pneumatic compression
Factors influencing adherence to performance mea- devices) within 48 hours of admission in
sures for patients with acute stroke or transient ischemic nonambulatory patients at risk of DVT (DVT
attack have been previously evaluated in the American pop- prophylaxis)
ulation. However, such predictors have been scarcely studied 4) Antithrombotic medication (antiplatelet or anti-
outside the United States.4,5 Brazil is a country with cul- coagulant) prescribed at discharge (antithrombotics
tural aspects and health-care practices that could influence at discharge)
predictors of adherence to stroke protocols. Brazil is also 5) Anticoagulation prescribed at discharge in pa-
a country with very limited availability of stroke quality tients with documented atrial fibrillation (AF) or
programs, with only 3 stroke centers certified by the Joint atrial flutter (anticoagulation for AF)
Commission International (JCI) as PSCs and 1 center cer- 6) Lipid-lowering medication prescribed at dis-
tified by the Canadian Stroke Network.4 Knowledge on charge if the low-density lipoprotein (LDL) is
the predictors of adherence to performance measures in higher than 100 mg/dL, if the patient was treated
Brazil could facilitate the implementation of stroke pro- with a lipid-lowering agent before admission, or
tocols worldwide. Our aim was to evaluate factors that if the LDL was not documented (cholesterol
influence temporal trends in indicators of health-care quality reduction)
performance of ischemic stroke (IS) in Brazil using a com- 7) Smoking cessation intervention (counseling or med-
posite measure based on the GWTG program for IS in a ication) at discharge for current or recent smokers
Brazilian tertiary hospital. (smoking cessation)
8) Door-to-computerized tomography (CT) read time
Methods in patients presenting with stroke symptoms within
3 hours or less (door-to-CT time target = 45
We evaluated a database of consecutive patients with minutes)
IS discharged from a private tertiary hospital in So Paulo 9) Door-to-needle time in patients who received IV
from January 2009 to December 2013. The hospital was rtPA (door-to-needle time)
certified by the JCI as a PSC since 2007 and had 625 beds 10) Stroke education provided to a patient or caregiver,
at the time of the present study. We included patients aged including 5 components: explanation of which are
18 years or older with a confirmed diagnosis of IS admitted the modifiable stroke risk factors, stroke warning
by the emergency department. In-hospital strokes, transient signs and symptoms, how to activate emergen-
ischemic attacks, and transferred patients were excluded. cy medical services, need for follow-up, and
Data collected included demographics, stroke risk factors, medications prescribed (stroke education)
National Institutes of Health Stroke Scale (NIHSS) score Eligible patients were those admitted without any
at admission, in-hospital treatment, modified Rankin Scale medical contraindications documented as reasons for
score at discharge, neuroimaging characteristics, and throm- nontreatment for each of the applicable measures. Dis-
bolysis status using a standardized, structured questionnaire. charge and subacute measures excluded patients who
Risk factors were considered if noted on the patients chart died.3,4 All quality indicators not documented in the pa-
or if medications for known risk factors were used before tients chart were scored as not done; therefore, we had
hospital admission or at discharge.6 As part of our hospital no missing data. Data for IV rtPA of 3 hours or less, early
stroke program, all patients admitted with a diagnosis of antithrombotics, DVT prophylaxis, antithrombotics at dis-
IS were identified and followed up daily by a case manager charge, anticoagulation therapy at discharge in patients
nurse who prospectively evaluated medical records. IS was with documented AF or atrial flutter, lipid-lowering med-
defined as an episode of neurological dysfunction caused ication prescribed at discharge if the LDL was higher than
by focal cerebral infarction confirmed by neuroimaging.7 100 mg/dL, and door-to-needle time in patients who re-
Ten predefined performance measures selected by the ceived IV rtPA were extracted from an electronic medical
GWTG stroke program as targets for stroke quality im- prescription system. Door-to-CT times were extracted di-
provement were evaluated8-10: rectly from the electronic medical record and the CT
1) Intravenous (IV) recombinant tissue plasmino- scanner report. When stroke education and smoking ces-
gen activator (rtPA) in patients who arrive 2 hours sation interventions were not documented at the patients
or less after symptom onset and who were treated chart, the performance indicators were scored as not per-
within 3 hours of symptom onset (IV rtPA 3 formed. The percentage of adherence to these measures
hours) was obtained for each individual patient through an
adherenceeligibility index calculated by the ratio between with achieving a perfect care index greater than 85% in
eligible measures and compliance to them in every patient. the univariate analysis with a P value greater than .10
Of note, until 2012, the recommended time window for were included in the logistic regression. A 2-tailed P value
IV thrombolysis in Brazil was 3 hours, but besides that of .05 was considered statistically significant. Statistical
fact, the private hospital adopted the 4.5-hour therapeu- analysis was performed with SPSS 16.0 software (SPSS
tic window since 2010 based on the updated statement Inc., Chicago, IL).
from the American Stroke Association supported by the
European Cooperative Acute Stroke Study (ECASS III)
The quality indicators early antithrombotics, antico- In the study period, 1417 patients were admitted to
agulation for AF, DVT prophylaxis, cholesterol reduction, our stroke center. A total of 25.6% patients had had a
and antithrombotics at discharge from the first year of transient ischemic attack, and 16.0% had hemorrhagic
the series were compared to the quality indicators col- strokes, including nontraumatic subarachnoid hemor-
lected at a secondary community public hospital located rhages, and were therefore excluded from the present study
in So Paulo using the same methodology. The hospi- (Fig 1). We also excluded from the analyses 276 pa-
tals institutional review board approved the present study. tients with IS: 66.2% were transferred-in or transferred-
out patients, 32.6% had in-hospital strokes, and 1.0% were
younger than 18 years old. The final analysis sample con-
Statistical Analysis
sisted of 551 consecutive patients with IS admitted to our
Means and standard deviations or medians and hospital. The median age was 77.0 years (interquartile
interquartile ranges were used to describe the patients range 64.0-84.0]), and 58.4% were men. The median time
characteristics. The appropriateness of nonparametric testing from symptom onset to hospital admission was 345.0
was tested after checking the normality diagnostics minutes (104.5-1417.5). Demographics and clinical char-
(KolmogorovSmirnov tests and histograms). One-way acteristics presented at admission are shown in Table 1.
analysis of variance and KruskalWallis tests were used Good outcome at discharge, defined as an modified
for comparison of continuous parametric and nonpara- Rankin Scale score of 3 or lower, was present in 67.6%
metric variables, respectively, among the different time of the patients. The median length of stay was 8.0 days
periods. Categorical variables were compared with the (4.0-14.0). A total of 42.5% of the patients were discharged
chi-square and chi-square trend tests. The composite perfect in a JCI visit year (2010 and 2013), and 7.9% of the patients
care was calculated, giving 10 points for each measure died (Table 1). Table 1 compares the stroke risk factors
achieved divided by the total of eligible measures mul- according to the year of discharge. Hypertension was the
tiplied by 10 (0 was the lowest score and 100 was the most common risk factor (60.3%) followed by diabetes
highest score). Multiple logistic regression was used to (31.2%) and dyslipidemia (30.1%). The only significant
investigate the influence of epidemiological and clinical difference in risk factors among years was having a pre-
data upon the perfect care index dichotomized in 85% vious stroke or TIA, more frequent in patients discharged
of the adherence (the GWTG program recognizes hos- in 2010 (39.0% of the patients, P = .02).
pitals with awards if they follow treatment guidelines in A total of 80 patients were treated with recanalization
key measures greater than 85% during the measure- therapies (17.1%). The most frequently used technique in
ment period). All variables that showed an association 57.5% of the patients was IV rtPA. Intra-arterial therapy

