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Impact of Increased Early Statin Administration on Ischemic Stroke Outcomes: A Multicenter Electronic Medical Record Intervention

View Article: PubMed Central - PubMed

ABSTRACT

Background: Statin administration early in ischemic stroke may influence outcomes. Our aim was to determine the clinical impact of increasing statin administration early in ischemic stroke hospitalization.

Methods and results: This is a retrospective analysis of a multicenter electronic medical record (EMR) intervention to increase early statin administration in ischemic stroke across all 20 hospitals of an integrated healthcare delivery system. A stroke EMR order set was modified from an “opt‐in” to “opt‐out” mode of statin ordering. Outcomes were mortality by 90 days, discharge disposition, and increase in stroke severity. We examined the relationship between intervention and outcome using autoregressive integrated moving average (ARIMA) time‐series modeling. The EMR intervention increased both overall in‐hospital statin administration (from 87.2% to 90.7%, P<0.001) and early statin administration (from 16.9% to 26.3%, P<0.001). ARIMA models showed a small increase in the rate of survival (difference in probability [Pdiff]=0.02, P=0.016) and discharge to home or rehabilitation facility (Pdiff=0.04, P=0.034) associated with the intervention. The increase in statin administration <8 hours was associated with much larger increases in survival (Pdiff=0.17, P=0.033) and rate of discharge to home or rehabilitation (Pdiff=0.29, P=0.011), as well as a decreased rate of neurological deterioration in‐hospital (Pdiff=−0.14, P=0.026).

Conclusions: A simple EMR change increased early statin administration in ischemic stroke and was associated with improved clinical outcomes. This is, to our knowledge, the first EMR intervention study to show that a modification of an electronic order set resulted in improved clinical outcomes.

No MeSH data available.


Related in: MedlinePlus

Time in hours to first statin administration and clinical outcomes. For all 3 panels, multivariable model‐derived estimates of clinical outcomes are plotted (solid lines with flanking dashed lines representing 95% CI for the estimates) corresponding to time in hours to administration of first statin dose. Underlying multivariable logistic regression models control for age, mNIHSS, Charlson comorbidity index, and presence of dysphagia. A, Model‐estimated percentage of patients alive at 90 days poststroke as a function of time to first statin dose in hours. B, Model‐estimated percentage of patients discharged to home or inpatient rehabilitation facility after any duration of hospitalization as a function of time to first statin dose in hours. C, Model‐estimated percentage of patients with in‐hospital neurological deterioration (defined as an increase in mNIHSS by 4 or more points) as a function of time to first statin dose in hours. mNIHSS, modified National Institutes of Health Stroke Scale.
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jah31614-fig-0003: Time in hours to first statin administration and clinical outcomes. For all 3 panels, multivariable model‐derived estimates of clinical outcomes are plotted (solid lines with flanking dashed lines representing 95% CI for the estimates) corresponding to time in hours to administration of first statin dose. Underlying multivariable logistic regression models control for age, mNIHSS, Charlson comorbidity index, and presence of dysphagia. A, Model‐estimated percentage of patients alive at 90 days poststroke as a function of time to first statin dose in hours. B, Model‐estimated percentage of patients discharged to home or inpatient rehabilitation facility after any duration of hospitalization as a function of time to first statin dose in hours. C, Model‐estimated percentage of patients with in‐hospital neurological deterioration (defined as an increase in mNIHSS by 4 or more points) as a function of time to first statin dose in hours. mNIHSS, modified National Institutes of Health Stroke Scale.

Mentions: Given that early statin administration was increased by the order set intervention and was strongly associated with improved clinical outcomes, one might expect that the hourly timing of statin administration, treated as a continuous predictor, would be associated with clinical outcomes. In logistic regression models of each of our 3 clinical outcomes, shorter time to first statin dose strongly predicted better outcomes, after controlling for age, stroke severity, tissue plasminogen activator administration, comorbidities, and dysphagia (Tables 2 and 3). Figure 3 graphically displays the relationship between hours to first statin dose administered and outcomes as estimated from multivariable models.


