Release Notes for the 2027A Manual

• Arnold, J., Acharya, D., Boricha, H., Chapagain, H., Kainat, A., McTigue, K.M., et al. (2025). Real-World Prescribing in Accordance to ACC/AHA Guidelines for Lipid-Lowering Therapy in Primary and Secondary Prevention of ASCVD: Real-World Prescribing for Lipid-Lowering Therapy. American Journal of Preventive Cardiology. Sept;(23),101067:1-10.
• Arnold, S., Kosiborod, M., Tang, F., Zhao, Z., Maddox, T. McCollam, P., et al. (2014). Patterns of Statin Initiation, Intensification, and Maximization Among Patients Hospitalized with an Acute Myocardial Infarction. Circulation. 2014 March 25; 129(12): 1303–1309.
• Endorsed by the American Association of Cardiovascular and Pulmonary Rehabilitation, American Society for Preventive Cardiology, American Society of Hypertension, Association of Black Cardiologists, National Lipid Association, Preventive Cardiovascular Nurses Association, and Women Heart: The National Coalition for Women with Heart Disease. (2014). 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 63(25 0 0), 2935–2959.
• Javed, U., Deedwania, P., Bhatt, D., Cannon, C., Dai, D., Hernandez, A., et al. (2010). Use of intensive lipid-lowering therapy in patients hospitalized with acute coronary syndrome: An analysis of 65,396 hospitalizations from 344 hospitals participating in Get With The Guidelines (GWTG). Am Heart J.160(6):1130-6, 1136.e1-3
• Jneid, H., Addison, D., Bhatt, D., Fonarow, G., Gokak, S., Grady, K., et. al. (2017). 2017 AHA/ACC Clinical Performance and Quality Measures for Adults With ST-Elevation and Non-ST-Elevation Myocardial Infarction: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. J Am Coll Cardiol. 2017 Oct 17;70(16):2048-2090.
• Rao, S.V., O’Donoghue, M.L., Ruel, M., Rab, T., Tamis-Holland, J.E., Williams, M.S., et al. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. JACC. June 10;85(22):2165-2168.

• American College of Cardiology/American Heart Association Task Force on Practice Guidelines. (2014). 2013 ACC/AHA guideline on the assessment of cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 63 (25 Pt B), 2935–2959. https://doi.org/10.1016/j.jacc.2013.11.005
• Arnold, J., Acharya, D., Boricha, H., Chapagain, H., Kainat, A., McTigue, K. M., et al. (2025). Real-world prescribing in accordance with ACC/AHA guidelines for lipid-lowering therapy in primary and secondary prevention of ASCVD. American Journal of Preventive Cardiology, 23, 101067, 1–10.
• Arnold, S. V., Kosiborod, M., Tang, F., Zhao, Z., Maddox, T. M., McCollam, P. L., et al. (2014). Patterns of statin initiation, intensification, and maximization among patients hospitalized with an acute myocardial infarction. Circulation, 129 (12), 1303–1309. https://doi.org/10.1161/CIRCULATIONAHA.113.002880
• Blumenthal, R. S., Morris, P. B., Gaudino, M., Johnson, H. M., Anderson, T. S., Bittner, V. A., Blankstein, R., Brewer, L. C., Cho, L., de Ferranti, S. D., Gianos, E., Gluckman, T. J., Gradney, K. F., Isiadinso, I., Lloyd-Jones, D. M., Marrs, J. C., Martin, S. S., McLain, K. H., Mehta, L. S., Mora, S., Mulugeta, W. M., Natarajan, P., Navar, A. M., Orringer, C. E., Polonsky, T. S., Reynolds, H. R., Saseen, J. J., Shapiro, M. D., Soffer, D. E., Tynes, S. A., Villavaso, C. D., Virani, S. S., & Wilkins, J. T. (2026). 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology. Advance online publication. https://doi.org/10.1016/j.jacc.2025.11.016
• Javed, U., Deedwania, P., Bhatt, D. L., Cannon, C. P., Dai, D., Hernandez, A. F., et al. (2010). Use of intensive lipid-lowering therapy in patients hospitalized with acute coronary syndrome: An analysis of 65,396 hospitalizations from 344 hospitals participating in Get With The Guidelines (GWTG). American Heart Journal, 160 (6), 1130–1136.e3. https://doi.org/10.1016/j.ahj.2010.08.026
• Jneid, H., Addison, D., Bhatt, D. L., Fonarow, G. C., Gokak, S., Grady, K. L., et al. (2017). 2017 AHA/ACC clinical performance and quality measures for adults with ST-elevation and non–ST-elevation myocardial infarction: A report of the American College of Cardiology/American Heart Association Task Force on Performance Measures. Journal of the American College of Cardiology, 70 (16), 2048–2090. https://doi.org/10.1016/j.jacc.2017.06.032
• Matyori, A., Brown, C. P., Ali, A., & Sherbeny, F. (2023). Statins utilization trends and expenditures in the U.S. before and after the implementation of the 2013 ACC/AHA guidelines. Saudi Pharmaceutical Journal, 31 (6), 795–800. https://doi.org/10.1016/j.jsps.2023.04.002
• Rao, S. V., O’Donoghue, M. L., Ruel, M., Rab, T., Tamis-Holland, J. E., Williams, M. S., et al. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology, 85 (22), 2165–2168.

The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure states a benefit of prescribing Mineralocorticoid Receptor Antagonists across the spectrum of HFrEF, inclusive of a wide range of etiologies and disease severities. An MRA (spironolactone or eplerenone) is recommended in patients with HFrEF and NYHA class II to IV symptoms to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is <5.0 mEq/L. Hyperkalemia is a major risk of MRA therapy; therefore, careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely monitored thereafter (Heidenreich et al., 2022).

The 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure states a benefit of prescribing Mineralocorticoid Receptor Antagonists across the spectrum of HFrEF, inclusive of a wide range of etiologies and disease severities. An MRA (spironolactone or eplerenone) is recommended in patients with HFrEF and NYHA class II to IV symptoms to reduce morbidity and mortality, if eGFR is >30 mL/min/1.73 m2 and serum potassium is </=5.0 mEq/L. Hyperkalemia is a major risk of MRA therapy; therefore, careful monitoring of potassium, renal function, and diuretic dosing should be performed at initiation and closely monitored thereafter (Heidenreich et al., 2022).

• American Heart Association. Get With The Guidelines® Heart Failure Fact Sheet. 2016.
• Heidenreich, P., Bozkurt, B., Aguilar, D., Allen, L., Byun, J., Colvin, M., Deswal, A., Drazner, M., Dunlay, S., Evers, L., Fang, J., Fedson, S., Fonarow, G., Hayek, S., Hernandez, A., Khazanie, P., Kittleson, M., Lee, C., Link, M., Milano, C., Nnacheta, L., Sandhu, A., Stevenson, L., Vardeny, O., Vest, A., & Yancy, C. 2022 AHA/ACC2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2022;145(18):e895-e1032.
• Hunt SA, Abraham WT, Chin MH, Felman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update incorporated Into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. Circulation. 2009;119(14):e391-e479.
• Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Klapholz M, MoserDK, Rogers JG, Starling RC, Stevenson WG, Tang WHW, Teerlink JR, Walsh MN. Executive Summary: HFSA 2010 Comphrensive Heart Failure Practice Guideline. J Card Fail 2010;16:475-539.
• Rao, S.V., O’Donoghue, M.L., Ruel, M., Rab, T., Tamis-Holland, J.E., Williams, M.S., et al. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. JACC. June 10;85(22):2169.
• Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–e327.