Figure 1. Flowchart of included patients. Abbre-

viations: ICH, intracerebral hemorrhage; SAH,
subarachnoid hemorrhage; TIA, transient isch-
emic attack.
Table 1. Clinical and demographic characteristics according to the year of discharge

2009 2010 2011 2012 2013 All

Variable (n = 83) (n = 105) (n = 115) (n = 119) (n = 128) (n = 551) P Value

Age 77.0 (64.0-83.0) 77.0 (66.0-84.50) 75.0 (63.0-82.0) 78.0 (63.0-84.0) 80.0 (62.0-87.0) 77.0 (64.0-84.0) .600
Gender (male) (%) 57.8 61.9 57.4 54.6 60.5 58.4 .824
Median time from symptom onset 530.0 (87.0-1500.0) 420.0 (85.0-1301.0) 205.0 (102.0-655.0) 390.0 (110.0-1440.0) 465.0 (115.5-1440.0) 345.0 (104.5-1417.5) .137
to hospital admission (min)
Mean NIHSS score at admission 16.8 6.2 15.5 7.1 13.3 7.7 12.4 7.0 14.3 8.5 14.2 7.5 .242
Hypertension (%) 51.8 65.7 66.1 53.8 62.0 60.3 .105
Dyslipidemia (%) 27.7 27.6 27.8 31.1 34.9 30.1 .686
Diabetes (%) 31.3 33.3 27.8 26.9 36.4 31.2 .477
Smoking (%) 20.5 11.4 16.5 10.9 9.3 13.2 .113
Alcohol abuse (%) 10.8 5.7 1.7 .2 1.6 4.0 .004
CAD (%) 10.8 12.4 9.6 21.8 14.7 14.2 .065
Atrial fibrillation (%) 22.9 13.3 13.0 16.8 15.6 16.0 .350
Previous stroke or TIA (%) 25.3 39.0 21.7 28.6 22.5 27.2 .028
Length of stay (d) 7.0 (3.0-13.0) 9.0 (5.0-15.0) 7.0 (3.0-14.0) 8.0 (5.0-14.0) 7.0 (4.0-15.5) 8.0 (4.0-14.0) .376
In-hospital mortality (%) 6.0 10.4 13.0 3.3 9.3 8.5 <.001

