David Geffen School of Medicine, Comprehensive Stroke Center, Department of Neurology, University of California, Los Angeles, Los Angeles.
JAMA Neurol. 2020 May 1;77(5):606-612. doi: 10.1001/jamaneurol.2019.5061.
Comparative assessment of acute ischemic stroke care quality provided by hospitals in the United States has been hampered by the unavailability of the National Institutes of Health Stroke Scale (NIHSS) in administrative data sets, preventing adequate adjustment for variations in patient case-mix risk. In response to stakeholder concerns, the US Centers for Medicare & Medicaid Services in 2016 implemented optional reporting of NIHSS scores.
To analyze the distributional, convergent, and predictive validity of nationally submitted NIHSS values in the National Inpatient Sample.
DESIGN, SETTING, AND PARTICIPANTS: This population-based retrospective cross-sectional study took place from October 1 to December 31, 2016. The nationally representative sample included US adults who had ischemic stroke hospitalizations during the first calendar quarter in which optional NIHSS reporting was implemented. Analysis began September 2019.
Distribution of NIHSS scores, functional independence at discharge, inpatient mortality, and administrative reporting of NIHSS.
Among 154 165 ischemic stroke hospitalizations during the first 3 months of the reporting policy, NIHSS scores were reported in 21 685 patients (14%) (10 925 women [50.4%]; median [interquartile range] age, 72 [61-82] years). Median (interquartile range) NIHSS score was 4 (2-11), and frequency of severity categories included absent (NIHSS score, 0) in 2080 patients (9.6%), minor (NIHSS score, 1-4) in 8760 patients (40.4%), and severe (NIHSS score, 21-42) in 1930 patients (8.9%). National Institutes of Health Stroke Scale score of 10 or more, an indicator of possible large vessel occlusions, was present in 6290 patients (29%). Presenting NIHSS score was higher in very elderly patients (age ≥80 y) and women and also in patients receiving endovascular thrombectomy vs intravenous thrombolysis alone vs no reperfusion therapy (median [interquartile range], 17 [12-22] vs 6 [4-12] vs 4 [2-9], respectively) (P < .001). National Institutes of Health Stroke Scale scores were similarly higher for discharge outcomes of mortality vs discharge to skilled nursing facility vs discharge home (median [interquartile range], 19 [12-25] vs 7 [3-15] vs 2 [1-5], respectively) (P < .001). Likelihood of NIHSS scores being reported independently increased with interfacility transfer, receipt of acute reperfusion therapies, larger hospital size, academic centers, and region other than the West.
In the initial national optional reporting period in the United States, NIHSS scores were reported in nearly 1 in 7 ischemic stroke hospitalizations. The distribution of NIHSS scores was similar to that from narrow population-based studies and registries, and NIHSS scores were powerfully associated with discharge outcome, supporting the validity and potential to aid care quality assessment.
由于美国医院提供的急性缺血性脑卒中护理质量的比较评估受到国立卫生研究院脑卒中量表（NIHSS）在行政数据集不可用的阻碍，无法充分调整患者病例组合风险的变化。为了回应利益相关者的担忧，美国医疗保险和医疗补助服务中心于 2016 年实施了 NIHSS 评分的可选报告。
分析全国住院患者样本中提交的 NIHSS 值的分布、收敛和预测有效性。
设计、设置和参与者：这是一项基于人群的回顾性横断面研究，于 2016 年 10 月 1 日至 12 月 31 日进行。全国代表性样本包括在美国第一个日历季度期间接受缺血性脑卒中住院治疗的成年人，该季度实施了 NIHSS 可选报告。分析于 2019 年 9 月开始。
NIHSS 评分分布、出院时的功能独立性、住院死亡率和 NIHSS 的行政报告。
在报告政策实施后的头 3 个月内，154165 例缺血性脑卒中住院患者中，有 21685 例（14%）报告了 NIHSS 评分（10925 名女性[50.4%]；中位数[四分位距]年龄，72[61-82]岁）。中位数（四分位距）NIHSS 评分为 4（2-11），严重程度类别包括无（NIHSS 评分为 0）2080 例（9.6%）、轻度（NIHSS 评分为 1-4）8760 例（40.4%）和严重（NIHSS 评分为 21-42）1930 例（8.9%）。10 分或以上的 NIHSS 评分，可能是大血管闭塞的指标，在 6290 例患者（29%）中存在。非常高龄患者（年龄≥80 岁）和女性以及接受血管内血栓切除术与单独静脉溶栓治疗与未接受再灌注治疗的患者的 NIHSS 评分更高（中位数[四分位距]，17[12-22] vs 6[4-12] vs 4[2-9]，分别）（P<.001）。死亡率出院结局、出院至熟练护理机构和出院回家的 NIHSS 评分也更高（中位数[四分位距]，19[12-25] vs 7[3-15] vs 2[1-5]，分别）（P<.001）。在接受界面转移、急性再灌注治疗、更大的医院规模、学术中心和西部地区以外的地区时，NIHSS 评分报告的可能性独立增加。
在美国最初的全国可选报告期内，近 1/7 的缺血性脑卒中住院患者报告了 NIHSS 评分。NIHSS 评分的分布与来自狭义人群研究和登记处的分布相似，NIHSS 评分与出院结果密切相关，支持其有效性和潜在用于评估护理质量。
