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      Braillon contends that we should have stressed the poor and unacceptable levels of quality of care for ischemic stroke, which was even worse for transient ischemic attack. We do not agree that the quality of care for ischemic stroke was unacceptable and poor.
      For American Stroke Association
      • Smith E.E.
      • Saver J.L.
      • Alexander D.N.
      • et al.
      Clinical performance measures for adults hospitalized with acute ischemic stroke: performance measures for healthcare professionals from the American Heart Association/American Stroke Association.
      performance measures, the care provided to patients with acute ischemic stroke in the Get With The Guidelines-Stroke registry, although not perfect, was very high and among the best reported in this time frame. For example, in 2011 for ischemic stroke, antithrombotic at discharge was 98.4%, anticoagulation for atrial fibrillation was 94.8%, and statin at discharge was 91.3%.
      • Bangalore S.
      • Schwamm L.
      • Smith E.E.
      • et al.
      Secondary prevention after ischemic stroke or transient ischemic attack.
      The low defect-free measure is driven by the low percentage of weight counseling at discharge, a measure that is not well validated and is not a quality measure but only a reporting metric in the Get With The Guidelines-Stroke registry. Likewise, although the discharge to rehabilitation was low in patients with ischemic stroke, there is no evidence or guidelines to recommend that 100% of patients be discharged to inpatient stroke rehabilitation irrespective of their current functional state. The performance measure endorsed by the American Heart Association/American Stroke Association is “assessment for rehabilitation,”
      • Smith E.E.
      • Saver J.L.
      • Alexander D.N.
      • et al.
      Clinical performance measures for adults hospitalized with acute ischemic stroke: performance measures for healthcare professionals from the American Heart Association/American Stroke Association.
      which was not reported in our article.
      • Bangalore S.
      • Schwamm L.
      • Smith E.E.
      • et al.
      Secondary prevention after ischemic stroke or transient ischemic attack.
      The association of many of the medical therapies included as performance measures and improvement in outcomes is well established by randomized trials, as discussed in our article.
      • Bangalore S.
      • Schwamm L.
      • Smith E.E.
      • et al.
      Secondary prevention after ischemic stroke or transient ischemic attack.
      Although the actual outcome is important (eg, preventing new or recurrent acute ischemic stroke), the results of the present study emphasize that even the process of care measures are not met, especially in patients with transient ischemic attack. In addition, studies have shown that patients with ischemic stroke who were prescribed a medication at discharge were more likely to be adherent to the medication at 1 week, 1 year, and 2 years, emphasizing the importance of process of care, at least for medications.
      • Tsai J.P.
      • Rochon P.A.
      • Raptis S.
      • et al.
      A prescription at discharge improves long-term adherence for secondary stroke prevention.
      Other studies have shown that prescription of medications at hospital discharge was the strongest predictor of ongoing medication use in stroke survivors even at 10 years after stroke.
      • Thrift A.G.
      • Kim J.
      • Douzmanian V.
      • et al.
      Discharge is a critical time to influence 10-year use of secondary prevention therapies for stroke.
      In addition, adherence to secondary prevention medications has been associated with a significant decrease in long-term adverse events, including mortality.
      • Kumbhani D.J.
      • Steg P.G.
      • Cannon C.P.
      • et al.
      Adherence to secondary prevention medications and four-year outcomes in outpatients with atherosclerosis.
      • Kolandaivelu K.
      • Leiden B.B.
      • O'Gara P.T.
      • Bhatt D.L.
      Non-adherence to cardiovascular medications.
      Although the process of care measures may not all predict better outcomes,
      • Fonarow G.C.
      • Abraham W.T.
      • Albert N.M.
      • et al.
      Association between performance measures and clinical outcomes for patients hospitalized with heart failure.
      these data emphasize the need to improve hospital adherence to quality of care measures.

      References

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        • Saver J.L.
        • Alexander D.N.
        • et al.
        Clinical performance measures for adults hospitalized with acute ischemic stroke: performance measures for healthcare professionals from the American Heart Association/American Stroke Association.
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        • Schwamm L.
        • Smith E.E.
        • et al.
        Secondary prevention after ischemic stroke or transient ischemic attack.
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