Abbreviations: CAD, coronary artery disease; NIHSS, National Institutes of Health Stroke Scale; TIA, transient ischemic attack.


Table 2. Recanalization therapies according to the year of discharge

2009 2010 2011 2012 2013 All P

Treatment with reperfusion therapy (%) 12.0 16.2 17.4 13.4 13.5 17.1 .806
IV rtPA (%) 70.0 64.7 65.0 43.8 47.1 57.5 .513
IA therapy (%) 10.0 29.4 35.0 50.0 29.4 33.8
Combined therapy (%) 20.0 5.9 .0 6.3 23.5 8.8

Abbreviations: IA, intra-arterial; IV, intravenous; rtPA, recombinant tissue plasminogen activator.
Combined therapy includes an IV therapy followed by an IA procedure.

Table 3. Adherence to Performance Measures according to the year of discharge

Patterns of care 2009 2010 2011 2012 2013 All P

IV rtPA (3 h) (%) 85.7 100.0 77.8 100.0 91.7 91.3 .397

Early antithrombotics (%) 98.7 100.0 99.1 99.1 100.0 99.4 .673
DVT prophylaxis (%) 100.0 100.0 100.0 100.0 100.0 100.0 ns
Antithrombotics at discharge (%) 90.0 100.0 100.0 95.5 99.1 97.4 <.001
Anticoagulation for AF (%) 66.7 84.6 80.0 73.7 62.5 72.6 .678
Cholesterol reduction* (%) 69.2 78.7 69.0 70.4 88.0 75.6 .003
Smoking cessation (%) 71.4 100.0 70.0 92.3 100.0 84.0 .021
Door-to-CT time (45 min) (%) 89.7 70.7 67.3 67.5 66.7 71.1 .210
Mean door-to-CT (min) 33.3 22.9 45.8 37.8 47.8 41.2 41.6 38.2 45.2 23.4 43.6 34.7 .450
Door-to-needle time (60 min) 33.3 75.0 61.5 50.0 66.7 58.5 .226
Mean door-to-needle time (min) 82.5 28.4 49.0 20.0 59.3 26.1 64.6 28.59 65.3 30.8 62.6 27.8 .118
Stroke education* (%) 73.1 85.1 78.0 74.8 90.6 80.8 .006
Perfect care (%) 83.0 18.9 90.7 11.7 85.6 17.4 85.8 17.7 92.6 11.4 87.8 15.8 <.001

Abbreviations: AF, atrial fibrillation; CT, computerized tomography; DVT, deep vein thrombosis; IV, intravenous; ns, not significant; rtPA,
recombinant tissue plasminogen activator.
*P < .05 in the chi-square trend test.

