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  • Measure Summary
  • NQMC:008010
  • Jul 2012

Diagnosis and treatment of ischemic stroke: percentage of tPA non-recipients who have hypertension appropriately managed in the first 48 hours of hospitalization or until neurologically stable.

Anderson D, Larson D, Bluhm J, Charipar R, Fiscus L, Hanson M, Larson J, Rabinstein A, Wallace G, Zinkel A. Diagnosis and initial treatment of ischemic stroke. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jul. 122 p. [238 references]

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of tissue plasminogen activator (tPA) non-recipients, age 18 years and older, initially presenting with acute symptoms of ischemic stroke who have hypertension appropriately managed in the first 48 hours of hospitalization or until neurologically stable.

Rationale

The priority aim addressed by this measure is to increase the percentage of tissue plasminogen activator (tPA) non-recipients who have hypertension appropriately managed in the first 48 hours of hospitalization or until neurologically stable.

Stroke is the fourth leading cause of death, recently dropping from third after decades long efforts to reduce incidence by treatment of risk factors. It remains the leading cause of disability among adults. Costs of hospitalizations, other cares and lost wages are simply enormous.

Treatment of extreme hypertension in patients in the acute stroke phase is widely accepted based on consensus guidelines showing poor outcomes at the far end of the hypertension spectrum (e.g., systolic >220 mmHg, diastolic >120 mmHg or mean arterial blood pressure [BP] >130 mmHg). There is no definitive information available yet on the effect of altering BP on outcome during the acute stroke phase. Until there is more information available, a recommendation to treat the extreme and monitor and treat where necessary in the less extreme is warranted.

There are rational but also theoretic arguments for reducing elevated BP in the setting of acute ischemic stroke. Lowering the pressure may reduce edema, blood-brain barrier disruption, and conversion to hemorrhagic infarction. Beginning treatment in the acute setting would be a head start in an important pillar of secondary prevention.

Observational studies and reviews not examining deliberate interventions have suggested a U-shaped relationship between BP and various outcomes with poorer outcomes at very low and very high blood pressures and best outcomes around systolic BP 150 mmHg, providing grounds for the current consensus-based guidelines to treat BP if it falls outside of arbitrarily derived thresholds established according to thrombolysis status (see Table 3, "Approach to Elevated Blood Pressure in Acute Ischemic Stroke," in the original measure document). To be anticipated is more research to gather evidence about what the thresholds should actually be.

Evidence for Rationale

Adams HP Jr, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EFM, American Heart Association, American Stroke Association Stroke Council, Clinical Cardiology Council. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology [trunc]. Stroke. 2007 May;38(5):1655-711. [738 references] PubMed External Web Site Policy

Ahmed N, Wahlgren N, Brainin M, Castillo J, Ford GA, Kaste M, Lees KR, Toni D, SITS Investigators. Relationship of blood pressure, antihypertensive therapy, and outcome in ischemic stroke treated with intravenous thrombolysis: retrospective analysis from Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register . Stroke. 2009 Jul;40(7):2442-9. PubMed External Web Site Policy

Anderson D, Larson D, Bluhm J, Charipar R, Fiscus L, Hanson M, Larson J, Rabinstein A, Wallace G, Zinkel A. Diagnosis and initial treatment of ischemic stroke. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jul. 122 p. [238 references]

Castillo J, Leira R, Garcia MM, Serena J, Blanco M, Davalos A. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke. 2004 Feb;35(2):520-6. PubMed External Web Site Policy

Leonardi-Bee J, Bath PM, Phillips SJ, Sandercock PA, IST Collaborative Group. Blood pressure and clinical outcomes in the International Stroke Trial. Stroke. 2002 May;33(5):1315-20. PubMed External Web Site Policy

Willmot M, Leonardi-Bee J, Bath PM. High blood pressure in acute stroke and subsequent outcome: a systematic review. Hypertension. 2004 Jan;43(1):18-24. [57 references] PubMed External Web Site Policy

Primary Health Components

Ischemic stroke; hypertension

Denominator Description

Number of patients presenting with acute symptoms of ischemic stroke who are non-tissue plasminogen activator (tPA) recipients (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of patients who have hypertension managed in the first 48 hours of hospitalization or until neurologically stable (see the related "Numerator Inclusions/Exclusions" field)

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Emergency Department

Hospital Inpatient

Professionals Involved in Delivery of Health Services

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

IOM Domain

Effectiveness

Timeliness

Case Finding Period

The time frame pertaining to data collection is monthly.

Denominator Sampling Frame

Patients associated with provider

Denominator (Index) Event or Characteristic

Clinical Condition

Encounter

Patient/Individual (Consumer) Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of patients presenting with acute symptoms of ischemic stroke who are non-tissue plasminogen activator (tPA) recipients

Population Definition: Patients age 18 years and older.

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of patients who have hypertension managed in the first 48 hours of hospitalization or until neurologically stable

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Paper medical record

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Original Title

Percentage of tPA non-recipients who have hypertension appropriately managed in the first 48 hours of hospitalization or until neurologically stable.