• American Heart Association. (2016). Get with the guidelines® heart failure fact sheet.
• Heidenreich, P. A., Bozkurt, B., Aguilar, D., Allen, L. A., Byun, J. J., Colvin, M. M., Deswal, A., Drazner, M. H., Dunlay, S. M., Evers, L. R., Fang, J. C., Fedson, S. E., Fonarow, G. C., Hayek, S. S., Hernandez, A. F., Khazanie, P., Kittleson, M. M., Lee, C. S., Link, M. S., Milano, C. A., Nnacheta, L. C., Sandhu, A. T., Stevenson, L. W., Vardeny, O., Vest, A. R., & Yancy, C. W. (2022). 2022 AHA/ACC/HFSA guideline for the management of heart failure: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 145 (18), e895–e1032. https://doi.org/10.1161/CIR.0000000000001063
• Hunt, S. A., Abraham, W. T., Chin, M. H., Feldman, A. M., Francis, G. S., Ganiats, T. G., Jessup, M., Konstam, M. A., Mancini, D. M., Michl, K., Oates, J. A., Rahko, P. S., Silver, M. A., Stevenson, L. W., & Yancy, C. W. (2009). Focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation, 119 (14), e391–e479. https://doi.org/10.1161/CIRCULATIONAHA.109.192065
• Lindenfeld, J., Albert, N. M., Boehmer, J. P., Collins, S. P., Ezekowitz, J. A., Givertz, M. M., Klapholz, M., Moser, D. K., Rogers, J. G., Starling, R. C., Stevenson, W. G., Tang, W. H. W., Teerlink, J. R., & Walsh, M. N. (2010). Executive summary: HFSA 2010 comprehensive heart failure practice guideline. Journal of Cardiac Failure, 16, 475–539. https://doi.org/10.1016/j.cardfail.2010.04.005
• Rao, S. V., O’Donoghue, M. L., Ruel, M., Rab, T., Tamis-Holland, J. E., Williams, M. S., et al. (2025). 2025 ACC/AHA/ACEP/NAEMSP/SCAI guideline for the management of patients with acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Journal of the American College of Cardiology, 85 (22), 2169.
• Yancy, C. W., Jessup, M., Bozkurt, B., Butler, J., Casey, D. E., Jr., Drazner, M. H., Fonarow, G. C., Geraci, S. A., Horwich, T., Januzzi, J. L., Johnson, M. R., Kasper, E. K., Levy, W. C., Masoudi, F. A., McBride, P. E., McMurray, J. J. V., Mitchell, J. E., Peterson, P. N., Riegel, B., Sam, F., Stevenson, L. W., Tang, W. H. W., Tsai, E. J., & Wilkoff, B. L. (2013). 2013 ACCF/AHA guideline for the management of heart failure: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 128, e240–e327. https://doi.org/10.1161/CIR.0b013e31829e8776

• Ades, P., Keteyian, S., Wright, J., Hamm, L., Lui, K., Newlin, K., et al. (2017). Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clin Proc. Feb; 92(2): 234-242.
• American Heart Association. (2018). Cardiac Rehab 101. Retrieved April 27, 2018 at: http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp#.WuNs0C7waUl
• Amsterdam EA, Wenger NK, Brindis RG, et al. (2014). AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 64:e139–228.
• Beatty, A., Bradley, S., Maynard, C., McCabe, J., (2017). Referral to Cardiac Rehabilitation After Percutaneous Coronary Intervention, Coronary Artery Bypass Surgery, and Valve Surgery Data From the Clinical Outcomes Assessment Program. Circ Cardiovasc Qual Outcomes. 10:e003364.
• Hillis LD, Smith PK, Anderson JL, et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery. a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 58:e123–210.
• Levine GN, Bates ER, Blankenship JC, et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of CardiologyFoundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 58:e44–122.
• O’Gara PT, Kushner FG, Ascheim DD, et al. (2013). ACCF/AHA guideline for the management of ST elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78–140.
• Smith SC Jr., Benjamin EJ, Bonow RO, et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. J Am Coll Cardiol. 58:2432–46.
• Thomas, R., Balady, G., Banka, G., Beckie, T., Chiu, J., Gokak, S. (2018). 2018 ACC/AHA Clinical Performance and Quality Measures for Cardiac Rehabiliation. Circ Cardiovasc Qual Outcomes. 2018 Apr;11(4):e000037.

• Ades, P. A., Keteyian, S. J., Wright, J. S., Hamm, L. F., Lui, K., Newlin, K., et al. (2017). Increasing cardiac rehabilitation participation from 20% to 70%: A road map from the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clinic Proceedings, 92 (2), 234–242. https://doi.org/10.1016/j.mayocp.2016.10.014
• American Heart Association. (2018). Cardiac rehab 101. http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp
• Amsterdam, E. A., Wenger, N. K., Brindis, R. G., et al. (2014). AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64, e139–e228. https://doi.org/10.1016/j.jacc.2014.09.017
• Beatty, A. L., Bradley, S. M., Maynard, C., & McCabe, J. M. (2017). Referral to cardiac rehabilitation after percutaneous coronary intervention, coronary artery bypass surgery, and valve surgery: Data from the Clinical Outcomes Assessment Program. Circulation: Cardiovascular Quality and Outcomes, 10, e003364. https://doi.org/10.1161/CIRCOUTCOMES.116.003364
• Hillis, L. D., Smith, P. K., Anderson, J. L., et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 58, e123–e210. https://doi.org/10.1016/j.jacc.2011.08.009
• Levine, G. N., Bates, E. R., Blankenship, J. C., et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Journal of the American College of Cardiology, 58, e44–e122. https://doi.org/10.1016/j.jacc.2011.08.007
• O’Gara, P. T., Kushner, F. G., Ascheim, D. D., et al. (2013). ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61, e78–e140. https://doi.org/10.1016/j.jacc.2012.11.019
• Smith, S. C., Jr., Benjamin, E. J., Bonow, R. O., et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. Journal of the American College of Cardiology, 58, 2432–2446. https://doi.org/10.1016/j.jacc.2011.10.824
• Thomas, R. J., Balady, G. J., Banka, G., Beckie, T. M., Chiu, J., & Gokak, S. (2018). 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation. Circulation: Cardiovascular Quality and Outcomes, 11 (4), e000037. https://doi.org/10.1161/HCQ.0000000000000037

• Ades, P., Keteyian, S., Wright, J., Hamm, L., Lui, K., Newlin, K., et al. (2017). Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clin Proc. Feb; 92(2): 234-242.
• American Heart Association. (2018). Cardiac Rehab 101. Retrieved April 27, 2018 at: http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp#.WuNs0C7waUl
• Amsterdam EA, Wenger NK, Brindis RG, et al. (2014). AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 64:e139–228.
• Hillis LD, Smith PK, Anderson JL, et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery. a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 58:e123–210.
• Levine GN, Bates ER, Blankenship JC, et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of CardiologyFoundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 58:e44–122.
• O’Gara PT, Kushner FG, Ascheim DD, et al. (2013). ACCF/AHA guideline for the management of ST elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78–140.
• Smith SC Jr., Benjamin EJ, Bonow RO, et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. J Am Coll Cardiol. 58:2432–46.

• Ades, P. A., Keteyian, S. J., Wright, J. S., Hamm, L. F., Lui, K., Newlin, K., et al. (2017). Increasing cardiac rehabilitation participation from 20% to 70%: A road map from the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clinic Proceedings, 92 (2), 234–242. https://doi.org/10.1016/j.mayocp.2016.10.014
• American Heart Association. (2018). Cardiac rehab 101. http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp
• Amsterdam, E. A., Wenger, N. K., Brindis, R. G., et al. (2014). AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64, e139–e228. https://doi.org/10.1016/j.jacc.2014.09.017
• Hillis, L. D., Smith, P. K., Anderson, J. L., et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 58, e123–e210. https://doi.org/10.1016/j.jacc.2011.08.009
• Levine, G. N., Bates, E. R., Blankenship, J. C., et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Journal of the American College of Cardiology, 58, e44–e122. https://doi.org/10.1016/j.jacc.2011.08.007
• O’Gara, P. T., Kushner, F. G., Ascheim, D. D., et al. (2013). ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61, e78–e140. https://doi.org/10.1016/j.jacc.2012.11.019
• Smith, S. C., Jr., Benjamin, E. J., Bonow, R. O., et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. Journal of the American College of Cardiology, 58, 2432–2446. https://doi.org/10.1016/j.jacc.2011.10.824
• Thomas, R. J., Balady, G. J., Banka, G., Beckie, T. M., Chiu, J., & Gokak, S. (2018). 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation. Circulation: Cardiovascular Quality and Outcomes, 11 (4), e000037. https://doi.org/10.1161/HCQ.0000000000000037

• Ades, P., Keteyian, S., Wright, J., Hamm, L., Lui, K., Newlin, K., et al. (2017). Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clin Proc. Feb; 92(2): 234-242.
• American Heart Association. (2018). Cardiac Rehab 101. Retrieved April 27, 2018 at: http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp#.WuNs0C7waUl
• Amsterdam EA, Wenger NK, Brindis RG, et al. (2014). AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 64:e139–228.
• Beatty, A., Bradley, S., Maynard, C., McCabe, J., (2017). Referral to Cardiac Rehabilitation After Percutaneous Coronary Intervention, Coronary Artery Bypass Surgery, and Valve Surgery Data From the Clinical Outcomes Assessment Program. Circ Cardiovasc Qual Outcomes. 10:e003364.
• Hillis LD, Smith PK, Anderson JL, et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery. a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 58:e123–210.
• Levine GN, Bates ER, Blankenship JC, et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of CardiologyFoundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 58:e44–122.
• O’Gara PT, Kushner FG, Ascheim DD, et al. (2013). ACCF/AHA guideline for the management of ST elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78–140.
• Smith SC Jr., Benjamin EJ, Bonow RO, et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. J Am Coll Cardiol. 58:2432–46.

