Protected: Qi02 – Stroke or TIA

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Operationalisation

Denominator

All patients who survived a hospitalisation for ischemic stroke (ICD-10 I63 or I64) or transient ischemic attack (TIA) (ICD-10 G45)

Numerator

All defined in the denominator who were dispensed the following at least once within 6 months of the end of the hospital-level care episode:

  • blood pressure lowering medication = diuretics, beta blockers, calcium channel blockers, or agents acting on the renin-angiotensin system ATC C03, C07, C08, C09, or C10BX03/04/06/07/09-21
  • lipid lowering medications = statins ATC C10AA or C10BA except C10BA10, or C10BX, or combination products including a statin component A10BH5*, or PCSK9-inhibitors alirocumab C10AX14, evolocumab C10AX13, inclisiran C10AX16

Exclusions (Numerator, denominator)

Patients aged below 18 at the end of the year of hospital discharge.
Patients who die or emigrate within 6 months (180 days) of the discharge.

Notes

If a patient has had multiple qualifying events during the year, the first one is included.

Sources of Data

  • Population register
  • Secondary care patient registers
  • Outpatient medication dispensations register

Information about the indicator set

Purpose

  • The quality indicator set is intended for comparison of effectiveness and/or safety aspects of prescribing across Nordic countries and subnational regions.
  • Further comparisons across population subgroups (e.g., socioeconomic position, immigration background) can inform equity considerations.
  • Further comparisons in relation to expenditures can inform efficiency considerations

Limitations

  • The indicators in the set use medication dispensings and/or sales data as a proxy for appropriate prescribing and medication use. This is to allow comparisons using register data, which have the advantage of being readily available and comprehensive in terms of population coverage and over time (5–7).
  • Register data are not without limitations. Medications may have been prescribed, but not collected from the pharmacy by the user. Collected medications may not have been (appropriately) used by the patient. Sales data may not be fully comparable across countries.
  • Register data are collected primarily for other purposes than quality assessment. Thus, discontinuities over time due to, e.g., legislative changes and administrative reforms need to be acknowledged in the interpretation of the results.
  • Indicators need to be updated regularly because clinical guidelines and the range of available medications change over time.
  • ATC-codes are based on WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index version 2024

Background and literature related to the proposed indicator

Clinical guidelines

The European Stroke Organisation (ESO) guideline (16)

  • HMGCoA reductase inhibitor (statins) for patients with previous ischemic stroke or TIA. High quality evidence suggests that use of a HMGCoA reductase inhibitor reduces risk of ischaemic stroke and major cardiovascular events in people with previous ischaemic stroke or TIA.
  • There is insufficient evidence to support a recommendation concerning add-on therapy with ezetimibe and/or PCSK9-inhibitor to reduce risk of recurrent stroke in people with ischaemic stroke or TIA who do not achieve the recommended LDL-C targets despite taking maximally tolerated dose of a HMGCoA reductase inhibitor for at least 6 weeks.
  • However, based on expert consensus, ezetimibe may be considered when lipid targets are not achieved.
  • The use of a PCSK9 inhibitor may be considered in some people with difficulties to attain low LDL-C targets.
  • Based on evidence, blood pressure lowering medication in people with previous ischemic stroke or TIA, to reduce the risk of recurrent stroke.
  • Based on consensus, the use of combination treatment for blood pressure control is supported.

Finnish Current Care guidelines (17,18)

  • patients with TIA or stroke are considered at high risk and thus in most cases recommended cholesterol-lowering medications.
  • Statins are primary choice, ezetimibe may be added if targets are not achieved by statins alone.
  • PCSK9 inhibitors may be used for very high risk patients with or without a statin.
  • Blood pressure lowering therapies based on diuretics, beta blockers, calcium channel blockers, ACEIs and ARBs are all effective in reducing the risk of cardiovascular events.
  • Combination therapies are often needed to reach target blood pressure levels.