Measure Collection Name

Diagnosis and Treatment of Ischemic Stroke

Submitter

Institute for Clinical Systems Improvement - Nonprofit Organization

Developer

Institute for Clinical Systems Improvement - Nonprofit Organization

Funding Source(s)

The Institute for Clinical Systems Improvement's (ICSI's) work is funded by the annual dues of the member medical groups and five sponsoring health plans in Minnesota and Wisconsin.

Composition of the Group that Developed the Measure

Work Group Members: David Anderson, MD (Work Group Co-Leader) (University of Minnesota Physicians and Hennepin County Medical Center) (Neurology); David Larson, MD, FACEP (Work Group Co-Leader) (Ridgeview Medical Center) (Emergency Medicine); Gail Wallace, NP (Essentia Health) (Nursing); Lynne Fiscus, MD, MPH (Fairview Health Services) (Internal Medicine and Pediatrics); Andrew Zinkel, MD (HealthPartners Medical Group and Regions Hospital) (Emergency Medicine); Ron Charipar, MD (Marshfield Clinic) (Internal Medicine and Pediatrics); Alejandro Rabinstein, MD (Mayo Clinic) (Neurology); Jeff Larson, PharmD (Park Nicollet Health Services) (Pharmacy); Myounghee Hanson, BA (Institute for Clinical Systems Improvement) (Clinical Systems Improvement Facilitator); Jim Bluhm, MPH (Institute for Clinical Systems Improvement) (Team Director)

Financial Disclosures/Other Potential Conflicts of Interest

David Anderson, MD (Work Group Leader)
Professor, Neurology Department, Neurology, University of Minnesota Physicians and Hennepin County Medical Center
National, Regional, Local Committee Affiliations: NNINDS NHLBI as an event adjudicator for two clinical trials: SAMMPRIS (Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke), and AIM-HIGH (Atherothrombosis Intervention in Metabolic Syndrome with Low HDL Cholesterol/High Triglyceride and Impact on Global Health Outcomes)
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: MN Acute Stroke Systems Council, MDH and member of MN Time Critical Care Committee, MDH

Ron Charipar, MD (Work Group Member)
Professor, Internal Medicine, Marshfield Clinic
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Lynne Fiscus, MD, MPH (Work Group Member)
Internal Medicine and Pediatrics, Department, Fairview Health Services
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

David Larson, MD, FACEP (Work Group Member)
Medical Director, Ridgeview Emergency Department, Ridgeview Medical Center
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Clinical Advisory Panel Leader, TogetherMD, LLC, MN Acute Stroke Systems Council, MDH and member of MN Time Critical Care Committee, MDH

Jeff Larson, PharmD (Work Group Member)
Staff Pharmacist, Pharmacy, Park Nicollet Health Services
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Alejandro Rabinstein, MD (Work Group Member)
Professor, Neurology, Mayo Clinic
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: Cardionet, MCOT use for an investigator-initiated project
Financial/Non-Financial Conflicts of Interest: Member of the Data Safety Monitoring Board for the PREVAIL study by ARTITECH (now Boston Scientific)

Gail Wallace, NP (Work Group Member)
Neurology Nurse Practitioner, Nursing, Essentia Health East Region
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: None

Andrew Zinkel, MD (Work Group Member)
Section Head and Medical Director of Quality, Department of Emergency Medicine, HealthPartners Medical Group and Regions Hospital
National, Regional, Local Committee Affiliations: None
Guideline-Related Activities: None
Research Grants: None
Financial/Non-Financial Conflicts of Interest: Clinical Advisory Panel Leader, TogetherMD, LLC

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2012 Jul

Measure Maintenance

Scientific documents are revised every 12 to 24 months as indicated by changes in clinical practice and literature.

Date of Next Anticipated Revision

The next scheduled revision will occur within 24 months.

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in January 2016.

Source(s)

Anderson D, Larson D, Bluhm J, Charipar R, Fiscus L, Hanson M, Larson J, Rabinstein A, Wallace G, Zinkel A. Diagnosis and initial treatment of ischemic stroke. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jul. 122 p. [238 references]

Measure Availability

Source available from the Institute for Clinical Systems Improvement (ICSI) Web site External Web Site Policy.

For more information, contact ICSI at 8009 34th Avenue South, Suite 1200, Bloomington, MN 55425; Phone: 952-814-7060; Fax: 952-858-9675; Web site: www.icsi.org External Web Site Policy; E-mail: icsi.info@icsi.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on November 14, 2012.

The information was reaffirmed by the measure developer on January 13, 2016.

Copyright Statement

This NQMC summary (abstracted Institute for Clinical Systems Improvement [ICSI] Measure) is based on the original measure, which is subject to the measure developer's copyright restrictions.

The abstracted ICSI Measures contained in this Web site may be downloaded by any individual or organization. If the abstracted ICSI Measures are downloaded by an individual, the individual may not distribute copies to third parties.

If the abstracted ICSI Measures are downloaded by an organization, copies may be distributed to the organization's employees but may not be distributed outside of the organization without the prior written consent of the Institute for Clinical Systems Improvement, Inc.

All other copyright rights in the abstracted ICSI Measures are reserved by the Institute for Clinical Systems Improvement, Inc. The Institute for Clinical Systems Improvement, Inc. assumes no liability for any adaptations or revisions or modifications made to the abstracts of the ICSI Measures.

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