• Ades, P. A., Keteyian, S. J., Wright, J. S., Hamm, L. F., Lui, K., Newlin, K., et al. (2017). Increasing cardiac rehabilitation participation from 20% to 70%: A road map from the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clinic Proceedings, 92 (2), 234–242. https://doi.org/10.1016/j.mayocp.2016.10.014
• American Heart Association. (2018). Cardiac rehab 101. http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp
• Amsterdam, E. A., Wenger, N. K., Brindis, R. G., et al. (2014). AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64, e139–e228. https://doi.org/10.1016/j.jacc.2014.09.017
• Beatty, A. L., Bradley, S. M., Maynard, C., & McCabe, J. M. (2017). Referral to cardiac rehabilitation after percutaneous coronary intervention, coronary artery bypass surgery, and valve surgery: Data from the Clinical Outcomes Assessment Program. Circulation: Cardiovascular Quality and Outcomes, 10, e003364. https://doi.org/10.1161/CIRCOUTCOMES.116.003364
• Hillis, L. D., Smith, P. K., Anderson, J. L., et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 58, e123–e210. https://doi.org/10.1016/j.jacc.2011.08.009
• Levine, G. N., Bates, E. R., Blankenship, J. C., et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Journal of the American College of Cardiology, 58, e44–e122. https://doi.org/10.1016/j.jacc.2011.08.007
• O’Gara, P. T., Kushner, F. G., Ascheim, D. D., et al. (2013). ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61, e78–e140. https://doi.org/10.1016/j.jacc.2012.11.019
• Smith, S. C., Jr., Benjamin, E. J., Bonow, R. O., et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. Journal of the American College of Cardiology, 58, 2432–2446. https://doi.org/10.1016/j.jacc.2011.10.824
• Thomas, R. J., Balady, G. J., Banka, G., Beckie, T. M., Chiu, J., & Gokak, S. (2018). 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation. Circulation: Cardiovascular Quality and Outcomes, 11 (4), e000037. https://doi.org/10.1161/HCQ.0000000000000037

• Ades, P., Keteyian, S., Wright, J., Hamm, L., Lui, K., Newlin, K., et al. (2017). Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clin Proc. Feb; 92(2): 234-242.
• American Heart Association. (2018). Cardiac Rehab 101. Retrieved April 27, 2018 at: http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp#.WuNs0C7waUl
• Amsterdam EA, Wenger NK, Brindis RG, et al. (2014). AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 64:e139–228.
• Beatty, A., Bradley, S., Maynard, C., McCabe, J., (2017). Referral to Cardiac Rehabilitation After Percutaneous Coronary Intervention, Coronary Artery Bypass Surgery, and Valve Surgery Data From the Clinical Outcomes Assessment Program. Circ Cardiovasc Qual Outcomes. 10:e003364.
• Hillis LD, Smith PK, Anderson JL, et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery. a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 58:e123–210.
• Levine GN, Bates ER, Blankenship JC, et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of CardiologyFoundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 58:e44–122.
• O’Gara PT, Kushner FG, Ascheim DD, et al. (2013). ACCF/AHA guideline for the management of ST elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78–140.
• Smith SC Jr., Benjamin EJ, Bonow RO, et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. J Am Coll Cardiol. 58:2432–46.

• Ades, P. A., Keteyian, S. J., Wright, J. S., Hamm, L. F., Lui, K., Newlin, K., et al. (2017). Increasing cardiac rehabilitation participation from 20% to 70%: A road map from the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clinic Proceedings, 92 (2), 234–242. https://doi.org/10.1016/j.mayocp.2016.10.014
• American Heart Association. (2018). Cardiac rehab 101. http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp
• Amsterdam, E. A., Wenger, N. K., Brindis, R. G., et al. (2014). AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64, e139–e228. https://doi.org/10.1016/j.jacc.2014.09.017
• Beatty, A. L., Bradley, S. M., Maynard, C., & McCabe, J. M. (2017). Referral to cardiac rehabilitation after percutaneous coronary intervention, coronary artery bypass surgery, and valve surgery: Data from the Clinical Outcomes Assessment Program. Circulation: Cardiovascular Quality and Outcomes, 10, e003364. https://doi.org/10.1161/CIRCOUTCOMES.116.003364
• Hillis, L. D., Smith, P. K., Anderson, J. L., et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 58, e123–e210. https://doi.org/10.1016/j.jacc.2011.08.009
• Levine, G. N., Bates, E. R., Blankenship, J. C., et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Journal of the American College of Cardiology, 58, e44–e122. https://doi.org/10.1016/j.jacc.2011.08.007
• O’Gara, P. T., Kushner, F. G., Ascheim, D. D., et al. (2013). ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61, e78–e140. https://doi.org/10.1016/j.jacc.2012.11.019
• Smith, S. C., Jr., Benjamin, E. J., Bonow, R. O., et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. Journal of the American College of Cardiology, 58, 2432–2446. https://doi.org/10.1016/j.jacc.2011.10.824
• Thomas, R. J., Balady, G. J., Banka, G., Beckie, T. M., Chiu, J., & Gokak, S. (2018). 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation. Circulation: Cardiovascular Quality and Outcomes, 11 (4), e000037. https://doi.org/10.1161/HCQ.0000000000000037

• Ades, P., Keteyian, S., Wright, J., Hamm, L., Lui, K., Newlin, K., et al. (2017). Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clin Proc. Feb; 92(2): 234-242.
• American Heart Association. (2018). Cardiac Rehab 101. Retrieved April 27, 2018 at: http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp#.WuNs0C7waUl
• Amsterdam EA, Wenger NK, Brindis RG, et al. (2014). AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 64:e139–228.
• Hillis LD, Smith PK, Anderson JL, et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery. a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 58:e123–210.
• Levine GN, Bates ER, Blankenship JC, et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of CardiologyFoundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 58:e44–122.
• O’Gara PT, Kushner FG, Ascheim DD, et al. (2013). ACCF/AHA guideline for the management of ST elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78–140.
• Smith SC Jr., Benjamin EJ, Bonow RO, et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. J Am Coll Cardiol. 58:2432–46.

• Ades, P. A., Keteyian, S. J., Wright, J. S., Hamm, L. F., Lui, K., Newlin, K., et al. (2017). Increasing cardiac rehabilitation participation from 20% to 70%: A road map from the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clinic Proceedings, 92 (2), 234–242. https://doi.org/10.1016/j.mayocp.2016.10.014
• American Heart Association. (2018). Cardiac rehab 101. http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp
• Amsterdam, E. A., Wenger, N. K., Brindis, R. G., et al. (2014). AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64, e139–e228. https://doi.org/10.1016/j.jacc.2014.09.017
• Hillis, L. D., Smith, P. K., Anderson, J. L., et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 58, e123–e210. https://doi.org/10.1016/j.jacc.2011.08.009
• Levine, G. N., Bates, E. R., Blankenship, J. C., et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Journal of the American College of Cardiology, 58, e44–e122. https://doi.org/10.1016/j.jacc.2011.08.007
• O’Gara, P. T., Kushner, F. G., Ascheim, D. D., et al. (2013). ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61, e78–e140. https://doi.org/10.1016/j.jacc.2012.11.019
• Smith, S. C., Jr., Benjamin, E. J., Bonow, R. O., et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. Journal of the American College of Cardiology, 58, 2432–2446. https://doi.org/10.1016/j.jacc.2011.10.824
• Thomas, R. J., Balady, G. J., Banka, G., Beckie, T. M., Chiu, J., & Gokak, S. (2018). 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation. Circulation: Cardiovascular Quality and Outcomes, 11 (4), e000037. https://doi.org/10.1161/HCQ.0000000000000037

• Ades, P., Keteyian, S., Wright, J., Hamm, L., Lui, K., Newlin, K., et al. (2017). Increasing Cardiac Rehabilitation Participation From 20% to 70%: A Road Map From the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clin Proc. Feb; 92(2): 234-242.
• American Heart Association. (2018). Cardiac Rehab 101. Retrieved April 27, 2018 at: http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp#.WuNs0C7waUl
• Amsterdam EA, Wenger NK, Brindis RG, et al. (2014). AHA/ACC guideline for the management of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 64:e139–228.
• Beatty, A., Bradley, S., Maynard, C., McCabe, J., (2017). Referral to Cardiac Rehabilitation After Percutaneous Coronary Intervention, Coronary Artery Bypass Surgery, and Valve Surgery Data From the Clinical Outcomes Assessment Program. Circ Cardiovasc Qual Outcomes. 10:e003364.
• Hillis LD, Smith PK, Anderson JL, et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery. a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Developed in collaboration with the American Association for Thoracic Surgery, Society of Cardiovascular Anesthesiologists, and Society of Thoracic Surgeons. J Am Coll Cardiol. 58:e123–210.
• Levine GN, Bates ER, Blankenship JC, et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: a report of the American College of CardiologyFoundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. J Am Coll Cardiol. 58:e44–122.
• O’Gara PT, Kushner FG, Ascheim DD, et al. (2013). ACCF/AHA guideline for the management of ST elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013;61:e78–140.
• Smith SC Jr., Benjamin EJ, Bonow RO, et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. J Am Coll Cardiol. 58:2432–46.