was performed in 33.8%, and combined therapy was 2.03, CI 1.36-3.02, P < .01), and discharge in a JCI year of
performed in 8.8% of the patients (Table 2). There was visit (OR 1.8, CI 1.29-2.65, P < .01) remained in the model
no difference among years in the following measures: IV as predictors of higher perfect care index (Table 4).
rtPA (3 hours), DVT prophylaxis, antithrombotics in the The quality indicator DVT prophylaxis was significantly
first 24 hours of admission, anticoagulation therapy for better at the tertiary hospital when compared with the
AF, door-to-CT read time, and door-to-needle time. Table 3
shows the performance measures according to the discharge
year. Table 4. Factors associated with compliance to the adherence
The quality indicators that improved along the years index on a multivariate logistic regression model
were cholesterol-lowering therapy (range 69.2%-88.0%,
P = .02) and stroke education (range 73.1%-90.6%, P = .04) 95 % CI
for exp (B)
(Table 3). The median composite perfect care was different
(range 83.0 18.9 to 92.6 11.4, P < .001) but did not con- Exp Lower Upper
sistently improve along the years (P = .13 in the chi-square Variable Sig. (B) CI CI
trend test). The highest scores were obtained in 2010 and
2013 (Table 3). Age .297 1.006 .995 1.017
In the univariate analysis, being discharged in a JCI Female sex .049 .703 .495 .999
visit year (odds ratio [OR] 1.84, confidence interval [CI] Thrombolytic treatment <0.01 2.06 1.21 3.51
Discharged in a joint <0.01 1.834 1.285 2.617
1.29-2.61, P < .01), female gender (OR .68, CI .48-.96, P = .03),
commissions year
dyslipidemia (OR 1.95, CI 1.33-2.88, P < .01), and undergoing
Dyslipidemia <0.01 2.03 1.36 3.02
thrombolytic treatment (OR 1.81, CI 1.08-3.02, P = .02) were Length of stay .996 1.000 .896 1.004
found to be associated with a perfect care index of 85% or Constant .514 .753
higher. After the multivariable adjustment, only thrombolytic
treatment (OR 2.06, CI 1.21-3.51, P < .01), dyslipidemia (OR Abbreviations: CI, confidence interval; sig., significance.

Figure 2. Comparison of 5 quality indicators

between a tertiary private hospital and a public sec-
ondary community hospital for the year of 2009.
The dashed line indicates the 85% goal suggested
by the Get With the Guidelines-Stroke program. Ab-
breviations: AF, atrial fibrillation; DVT, deep venous