Impact of Increased Early Statin Administration on Ischemic Stroke Outcomes: A Multicenter Electronic Medical Record Intervention
Time in hours to first statin administration and clinical outcomes. For all 3 panels, multivariable model‐derived estimates of clinical outcomes are plotted (solid lines with flanking dashed lines representing 95% CI for the estimates) corresponding to time in hours to administration of first statin dose. Underlying multivariable logistic regression models control for age, mNIHSS, Charlson comorbidity index, and presence of dysphagia. A, Model‐estimated percentage of patients alive at 90 days poststroke as a function of time to first statin dose in hours. B, Model‐estimated percentage of patients discharged to home or inpatient rehabilitation facility after any duration of hospitalization as a function of time to first statin dose in hours. C, Model‐estimated percentage of patients with in‐hospital neurological deterioration (defined as an increase in mNIHSS by 4 or more points) as a function of time to first statin dose in hours. mNIHSS, modified National Institutes of Health Stroke Scale.
© Copyright Policy - creativeCommonsBy-nc-nd
Related In: Results  -  Collection

License
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getmorefigures.php?uid=PMC5015276&req=5

jah31614-fig-0003: Time in hours to first statin administration and clinical outcomes. For all 3 panels, multivariable model‐derived estimates of clinical outcomes are plotted (solid lines with flanking dashed lines representing 95% CI for the estimates) corresponding to time in hours to administration of first statin dose. Underlying multivariable logistic regression models control for age, mNIHSS, Charlson comorbidity index, and presence of dysphagia. A, Model‐estimated percentage of patients alive at 90 days poststroke as a function of time to first statin dose in hours. B, Model‐estimated percentage of patients discharged to home or inpatient rehabilitation facility after any duration of hospitalization as a function of time to first statin dose in hours. C, Model‐estimated percentage of patients with in‐hospital neurological deterioration (defined as an increase in mNIHSS by 4 or more points) as a function of time to first statin dose in hours. mNIHSS, modified National Institutes of Health Stroke Scale.
Mentions: Given that early statin administration was increased by the order set intervention and was strongly associated with improved clinical outcomes, one might expect that the hourly timing of statin administration, treated as a continuous predictor, would be associated with clinical outcomes. In logistic regression models of each of our 3 clinical outcomes, shorter time to first statin dose strongly predicted better outcomes, after controlling for age, stroke severity, tissue plasminogen activator administration, comorbidities, and dysphagia (Tables 2 and 3). Figure 3 graphically displays the relationship between hours to first statin dose administered and outcomes as estimated from multivariable models.

View Article: PubMed Central - PubMed

ABSTRACT

Background: Statin administration early in ischemic stroke may influence outcomes. Our aim was to determine the clinical impact of increasing statin administration early in ischemic stroke hospitalization.

Methods and results: This is a retrospective analysis of a multicenter electronic medical record (EMR) intervention to increase early statin administration in ischemic stroke across all 20 hospitals of an integrated healthcare delivery system. A stroke EMR order set was modified from an “opt‐in” to “opt‐out” mode of statin ordering. Outcomes were mortality by 90 days, discharge disposition, and increase in stroke severity. We examined the relationship between intervention and outcome using autoregressive integrated moving average (ARIMA) time‐series modeling. The EMR intervention increased both overall in‐hospital statin administration (from 87.2% to 90.7%, P<0.001) and early statin administration (from 16.9% to 26.3%, P<0.001). ARIMA models showed a small increase in the rate of survival (difference in probability [Pdiff]=0.02, P=0.016) and discharge to home or rehabilitation facility (Pdiff=0.04, P=0.034) associated with the intervention. The increase in statin administration <8 hours was associated with much larger increases in survival (Pdiff=0.17, P=0.033) and rate of discharge to home or rehabilitation (Pdiff=0.29, P=0.011), as well as a decreased rate of neurological deterioration in‐hospital (Pdiff=−0.14, P=0.026).

Conclusions: A simple EMR change increased early statin administration in ischemic stroke and was associated with improved clinical outcomes. This is, to our knowledge, the first EMR intervention study to show that a modification of an electronic order set resulted in improved clinical outcomes.

No MeSH data available.


Related in: MedlinePlus