• Ades, P. A., Keteyian, S. J., Wright, J. S., Hamm, L. F., Lui, K., Newlin, K., et al. (2017). Increasing cardiac rehabilitation participation from 20% to 70%: A road map from the Million Hearts Cardiac Rehabilitation Collaborative. Mayo Clinic Proceedings, 92 (2), 234–242. https://doi.org/10.1016/j.mayocp.2016.10.014
• American Heart Association. (2018). Cardiac rehab 101. http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/What-is-Cardiac-Rehabilitation_UCM_307049_Article.jsp
• Amsterdam, E. A., Wenger, N. K., Brindis, R. G., et al. (2014). AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 64, e139–e228. https://doi.org/10.1016/j.jacc.2014.09.017
• Beatty, A. L., Bradley, S. M., Maynard, C., & McCabe, J. M. (2017). Referral to cardiac rehabilitation after percutaneous coronary intervention, coronary artery bypass surgery, and valve surgery: Data from the Clinical Outcomes Assessment Program. Circulation: Cardiovascular Quality and Outcomes, 10, e003364. https://doi.org/10.1161/CIRCOUTCOMES.116.003364
• Hillis, L. D., Smith, P. K., Anderson, J. L., et al. (2011). 2011 ACCF/AHA guideline for coronary artery bypass graft surgery: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 58, e123–e210. https://doi.org/10.1016/j.jacc.2011.08.009
• Levine, G. N., Bates, E. R., Blankenship, J. C., et al. (2011). 2011 ACCF/AHA/SCAI guideline for percutaneous coronary intervention: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the Society for Cardiovascular Angiography and Interventions. Journal of the American College of Cardiology, 58, e44–e122. https://doi.org/10.1016/j.jacc.2011.08.007
• O’Gara, P. T., Kushner, F. G., Ascheim, D. D., et al. (2013). ACCF/AHA guideline for the management of ST-elevation myocardial infarction: A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Journal of the American College of Cardiology, 61, e78–e140. https://doi.org/10.1016/j.jacc.2012.11.019
• Smith, S. C., Jr., Benjamin, E. J., Bonow, R. O., et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update. Journal of the American College of Cardiology, 58, 2432–2446. https://doi.org/10.1016/j.jacc.2011.10.824
• Thomas, R. J., Balady, G. J., Banka, G., Beckie, T. M., Chiu, J., & Gokak, S. (2018). 2018 ACC/AHA clinical performance and quality measures for cardiac rehabilitation. Circulation: Cardiovascular Quality and Outcomes, 11 (4), e000037. https://doi.org/10.1161/HCQ.0000000000000037

• Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1664-1666.
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• Leifer, D., Bravata, D. M., Connors, J. J., III, Hinchey, J. A., Jauch, E. C., Johnston, S. C., Latchaw, R., Likosky, W., Ogilvy, C., Qureshi, A. I., Summers, D., Sung, G. Y., Williams, L. S., & Zorowitz, R. (2011). Metrics for measuring quality of care in comprehensive stroke centers: Detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42, 853-54.
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• Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513

Recent clinical studies (e.g., AURORA, BEST, BASICS, BAOCHE, ATTENTION) have evaluated stroke disability at 90 days following endovascular therapy (EVT) for patients with large vessel occlusions. Patients undergoing EVT were more likely to achieve favorable outcomes and functional independence as assessed by mRS score of 0-2 when compared to medical management.

Recent clinical studies (e.g., AURORA, BEST, BASICS, BAOCHE, ATTENTION) have evaluated stroke disability at 90 day following endovascular therapy (EVT) for patients with large vessel occlusions. Patients undergoing EVT were more likely to achieve favorable outcomes and functional independence as assessed by mRS score of 0-2 when compared to medical management. (Palaniappan, L. P., et al., 2026).

• Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1675-1678.
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• Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:857.
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• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
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• Leifer, D., Bravata, D. M., Connors, J. J., III, Hinchey, J. A., Jauch, E. C., Johnston, S. C., Latchaw, R., Likosky, W., Ogilvy, C., Qureshi, A. I., Summers, D., Sung, G. Y., Williams, L. S., & Zorowitz, R., on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. (2011). Metrics for measuring quality of care in comprehensive stroke centers: Detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42, 853-54.
• Martin, S. S., Aday, A. W., Allen, N. B., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., … Palaniappan, L. P. (2025). 2025 heart disease and stroke statistics: A report of U.S. and global data from the American Heart Association. Circulation, 151, e354.
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The Hunt and Hess (HH) grade is a recommended scoring methodology for patients with SAH (Hoh, B.L., et al., 2023). The ICH score is a validated methodology with clinical data supporting its usefulness for ICH assessment, risk stratification, and quality measurement (Greenberg, S.M., et al., 2022). For both severity methodologies, higher scores are associated with increased mortality.

• Greenberg, S. M., Ziai, W. C., Cordonnier, C., Dowlatshahi, D., Francis, B., Goldstein, J. N., Hemphill, J. C., III, Johnson, R., Keigher, K. M., Mack, W. J., Mocco, J., Newton, E. J., Ruff, I. M., Sansing, L. H., Schulman, S., Selim, M. H., Sheth, K. N., Sprigg, N., & Sunnerhagen, K. S. (2022). 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: A guideline from the American Heart Association/American Stroke Association. Stroke, 53 (7), e325–e326.
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• Frontera, J. A., Lewin, J. J., 3rd, Rabinstein, A. A., Aisiku, I. P., Alexandrov, A. W., Cook, A. M., del Zoppo, G. J., Kumar, M. A., Peerschke, E. I., Stiefel, M. F., Teitelbaum, J. S., Wartenberg, K. E., & Zerfoss, C. L. (2016). Guideline for reversal of antithrombotics in intracranial hemorrhage: A statement for healthcare professionals from the Neurocritical Care Society and Society of Critical Care Medicine. Neurocritical Care, 24 (1), 6–46.
• Greenberg, S. M., Ziai, W. C., Cordonnier, C., Dowlatshahi, D., Francis, B., Goldstein, J. N., Hemphill, J. C., III, Johnson, R., Keigher, K. M., Mack, W. J., Mocco, J., Newton, E. J., Ruff, I. M., Sansing, L. H., Schulman, S., Selim, M. H., Sheth, K. N., Sprigg, N., & Sunnerhagen, K. S. (2022). 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: A guideline from the American Heart Association/American Stroke Association. Stroke, 53 (7), e282–e361.
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Endovascular reperfusion therapy in acute ischemic stroke comprises a number of pharmacological and mechanical procedures. Mechanical endovascular thrombectomy is a treatment option for patients with large vessel occlusions in whom pharmacological thrombolysis is contraindicated or might be ineffective. For eligible patients, initiation of EVT (e.g., groin puncture) within 6 hours of stroke symptom onset using a stent retriever is preferred (Powers WJ, et. al., 2015). The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances (Powers WJ, et. al., 2018). Mechanical endovascular thrombectomy devices are intended to improve tissue rescue and diminish reperfusion hemorrhage while broadening the population eligible for therapy. These devices may be used alone or in conjunction with chemical thrombolysis (i.e., IV or IA alteplase).

Endovascular reperfusion therapy in acute ischemic stroke comprises a number of pharmacological and mechanical procedures. Mechanical endovascular thrombectomy is a treatment option for patients with large vessel occlusions in whom pharmacological thrombolysis is contraindicated or might be ineffective. For eligible patients, initiation of EVT (e.g., groin puncture) within 6 hours of stroke symptom onset using a stent retriever is preferred (Powers, W.J., et al., 2015). The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances (Powers W.J., et al., 2018). Mechanical endovascular thrombectomy devices are intended to improve tissue rescue and diminish reperfusion hemorrhage while broadening the population eligible for therapy. These devices may be used alone or in conjunction with chemical thrombolysis (i.e., IV or IA alteplase).

Over the last decade, mechanical thrombectomy (MT) has become the standard of care for the treatment of acute ischemic stroke caused by large vessel occlusions (LVO). Clinical studies have reported sICH rates between 3.6% and 9.3% following MT, (Hall, E., et al., 2024). Higher rates up to 16% have been reported in real-world practice. The risk of sICH varies significantly based on the location and severity of the initial stroke with higher risk and more severe hemorrhages (i.e., intraventricular and large parenchymal) generally reported for EVT in proximal vessels (e.g., ICA). However, one recent meta-analysis reported higher risk associated with MT in the posterior circulation (RR: 7.48; 95% CI: 2.27-24.61 vs RR: 1.18; 95%CI: 0.90—1.56 )(p=0.003), (Reda, A., et al., 2025).