Similar or related indicators in Nordic or European quality assessment

 Key Performance Measures of the Quality of Acute Stroke Care in Western Europe (19)

  • Proportion of ischemic stroke / TIA patients prescribed antiplatelet therapy
  • Proportion of ischemic stroke patients prescribed a statin on discharge
  • Proportion of patients with TIA prescribed a statin
  • Proportion of patients prescribed blood pressure–lowering therapy on discharge

Norwegian Directorate of Health & quality register Norsk hjerneslagregister

  • Antithrombotic agents prescribed at discharge after stroke (20,21)
  • Antihypertensive treatment after stroke (20,22)
  • Cholesterol lowering medication for patients after cerebral infarction (20,23)

Swedish Association of Local Authorities and Regions quality indicators (Vården i siffror) and/or Riksstroke quality register

  • Share of patients hospitalised for TIA who were prescribed antiplatelets at discharge (excluding patients with atrial fibrillation and/or anticoagulants) (24)
  • Share of patients hospitalised for stroke who were prescribed antiplatelets at discharge (excluding patients with atrial fibrillation and/or anticoagulants) (25)
  • Share of patients hospitalised for stroke who were prescribed antihypertensives at discharge (26)
  • Share of patients hospitalised for TIA who were prescribed antihypertensives medications at discharge (27)
  • Share of patients hospitalised for TIA who were prescribed cholesterol-lowering medications at discharge (28)
  • Share of patients (18-79 years) hospitalised for stroke who were dispensed cholesterol-lowering medications 12-18 months after hospital discharge (29)
  • Share of patients (≥80 years) hospitalised for stroke who were dispensed cholesterol-lowering medications 12-18 months after hospital discharge (30)
  • Share of patients hospitalised for ischemic stroke who were prescribed cholesterol-lowering medications at discharge (31)

Set quality targets

The Norwegian quality register Norsk hjerneslagregister targets:

  • ≥95% of patients with cerebral infarction prescribed antithrombotic agents at discharge (20)
  • ≥70% of patients with stroke prescribed blood pressure lowering medication at discharge (20)
  • ≥75% of patients with stroke prescribed lipid-lowering medications at discharge (20)

The Swedish National Board of Health and Welfare, Swedish Association of Local Authorities and Regions (Vården i siffror) and/or Riksstroke quality register targets:

  • ≥ 80% of patients (≥18–79 years) with stroke dispensed statins 12-18 months after discharge (29)
  • ≥ 75% of patients (≥ 80 years) with stroke dispensed statins 12-18 months after discharge (30)
  • 85–89% of patients with stroke (excluding patients with atrial fibrillation or anticoagulants) prescribed antiplatelets at discharge (25)
  • 85–90% of patients with TIA (excluding patients with atrial fibrillation or anticoagulants) prescribed antiplatelets at discharge (24)
  • ≥70–80% of patients with stroke prescribed lipid-lowering medications after stroke (any age) (31)
  • ≥70–80% of patients with TIA prescribed lipid-lowering medications after stroke (28)
  • ≥70–80% of patients with stroke prescribed blood pressure lowering medications after stroke (any age) (26)
  • ≥70–80% of patients with TIA prescribed blood pressure lowering medications after stroke (27)

Similar or related indicators in international scientific literature

  • ER visit/hospitalization due to cerebrovascular event in patient with diagnosis of isolated systolic hypertension, and no use of pharmacologic treatment (32)
  • Appropriate: Patient with previous stroke/TIA – is co-prescribed aspirin and dipyridamole (unless on warfarin or clopidogrel) (33)
  • Statins used, and dosing of statins simvastatin ≥40 mg/d (or equivalent) in patients with previous vascular event (33)
  • Inappropriate: % of patients with stroke or TIA using low doses of ASA and clopidogrel (34)
  • Statin use after ischemic stroke (35)
  • Non-cardioembolic stroke and TIA: start statin, antiplatelet therapy (36)
  • Aspirin, statins after stroke (37)
  • Inappropriate: % of patients with a documented history of coronary, cerebral or peripheral vascular disease, who are not prescribed a statin (38)

References

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