community hospital (100% versus 84.6%, P < .01). Con- predictor of a higher adherenceeligibility index. Physi-
versely, antithrombotics at discharge were more frequently cians might be more concerned with patients who could
prescribed at the community hospital (100% versus 90%, achieve more favorable functional outcomes and there-
P < .01). The quality indicators with worse performance (an- fore could be more compliant with treatment measures.
ticoagulation for AF and cholesterol reduction) were similar Finally, the finding of a higher perfect care index in the
in the tertiary and secondary community hospitals (Fig 2). years of JCI visits points out to the importance of a more
continuous evaluation of the quality indicators by the ac-
creditation process using methods like unannounced surveys
or periodic data reports. Audit and feedback, as used in
We found a significant improvement across the years the JCI evaluation process, is a common approach to
in 2 quality indicators (cholesterol reduction and stroke promote the implementation of evidence-based practices.
education) in a PSC located in Brazil. The overall perfect Overall, one quarter of the audit and feedback interven-
care measure did not consistently improve over time and tions have a large positive effect on quality of care. The
was influenced by being discharged in a JCI visit year, identification of factors that distinguish more and less suc-
having dyslipidemia, and undergoing thrombolytic treat- cessful interventions, including the frequency of visits and
ment. The GWTG-Stroke program has improved the quality the adaptation of the quality evaluation process to each
of stroke care in U.S. academic and community hospi- country reality, constitutes a real challenge.15,16
tals, with important implications for the entire country. Our higher adherence mean rates were for IV rtPA use,
The generalizability of GWTG-Stroke across distinct na- early antithrombotics, DVT prophylaxis, and antithrombotics
tional and economic realities remains unanswered.8,10 at discharge across the years. Smoking cessation counsel-
Our hospital was the first institution outside the United ing, anticoagulation at discharge for patients with AF, and
States to be accredited by the JCI in 1999, when the in- cholesterol reduction had lower rates above the target of
ternational program was launched. In June 2007, Albert 85%. Interestingly, in a GWTG cohort, these 3 measures
Einstein Hospital became the first institution in Latin also had the lowest compliance and major improvement
America and one of only three worldwide to have a PSP across the period of 4 years evaluated.8
certified by JCI.4 Therefore, it is expected that the find- In the United States, being treated in a PSC increases
ings from our study likely reflect better performance in the chance of undergoing IV thrombolysis.17,18 The rates
acute stroke treatment than the overall national perfor- of thrombolysis treatment in Brazilian studies vary from
mance data.12 Actually, data evaluating quality of care 1.1% to 11.2%.4,14,19,20 A study in Massachusetts concluded
indicators in Brazilian stroke centers are largely unavail- that the PSC designation program improved the throm-
able. A previous study assessed the quality of hospital bolysis rates in early admissions.21 Our overall rate of use
care for acute IS in the Brazilian Unified National Health of reperfusion therapies was 17.1%.
System, but none of the quality indicators suggested by Early admissions were not related to higher perfect care
the GWTG stroke program were reported. Another study scores, and their frequencies did not change across the study
evaluating patients at the northeast region of the country period. At least 25% of our patients arrived in a therapeutic
reported a mean door-to-CT time of 75.6 minutes, but time window for IV rtPA. The finding of a stable propor-
data on other quality indicators were also not available.13,14 tion of patients arriving in a therapeutic time window was
In our series, the presence of certain risk factors might also reported in a previous international study from the
have triggered the clinician to be more attentive to the treat- GWTG Stroke Program.22 Albert Einstein Hospital is a
ment measures, it could be observed in patients with private institution in So Paulo, a city with 11.3 million
dyslipidemia with better perfect care. Likely for similar inhabitants. Around 1.5 million people have potential access
reasons, thrombolysis treatment was also an independent to our hospital. It is possible that the high socioeconomic
and educational levels of the patients who have access to to guidelines-based care and should result in a signifi-
Albert Einstein explain at least in part the high frequen- cant improvement in patient outcomes.10,12,26 Quality
cy of early arrivals observed in our series. programs facilitate the implementation of improvement
We found an interesting difference in in-hospital mor- efforts, certainly influencing the time-dependent process
tality between the 5 years (ranging from 3.3% in 2012 such as neuroimaging, laboratory analysis, and in-
to 13% in 2011). The overall mortality rate for the 5 years hospital transportation, and could possibly decrease time-
was 8.5%, which was similar to other national and in- dependent measures.12
ternational stroke series. We could not find a good reason The present study has several limitations. First, we report
to explain such differences, except for the slightly low data from a single center, with predominantly white pa-
NIHSS scores in 2012. It is possible that differences in tients and no concurrent controls; therefore, our findings
stroke mortality could be attributable to some unmea- might not be generalizable to all Brazilian stroke centers.
sured factors such as previous modified stroke scale Despite this limitation, our comparison with the quality
differences and clinical complications such as pneumonia. indicators available for the first year of the study from a
Brazil is a country of great social inequalities; there- secondary public community hospital suggests that there
fore, it is not simple to apply international data to our are similarities between the public and the private systems,
reality. Fortunately in the last decade, Brazil had a great and that indeed the poor performances on some specific
evolution in stroke care. From 2008 to 2012, the number quality indicators might reflect cultural aspects of adher-
of stroke centers increased from 35 to 82. In 2012, the ence to protocols that might indeed be generalizable for
Brazilian national stroke policy was published.23 The policy the whole country. Second, data were prospectively col-
includes definitions for stroke centers by level, reim- lected in a period when the certification was already
bursement values, telemedicine, rehabilitation and training achieved; therefore, trends in improvement could not be
funding, population awareness, and establishment of a observed in all quality measures as in 2009 several actions
stroke care program integrating available resources from have already been implemented. Moreover, our final sample
other health programs. A National Stroke Registry was size was relatively small and probably not sufficiently
initiated linked to the Ministry of Health to improve quality, powered to detect what could still be considered a clin-
and hospitals were invited to participate. Data from this ically meaningful change over time, particularly for indicators
registry are not yet published.24 In 2015, the Brazilian with low eligibility numbers. However, at least for the perfect
Academy of Neurology launched an important survey care score, our main outcome measure, we had a power
evaluating the medical perception of stroke treatment in of 98% to detect an annual change of 5%. Finally, data from
the country. In a structured questionnaire, several dif- patients with TIA were excluded from the present anal-
ferences from the public and private services were ysis mostly because benchmarks from the literature regarding
highlighted, with a focus on triage, infrastructure, and quality indicators in the care for such patients are largely
human resources. The survey is still ongoing and its results lacking. This finding could be explained by the fact that
will be of utmost importance for understanding stroke TIA patients have a shorter length of stay at hospitals or
gaps in the country.25 can be treated in outpatient clinics, such as TIA clinics.
In the United States, a study comparing PSC with non- In conclusion, the predictors of adherence to stroke care
PSCs found that all quality measures in stroke care were protocols in a Brazilian hospital appear to be similar to
significantly higher in certified centers.12 In our series, in those described in international series, and some quality
the first year reported (2009), we had already estab- indicators tend to improve over the years when moni-
lished the improvement plan needed for the certification; tored through a quality control program. If the existence
therefore, we do not have a real-life baseline performance of such protocols has proven important, their implemen-
to compare to evaluate the real progress of our program. tation across the country would be of utmost importance.
Although there are several cultural differences between Whether our results could be further reproduced by the
Brazil and the United States, having a PSC certification design of a national stroke quality improvement program
seems to be important in quality indicators in stroke care addressing the specific national challenges for Brazil
improvement. However, certification or award recognition remains to be evaluated.
programs alone may be insufficient to improve quality. They
should be accompanied by critical analysis, accountabili-
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