Symptomatic intracranial hemorrhage following reperfusion is a clinical event and potentially critical complication of therapy. The Heidelberg Classification uses both brain imaging to distinguish between hemorrhagic infarction (HI) and parenchymatous hematoma (PH), as well as, changes in NIHSS score to assess neurological deterioration (i.e., >/= 4 point increase). HI 1 and HI 2 are defined as petechial hemorrhages without space-occupying effect; PH 1 and PH 2 are solid clots in the area of infarction with space-occupying effect. PH 2 classification represents a larger blood clot and is associated with increased mortality at 90-days post-ischemic stroke (von Kummer, et al., 2015).

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Endovascular therapy (EVT) is now the standard of care for treatment of acute ischemic stroke due to large-vessel occlusion (LVO). In 2015, the American Heart Association/American Stroke Association published a focused update to the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke regarding endovascular treatment (Powers WJ, et. al., 2015). Endovascular therapy with a stent retriever is recommended for eligible patients. The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances, but stent retrievers remain the first choice (Powers WJ, et. al., 2018).

Endovascular thrombectomy (EVT) with a stent retriever is the standard of care for treatment of acute ischemic stroke from anterior circulation proximal large-vessel occlusion (LVO). The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances, but stent retrievers remain the first choice (Powers W.J., et al., 2018).

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• Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42; 857.
• Menon BK, Saver JL, Prabhakaran S, Reeves M, Liang L, Olson DWM, Peterson ED, Hernandez AF, Fonarow GC, Schwamm LH, Smith EE. Risk score for intracranial hemorrhage in patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator. Stroke. 2012;43: 1-9.
• Powers WJ, Derdeyn CP, Biller J, Coffey CS, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell CS, Meschia JF, Ovbiagele B, Yavagal DR, on behalf of the American Heart Association Stroke Council. 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46; 3021-3035.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e10-e11, e26-e30.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
• Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke.
• Sacks D, Black CM, Cognard C, Connors III JJ, Frei D, Gupta R, Jovin TG, Kluck B, Meyers PM, Murphy KJ, Ramee S, Rϋfenacht DA, Stallmeyer MJB, Vorwerk D. Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol. 2013;24:151-163.
• Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.
• Sharma VK, Teoh HL, Wong LYH, Su J, Ong BKC, and Chan BLP. Recanalization therapies in acute ischemic stroke: pharmacological agents, devices, and combinations. Stroke Research and Treatment. 2010.
• Sims JR, Gharai R, Schaefer PW, Vangel M, Rosenthal ES, Lev MH, Schwamm LH. ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes. Neurology. 2009;72:2104-2110.
• Tomsick T, Broderick J, Carrosella J, Khatari P, Hill M, Palesch Y, Khoury J; Interventional Management of Stroke II Investigators. Revascularizaton results in the Interventional Management of Stroke II Trial. American Journal of Neuroradiology. 2008 Mar; 29(3): 582-587.
• Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.

• Campbell, B. C. V., Mitchell, P. J., Kleinig, T. J., Dewey, H. M., Churilov, L., Yassi, N., et al. (2015). Endovascular therapy for ischemic stroke with perfusion imaging selection. The New England Journal of Medicine, 372 (11), 1009–1017.
• Demchuk, A. M., Goyal, M., Menon, B. K., Eesa, M., Ryckborst, K. J., Kamal, N., et al. (2015). Endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing CT to recanalization times (ESCAPE) trial: Methodology. International Journal of Stroke, 10 (3), 429–438.
• Leifer, D., Bravata, D. M., Connors, J. J., III, Hinchey, J. A., Jauch, E. C., Johnston, S. C., Latchaw, R., Likosky, W., Ogilvy, C., Qureshi, A. I., Summers, D., Sung, G. Y., Williams, L. S., & Zorowitz, R., on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. (2011). Metrics for measuring quality of care in comprehensive stroke centers: Detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42, 853-54.
• Menon, B. K., Saver, J. L., Prabhakaran, S., Reeves, M., Liang, L., Olson, D. W. M., Peterson, E. D., Hernandez, A. F., Fonarow, G. C., Schwamm, L. H., & Smith, E. E. (2012). Risk score for intracranial hemorrhage in patients with acute ischemic stroke treated with intravenous tissue type plasminogen activator. Stroke, 43, 1–9.
• Powers, W. J., Derdeyn, C. P., Biller, J., Coffey, C. S., Jauch, E. C., Johnston, K. C., Johnston, S. C., Khalessi, A. A., Kidwell, C. S., Meschia, J. F., Ovbiagele, B., & Yavagal, D. R., on behalf of the American Heart Association Stroke Council. (2015). 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 46, 3021–3035.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e26–e30.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.
• Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513
• Saver, J. L., Goyal, M., Bonafe, A., Diener, H.-C., Levy, E. I., Pereira, V. M., et al. (2015). Stent retriever thrombectomy after intravenous t PA vs. t PA alone in stroke. The New England Journal of Medicine, 372 (24), 2285–2295.

Since “time is brain”, the overall speed of the revascularization process is an important and appropriate measure. In multicenter clinical trials of intra-arterial catheter-directed therapies, the probability of good outcome as defined by a Modified Rankin Score of 0-2 at 90 days decreased as time to angiographic revascularization increased. It is estimated that for every 30-minute delay in time to revascularization, there is a 10% decrease in the likelihood of a good outcome from EVT. Five randomized clinical trials (RCTs) published in 2015 demonstrated the benefit of timely endovascular therapy in select patients with acute ischemic stroke due to large vessel occlusion (Jahan R et al., 2019).

American Heart Association Get With The Guidelines® (GWTG) sets a goal for Door-To-Puncture (DTP) Time within 90 minutes. Recent studies have reported that shorter DTP times may be achieved. Jahan and colleagues studied the time-benefit relationship in a large cohort of 6756 acute ischemic stroke patients from the GWTG clinical registry who underwent endovascular therapy within 8 hours of symptom onset. Findings from this study suggest that national quality target DTP times could be within 75 minutes for patients arriving directly to the hospital via emergency medical services (EMS) and within 45 minutes for patients transferred from another acute care hospital.

Since “time is brain”, the overall speed of the revascularization process is an important and appropriate measure. In multicenter clinical trials of intra-arterial catheter-directed therapies, the probability of good outcome as defined by a Modified Rankin Score of 0-2 at 90 days decreased as time to angiographic revascularization increased. It is estimated that for every 30-minute delay in time to revascularization, there is a 10% decrease in the likelihood of a good outcome from EVT. Five randomized clinical trials (RCTs) published in 2015 demonstrated the benefit of timely endovascular therapy in select patients with acute ischemic stroke due to large vessel occlusion (Jahan R. et al., 2019).

The American Heart Association® Target Stroke Phase III initiative raises the bar for timely EVT therapy with a goal for Door-To- Device (DTN), i.e., arrival to first pass of thrombectomy device, within 90 minutes (for direct arriving patients) and within 60 minutes (for transfer patients), (AHA, 2018). Door-To-Puncture (DTP) time should be less than these targets. Recent studies have reported that shorter DTP times may be achieved. Jahan and colleagues studied the time-benefit relationship in a large cohort of 6756 acute ischemic stroke patients from the GWTG clinical registry who underwent endovascular therapy within 8 hours of symptom onset. Findings from this study suggest that national quality target DTP times could be within 75 minutes for patients arriving directly to the hospital via emergency medical services (EMS) and within 45 minutes for patients transferred from another acute care hospital.

In AIS patients eligible for mechanical thrombectomy, Mobile Stroke Units (MSUs) may increase the identification and triage of LVO, notify a thrombectomy-capable center of impending transfer and expedite transport, resulting in faster treatment. 2026 updated guidelines from the American Heart Association/American Stroke Association recommend the use of MSU over conventional EMS transport where available. (Prabhakaran, S., et al., 2026).

