HCA Healthcare Expanding Its Evidence-Based Stroke Initiative

Steven V. Manoukian, M.D., vice president responsible for the Cardiovascular Service Line at Nashville-based HCA Healthcare (NYSE: HCA), recently spoke with Healthcare Innovation about HCA’s plans to expand its role in the Getting to the Heart of Stroke initiative. He explained that the effort, in partnership with the American Heart Association, is designed to improve patient outcomes by increasing cardiology and neurology collaboration, deploying evidence-based education and interventions, and identifying and minimizing health disparities.

Manoukian was American Heart Association’s 2024 Healthcare Volunteer of the Year. He is an interventional cardiologist who worked at Emory Healthcare in Atlanta for 19 years and transitioned to HCA Healthcare almost 20 years ago. In his role, he is a leader in the clinical and operational performance, research, and training and education of his service line.

He explained that a learning collaborative was set up involving 10 HCA Healthcare facilities focused on continuously improving quality of care. Since 2022, the participating Getting to the Heart of Stroke hospitals improved identification of the cause of stroke by 33%, through care team collaboration, best practice-sharing and increased utilization of evidence-based diagnostic testing. These and other findings have been presented at the American Heart Association's national meetings, such as Scientific Sessions and the International Stroke Conference.

Manoukian described HCA’s interest in the project. “We knew that between HCA Healthcare and the HCA Healthcare Foundation we wanted to align with a leading cardiovascular organization to do something great for our communities. I’m a big advocate for the AHA,” Manoukian said. “It works with community partners and has a lot of focus on primary prevention, and then it moves through the continuum of clinical and basic science research and even guideline statements.”

He said that when they thought about opportunities to work together, they recognized there are deficiencies in stroke care. “We designed the Getting to the Heart of Stroke initiative, and part of it is focused on how our teams are collaborating in the hospital and looking at clinical performance improvement,” he said. “Another focus is provider education. We’ve done internal and external presentations, spoken at scientific meetings, and then we moved into broader communication and education, which is how we worked with the American Heart Association, which works with third-party community organizations to help educate them on either stroke prevention or stroke management.”

Based on the successes that HCA has had over the first three years of the initiative, it is expanding in the fourth year. 

A key focus of the initiative is to do a better job of identifying the cause of a stroke. 
“A patient comes in with a suspected stroke and they get a CT scan, an MRI, and they determine that the patient has had a stroke,” Manoukian described. “The patient usually gets admitted to a hospital under the care of a hospitalist or maybe a stroke neurologist. But across the country, up to 50% of people when they're getting wheeled out of the hospital, the clinicians didn't find the cause of their stroke. That's a big number. This is important because the risk of a second stroke is highest in the next year following the first one.”

He said that the fact they couldn’t find the cause could be because they didn't look in the right places. “Certainly, if there are deficiencies or shortcomings on the healthcare side, the question is can we do better at that? Did we communicate well among the team? Did we check all the boxes and do all the tests they needed? Did we find and document the cause of the stroke? For instance, lots of clots come from irregular heartbeats. Did we treat the irregular heartbeat?”

Measuring the impact on outcomes

Among the next steps is measuring the impact of identifying the cause of strokes on longer term outcomes. The Heart Association has a registry in the stroke space called Get With the Guidelines. “I would say they are probably the top registry in this space. But regrettably the registry doesn’t include long-term clinical outcomes metrics,” Manoukian said. “So we said we'd like to do some test metrics. We want to figure out if they have been readmitted to the hospital. Have they had another stroke?”

Manoukian described HCA as a very pilot-driven company. “A pilot allows you to firewall your mistakes and extrapolate. We have about 190 hospitals and we are one of the largest health care systems in the United States. We're expanding this from 10 of our hospitals to 43 of our hospitals,” he said. “We’re going to get to all the relevant programs that see stroke patients. Also, we’ve presented at the American Heart Association’s Scientific Sessions and International Stroke Conference, American College of Cardiology national meeting and we're going to go to the Heart Rhythm Society. They're all asking us to tell them how we did this, so we're excited about doing that.”

Lessons learned

Manoukian said he thinks the roll-out will be easier for the expanded group of hospitals than it was with the first 10. “The lesson learned is to get champions who are aligned around an effort,” he said. “The partnership between the Heart Association and HCA was helpful. It brings in another stakeholder that has a very reputable brand that physicians think of as a source of truth. Oftentimes, the Heart Association guidelines are like our gold standard. So bringing in that branding around the initiative Getting to the Heart of Stroke gets everyone a cause they could rally around. Then you have data from the Get With the Guidelines registry. This gives them a playbook that they can follow. Then we support those who need coaching, and we  share those best practices.”