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• Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.
• Demchuk AM, Goyal M, Monon BK, Eesa M, Ryckborst KJ, Kamal N, et. al. Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial: methodology. Int J Stroke. 2015 Apr;10(3): 429-38.
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• Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.
• Khatari P, Abruzzo T, Yeatts SD, Nichols C, Broderick JP, Tomsick TA; IMS I and II Investigators. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009 Sep 29;73(13):1066-72.
• Khatari P, Hill MD, Palesch YY, et. al. Methodology of the Interventional Manaagement of Stroke III Trial. Int J Stroke. 2008;3:130-137.
• Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42; 857.
• Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et. al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. NEJM. 2018;378(1): 11-21.
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• Powers WJ, Derdeyn CP, Biller J, Coffey CS, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell CS, Meschia JF, Ovbiagele B, Yavagal DR, on behalf of the American Heart Association Stroke Council. 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46; 3021-3035.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e26-e30.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
• Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke.
• Sacks D, Black CM, Cognard C, Connors JJ III, Frei D, Gupta R, Jovin TG, Kluck B, Meyers PM, Murphy KJ, Ramee S, Rϋfenacht DA, Stallmeyer MJB, Vorwerk D. Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol. 2013;24:151-163.
• Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.
• Sharma VK, Teoh HL, Wong LYH, Su J, Ong BKC, and Chan BLP. Recanalization therapies in acute ischemic stroke: pharmacological agents, devices, and combinations. Stroke Research and Treatment. 2010.
• Smith WS, Sung G, Saver J, et. al. Mechanical thrombectomy for acute ischemic stroke: final results of the Multi MERCI trial. Stroke. 2008;39:1205-1212.
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• Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.

• Albers, G. W., Marks, M. P., Kemp, S., Christensen, S., Tsai, J. P., Ortega Gutierrez, S., et al. (2018). Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. The New England Journal of Medicine, 378 (8), 708–718.
• American Heart Association. (2018). Phase III Target: Stroke: Higher goals for greater good. https://www.stroke.org/-/media/files/professional/quality-improvement/target-stroke/target-stroke-phase-iii/aha-qi-target-stroke-phase-3-brochure.pdf.
• Campbell, B. C. V., Mitchell, P. J., Kleinig, T. J., Dewey, H. M., Churilov, L., Yassi, N., et al. (2015). Endovascular therapy for ischemic stroke with perfusion imaging selection. The New England Journal of Medicine, 372 (11), 1009–1017.
• Demchuk, A. M., Goyal, M., Menon, B. K., Eesa, M., Ryckborst, K. J., Kamal, N., et al. (2015). Endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing CT to recanalization times (ESCAPE) trial: Methodology. International Journal of Stroke, 10 (3), 429–438.
• Jahan, R., Saver, J. L., Schwamm, L. H., Fonarow, G., Liang, L., Matsouaka, R. A., & Xian, Y. (2019). Association between time to treatment with endovascular reperfusion therapy and outcomes in patients with acute ischemic stroke treated in clinical practice. JAMA, 322 (3), 252–263.
• Leifer, D., Bravata, D. M., Connors, J. J., III, Hinchey, J. A., Jauch, E. C., Johnston, S. C., Latchaw, R., Likosky, W., Ogilvy, C., Qureshi, A. I., Summers, D., Sung, G. Y., Williams, L. S., & Zorowitz, R., on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. (2011). Metrics for measuring quality of care in comprehensive stroke centers: Detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42, 853-54.
• Nogueira, R. G., Jadhav, A. P., Haussen, D. C., Bonafe, A., Budzik, R. F., Bhuva, P., …(2018). Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. New England Journal of Medicine, 378 (1), 11–21.
• Powers, W. J., Derdeyn, C. P., Biller, J., Coffey, C. S., Jauch, E. C., Johnston, K. C., Johnston, S. C., Khalessi, A. A., Kidwell, C. S., Meschia, J. F., Ovbiagele, B., & Yavagal, D. R., on behalf of the American Heart Association Stroke Council. (2015). 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 46, 3021–3035.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e26–e30.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.
• Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513
• Saver, J. L., Goyal, M., Bonafe, A., Diener, H.-C., Levy, E. I., Pereira, V. M., et al. (2015). Stent retriever thrombectomy after intravenous t PA vs. t PA alone in stroke. The New England Journal of Medicine, 372 (24), 2285–2295.

Recent clinical studies (e.g., AURORA, BEST, BASICS, BAOCHE, ATTENTION) have evaluated stroke disability at 90 days following endovascular therapy (EVT) for patients with large vessel occlusions. Patients undergoing EVT were more likely to achieve favorable outcomes and functional independence as assessed by mRS score of 0-2 when compared to medical management.

Recent clinical studies (e.g., AURORA, BEST, BASICS, BAOCHE, ATTENTION) have evaluated stroke disability at 90 day following endovascular therapy (EVT) for patients with large vessel occlusions. Patients undergoing EVT were more likely to achieve favorable outcomes and functional independence as assessed by mRS score of 0-2 when compared to medical management. (Palaniappan, L. P., et al., 2026).

• Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks E. Guidelines for the Early Management of Adults with Ischemic Stroke: A Guideline From the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1675-1678.
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• Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.
• Demchuk AM, Goyal M, Monon BK, Eesa M, Ryckborst KJ, Kamal N, et. al. Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial: methodology. Int J Stroke. 2015 Apr;10(3): 429-38.
• Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.
• Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:857.
• Martin, S.S., Aday, A.W., Allen, N.B., Almarzooq, Z.I., Anderson, C.A.M., Arora, P.,…Palaniappan, L.P. “2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.” [In eng]. Circulation 151, (Feb 25 2025): e354.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e10-e11.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
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• Schwamm LH, Holloway RG, Amarenco P. Audebert HJ, Bakas T, Chumbler NR, Handschu R, Jauch EC, Knight WA IV, Levine SR, Mayberg M, Meyer BC, Meyers PM, Skalabrin E, Wechsler LR; American Heart Association Stroke Council; Interdisciplinary Council on Peripheral Vascular Disease. A review of the evidence for the use of telemedicine within stroke systems of care: a scientific statement for the American Heart Association/American Stroke Association. Stroke. 2009;40:2616-2634.
• The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. New England Journal of Medicine 1995;333:1581-1587.
• Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.
• Wilson JT, Hareendran A, Hendry A, Potter J. Bone I, Muir KW. Reliability of the modified Rankin scale across multiple raters: benefits of a structured interview. Stroke. 2005;36:777-781.

• Campbell, B. C. V., Mitchell, P. J., Kleinig, T. J., Dewey, H. M., Churilov, L., Yassi, N., et al. (2015). Endovascular therapy for ischemic stroke with perfusion imaging selection. The New England Journal of Medicine, 372 (11), 1009–1017.
• Demchuk, A. M., Goyal, M., Menon, B. K., Eesa, M., Ryckborst, K. J., Kamal, N., et al. (2015). Endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing CT to recanalization times (ESCAPE) trial: Methodology. International Journal of Stroke, 10 (3), 429–438.
• Leifer, D., Bravata, D. M., Connors, J. J., III, Hinchey, J. A., Jauch, E. C., Johnston, S. C., Latchaw, R., Likosky, W., Ogilvy, C., Qureshi, A. I., Summers, D., Sung, G. Y., Williams, L. S., & Zorowitz, R., on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. (2011). Metrics for measuring quality of care in comprehensive stroke centers: Detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42, 853-54.
• Martin, S. S., Aday, A. W., Allen, N. B., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., … Palaniappan, L. P. (2025). 2025 heart disease and stroke statistics: A report of U.S. and global data from the American Heart Association. Circulation, 151, e354.
• Palaniappan, L. P., Allen, N. B., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., Avery, C. L., Baker-Smith, C. M., Bansal, N., Currie, M. E., Earlie, R. S., Fan, W., Fetterman, J. L., Barone Gibbs, B., Heard, D. G., Hiremath, S., Hong, H., Hyacinth, H. I., Ibeh, C., Jiang, T., … Khan, S. S. (2026). 2026 heart disease and stroke statistics: A report of U.S. and global data from the American Heart Association. Circulation. Advance online publication. https://doi.org/10.1161/CIR.0000000000001412
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e10–e11.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.
• Saver, J. L., Goyal, M., Bonafe, A., Diener, H.-C., Levy, E. I., Pereira, V. M., et al. (2015). Stent retriever thrombectomy after intravenous t PA vs. t PA alone in stroke. The New England Journal of Medicine, 372 (24), 2285–2295.

Endovascular therapy (EVT) is now the standard of care for treatment of acute ischemic stroke due to large-vessel occlusion (LVO). In 2015, the American Heart Association/American Stroke Association published a focused update to the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke regarding endovascular treatment (Powers WJ, et. al., 2015). Endovascular therapy with a stent retriever is recommended for eligible patients. The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances, but stent retrievers remain the first choice (Powers WJ, et. al., 2018).

To ensure benefit, reperfusion to TICI 2B/3 should be achieved as early as possible and within 6 hours of stroke onset. The DAWN Clinical Trial Investigators (Nogueira RG, et. al., 2018) reported the benefits of mechanical thrombectomy in the extended window up to 24 hours of last known well for select patients meeting certain criteria. As with IV alteplase (t-PA), reduced time from symptom onset to reperfusion with EVT is highly associated with better clinical outcomes. Recent recommendations from the Society of Vascular and Interventional Neurology (SVIN) offer procedural metrics which include time from hospital arrival to groin puncture less than 90 minutes, and time from groin puncture to TICI 2B or better or conclusion of procedure less than 60 minutes (English JD, et. al., 2016).

Endovascular thrombectomy (EVT) with a stent retriever is the standard of care for treatment of acute ischemic stroke from anterior circulation proximal large-vessel occlusion (LVO), (Powers W.J., et al., 2018). Reperfusion to TICI 2B/3 should be achieved as early as possible, preferably within 6 hours of stroke onset. The DAWN Clinical Trial Investigators, (Nogueira R.G., et al., 2018), reported the benefits of mechanical thrombectomy in the extended window up to 24 hours of last known well for select patients meeting certain criteria. Time from stroke onset to hospital arrival , initial NIHSS score, prestroke mRS, ASPECTS, patient age, and other factors should be considerations when deciding a treatment window between 6 and 24 hours (Prabhakaran, S., et al., 2026). As with IV alteplase (t-PA), reduced time from symptom onset to reperfusion with EVT is highly associated with better clinical outcomes. Recommendations from the Society of Vascular and Interventional Neurology (SVIN) offer procedural metrics which include time from hospital arrival to groin puncture less than 90 minutes, and time from groin puncture to TICI 2B or better or conclusion of procedure less than 60 minutes (English J.D., et al., 2016).

• Adams HP, Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Kwiatkowski T, Lyden PD, Marler JR, Torner J, et. al. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. Circulation. 1996;94:1167-1174.
• Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et. al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. NEJM. 2018;378(8): 708-718.
• Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.
• Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 focused update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;51:210-—47.
• Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.
• Demchuk AM, Goyal M, Monon BK, Eesa M, Ryckborst KJ, Kamal N, et. al. Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial: methodology. Int J Stroke. 2015 Apr;10(3): 429-38.
• English JD, Yavagal DR, Gupta R, Janardhan V, Zaidat OO, Xavier AR, Nogueira RG, Kirmani JF, Jovin TG. Mechanical thrombectomy-ready comprehensive stroke center requirements and endovascular stroke systems of care: recommendations from the endovascular stroke standards committee of the Society of Vascular and interventional Neurology (SVIN). Intervent Neurol. 2015;4:138-50.
• Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.
• Khatari P, Abruzzo T, Yeatts SD, Nichols C, Broderick JP, Tomsick TA; IMS I and II Investigators. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009 Sep 29;73(13):1066-72.
• Kole M, Amin B, Marin H, Russman A, Sanders W. Intracranial angioplasty and stent placement for direct cerebral revascularization o nonacute intracranial occlusions and near occlusions. Applications/LocalApps. NeuroSurg Focus. 2009; 26(3): E3.
• Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42; 857.
• Menon BK, Saver JL, Prabhakaran S, Reeves M, Liang L, Olson DWM, Peterson ED, Hernandez AF, Fonarow GC, Schwamm LH, Smith EE. Risk score for intracranial hemorrhage in patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator. Stroke. 2012;43: 1-9.
• Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et. al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. NEJM. 2018;378(1): 11-21.
• Powers WJ, Derdeyn CP, Biller J, Coffey CS, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell CS, Meschia JF, Ovbiagele B, Yavagal DR, on behalf of the American Heart Association Stroke Council. 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46; 3021-3035.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e26-e30.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
• Pride GL, Fraser JF, Gupta R, Alberts MJ, Rutledge JN, Fowler R, et. al. Prehospital care delivery and triage of stroke with emergent large vessel occlusion (LVO): report of the Standards and Guidelines Committee of the Society of Neurointerventional Surgery (SNIS). Applications/LocalApps. NeuroIntervent Surg. 2016;0:1-11.
• Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke.
• Sacks D, Black CM, Cognard C, Connors III JJ, Frei D, Gupta R, Jovin TG, Kluck B, Meyers PM, Murphy KJ, Ramee S, Rϋfenacht DA, Stallmeyer MJB, Vorwerk D. Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol. 2013;24:151-163.
• Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.
• Sharma VK, Teoh HL, Wong LYH, Su J, Ong BKC, and Chan BLP. Recanalization therapies in acute ischemic stroke: pharmacological agents, devices, and combinations. Stroke Research and Treatment. 2010.
• Sims JR, Gharai R, Schaefer PW, Vangel M, Rosenthal ES, Lev MH, Schwamm LH. ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes. Neurology. 2009;72:2104-2110.
• Tomsick T, Broderick J, Carrosella J, Khatari P, Hill M, Palesch Y, Khoury J; Interventional Management of Stroke II Investigators. Revascularizaton results in the Interventional Management of Stroke II Trial. American Journal of Neuroradiology. 2008 Mar; 29(3): 582-587.
• Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.

• Albers, G. W., Marks, M. P., Kemp, S., Christensen, S., Tsai, J. P., Ortega Gutierrez, S., et al. (2018). Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. The New England Journal of Medicine, 378 (8), 708–718.
• Campbell, B. C. V., Mitchell, P. J., Kleinig, T. J., Dewey, H. M., Churilov, L., Yassi, N., et al. (2015). Endovascular therapy for ischemic stroke with perfusion imaging selection. The New England Journal of Medicine, 372 (11), 1009–1017.
• Demchuk, A. M., Goyal, M., Menon, B. K., Eesa, M., Ryckborst, K. J., Kamal, N., et al. (2015). Endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing CT to recanalization times (ESCAPE) trial: Methodology. International Journal of Stroke, 10 (3), 429–438.
• English, J. D., Yavagal, D. R., Gupta, R., Janardhan, V., Zaidat, O. O., Xavier, A. R., Nogueira, R. G., Kirmani, J. F., & Jovin, T. G. (2015). Mechanical thrombectomy ready comprehensive stroke center requirements and endovascular stroke systems of care: Recommendations from the Endovascular Stroke Standards Committee of the Society of Vascular and Interventional Neurology (SVIN). Interventional Neurology, 4, 138–150.
• Leifer, D., Bravata, D. M., Connors, J. J., III, Hinchey, J. A., Jauch, E. C., Johnston, S. C., Latchaw, R., Likosky, W., Ogilvy, C., Qureshi, A. I., Summers, D., Sung, G. Y., Williams, L. S., & Zorowitz, R. (2011). Metrics for measuring quality of care in comprehensive stroke centers: Detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42, 853-54.
• Menon, B. K., Saver, J. L., Prabhakaran, S., Reeves, M., Liang, L., Olson, D. W. M., Peterson, E. D., Hernandez, A. F., Fonarow, G. C., Schwamm, L. H., & Smith, E. E. (2012). Risk score for intracranial hemorrhage in patients with acute ischemic stroke treated with intravenous tissue type plasminogen activator. Stroke, 43, 1–9.
• Nogueira, R. G., Jadhav, A. P., Haussen, D. C., Bonafe, A., Budzik, R. F., Bhuva, P., et al. (2018). Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. The New England Journal of Medicine, 378 (1), 11–21.
• Powers, W. J., Derdeyn, C. P., Biller, J., Coffey, C. S., Jauch, E. C., Johnston, K. C., Johnston, S. C., Khalessi, A. A., Kidwell, C. S., Meschia, J. F., Ovbiagele, B., & Yavagal, D. R., on behalf of the American Heart Association Stroke Council. (2015). 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 46, 3021–3035.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e26–e30.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.
• Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513
• Pride, G. L., Fraser, J. F., Gupta, R., Alberts, M. J., Rutledge, J. N., Fowler, R., et al. (2016). Prehospital care delivery and triage of stroke with emergent large vessel occlusion (LVO): Report of the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery (SNIS). Journal of NeuroInterventional Surgery, 0, 1–11.
• Saver, J. L., Goyal, M., Bonafe, A., Diener, H.-C., Levy, E. I., Pereira, V. M., et al. (2015). Stent retriever thrombectomy after intravenous t PA vs. t PA alone in stroke. The New England Journal of Medicine, 372 (24), 2285–2295.

Endovascular therapy (EVT) is now the standard of care for treatment of acute ischemic stroke due to large-vessel occlusion (LVO). In 2015, the American Heart Association/American Stroke Association published a focused update to the 2013 Guidelines for the Early Management of Patients with Acute Ischemic Stroke regarding endovascular treatment (Powers WJ, et. al., 2015). Endovascular therapy with a stent retriever is recommended for eligible patients. The use of mechanical thrombectomy devices other than stent retrievers as first-line devices for mechanical thrombectomy may be reasonable in some circumstances, but stent retrievers remain the first choice (Powers WJ, et. al., 2018).

To ensure benefit, reperfusion to TICI 2B/3 should be achieved as early as possible and within 6 hours of stroke onset. The DAWN Clinical Trial Investigators (Nogueira RG, et. al., 2018) reported the benefits of mechanical thrombectomy in the extended window up to 24 hours of last known well for select patients meeting certain criteria. As with IV alteplase (t-PA), reduced time from symptom onset to reperfusion with EVT is highly associated with better clinical outcomes. Recent recommendations from the Society of Vascular and Interventional Neurology (SVIN) offer procedural metrics which include time from hospital arrival to groin puncture less than 90 minutes, and time from groin puncture to TICI 2B or better or conclusion of procedure less than 60 minutes (English JD, et. al., 2016).

Endovascular thrombectomy (EVT) with a stent retriever is the standard of care for treatment of acute ischemic stroke from anterior circulation proximal large-vessel occlusion (LVO), (Powers W.J., et al., 2018). Reperfusion to TICI 2B/3 should be achieved as early as possible, preferably within 6 hours of stroke onset. The DAWN Clinical Trial Investigators, (Nogueira R.G., et al., 2018), reported the benefits of mechanical thrombectomy in the extended window up to 24 hours of last known well for select patients meeting certain criteria. Time from stroke onset to hospital arrival , initial NIHSS score, prestroke mRS, ASPECTS, patient age, and other factors should be considerations when deciding a treatment window between 6 and 24 hours (Prabhakaran, S., et al., 2026). As with IV alteplase (t-PA), reduced time from symptom onset to reperfusion with EVT is highly associated with better clinical outcomes. Recommendations from the Society of Vascular and Interventional Neurology (SVIN) offer procedural metrics which include time from hospital arrival to groin puncture less than 90 minutes, and time from groin puncture to TICI 2B or better or conclusion of procedure less than 60 minutes (English J.D., et al., 2016).

• Adams HP, Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, Kwiatkowski T, Lyden PD, Marler JR, Torner J, et. al. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke. Circulation. 1996;94:1167-1174.
• Albers GW, Marks MP, Kemp S, Christensen S, Tsai JP, Ortega-Gutierrez S, et. al. Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. NEJM. 2018;378(8): 708-718.
• Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.
• Antman EM, Hand M, Armstrong PW, Bates ER, Green LA, Halasyamani LK, et al. 2007 focused update of the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Group to Review New Evidence and Update the ACC/AHA 2004 Guidelines for the Management of Patients With ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;51:210-—47.
• Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, et. al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. NEJM. 2015 Mar;372(11): 1009-17.
• Demchuk AM, Goyal M, Monon BK, Eesa M, Ryckborst KJ, Kamal N, et. al. Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial: methodology. Int J Stroke. 2015 Apr;10(3): 429-38.
• English JD, Yavagal DR, Gupta R, Janardhan V, Zaidat OO, Xavier AR, Nogueira RG, Kirmani JF, Jovin TG. Mechanical thrombectomy-ready comprehensive stroke center requirements and endovascular stroke systems of care: recommendations from the endovascular stroke standards committee of the Society of Vascular and interventional Neurology (SVIN). Intervent Neurol. 2015;4:138-50.
• Jauch EC, Saver JL, Adams HP Jr, Bruno A, Connors JJ, Demaerschalk BM, Khatri P, et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:32-36.
• Khatari P, Abruzzo T, Yeatts SD, Nichols C, Broderick JP, Tomsick TA; IMS I and II Investigators. Good clinical outcome after ischemic stroke with successful revascularization is time-dependent. Neurology. 2009 Sep 29;73(13):1066-72.
• Kole M, Amin B, Marin H, Russman A, Sanders W. Intracranial angioplasty and stent placement for direct cerebral revascularization o nonacute intracranial occlusions and near occlusions. Applications/LocalApps. NeuroSurg Focus. 2009; 26(3): E3.
• Leifer D, Bravata DM, Connors JJ III, Hinchey JA, Jauch EC, Johnston SC, Latchaw R, Likosky W, Ogilvy C, Qureshi AI, Summers D, Sung GY, Williams LS, Zorowitz R, on behalf of the American Heart Association Special Writing Group of the Stroke Council, Atherosclerotic Peripheral Vascular Disease Working Group and Council on Cardiovascular Surgery and Anesthesia, and Council on Cardiovascular Nursing. Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42; 857.
• Menon BK, Saver JL, Prabhakaran S, Reeves M, Liang L, Olson DWM, Peterson ED, Hernandez AF, Fonarow GC, Schwamm LH, Smith EE. Risk score for intracranial hemorrhage in patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator. Stroke. 2012;43: 1-9.
• Nogueira RG, Jadhav AP, Haussen DC, Bonafe A, Budzik RF, Bhuva P, et. al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. NEJM. 2018;378(1): 11-21.
• Powers WJ, Derdeyn CP, Biller J, Coffey CS, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell CS, Meschia JF, Ovbiagele B, Yavagal DR, on behalf of the American Heart Association Stroke Council. 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46; 3021-3035.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e26-e30.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
• Pride GL, Fraser JF, Gupta R, Alberts MJ, Rutledge JN, Fowler R, et. al. Prehospital care delivery and triage of stroke with emergent large vessel occlusion (LVO): report of the Standards and Guidelines Committee of the Society of Neurointerventional Surgery (SNIS). Applications/LocalApps. NeuroIntervent Surg. 2016;0:1-11.
• Rha JH, Saver JL. The impact of recanalization on ischemic stroke outcome: a meta-analysis. Stroke.
• Sacks D, Black CM, Cognard C, Connors III JJ, Frei D, Gupta R, Jovin TG, Kluck B, Meyers PM, Murphy KJ, Ramee S, Rϋfenacht DA, Stallmeyer MJB, Vorwerk D. Multisociety consensus quality improvement guidelines for intraarterial catheter-directed treatment of acute ischemic stroke from the American Society of Neuroradiology, Canadian Interventional Radiology Association, Cardiovascular and interventional Radiological Society of Europe, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, European Society of Minimally Invasive Neurological Therapy, and Society of Vascular and Interventional Neurology. J Vasc Interv Radiol. 2013;24:151-163.
• Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, et. al. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. NEJM. 2015 Apr: 1-11.
• Sharma VK, Teoh HL, Wong LYH, Su J, Ong BKC, and Chan BLP. Recanalization therapies in acute ischemic stroke: pharmacological agents, devices, and combinations. Stroke Research and Treatment. 2010.
• Sims JR, Gharai R, Schaefer PW, Vangel M, Rosenthal ES, Lev MH, Schwamm LH. ABC/2 for rapid clinical estimate of infarct, perfusion, and mismatch volumes. Neurology. 2009;72:2104-2110.
• Tomsick T, Broderick J, Carrosella J, Khatari P, Hill M, Palesch Y, Khoury J; Interventional Management of Stroke II Investigators. Revascularizaton results in the Interventional Management of Stroke II Trial. American Journal of Neuroradiology. 2008 Mar; 29(3): 582-587.
• Turk AS, Frei D, Fiorella D, Mocco J, Baxter B, Siddiqui A, et. al. ADAPT FAST study: a direct aspiration first pass technique for acute stroke thrombectomy. J Neurointerv Surg. 2014 May;694): 260-4.

• Albers, G. W., Marks, M. P., Kemp, S., Christensen, S., Tsai, J. P., Ortega Gutierrez, S., et al. (2018). Thrombectomy for stroke at 6 to 16 hours with selection by perfusion imaging. The New England Journal of Medicine, 378 (8), 708–718.
• Campbell, B. C. V., Mitchell, P. J., Kleinig, T. J., Dewey, H. M., Churilov, L., Yassi, N., et al. (2015). Endovascular therapy for ischemic stroke with perfusion imaging selection. The New England Journal of Medicine, 372 (11), 1009–1017.
• Demchuk, A. M., Goyal, M., Menon, B. K., Eesa, M., Ryckborst, K. J., Kamal, N., et al. (2015). Endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing CT to recanalization times (ESCAPE) trial: Methodology. International Journal of Stroke, 10 (3), 429–438.
• English, J. D., Yavagal, D. R., Gupta, R., Janardhan, V., Zaidat, O. O., Xavier, A. R., Nogueira, R. G., Kirmani, J. F., & Jovin, T. G. (2015). Mechanical thrombectomy ready comprehensive stroke center requirements and endovascular stroke systems of care: Recommendations from the Endovascular Stroke Standards Committee of the Society of Vascular and Interventional Neurology (SVIN). Interventional Neurology, 4, 138–150.
• Leifer, D., Bravata, D. M., Connors, J. J., III, Hinchey, J. A., Jauch, E. C., Johnston, S. C., Latchaw, R., Likosky, W., Ogilvy, C., Qureshi, A. I., Summers, D., Sung, G. Y., Williams, L. S., & Zorowitz, R. (2011). Metrics for measuring quality of care in comprehensive stroke centers: Detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 42, 853-54.
• Menon, B. K., Saver, J. L., Prabhakaran, S., Reeves, M., Liang, L., Olson, D. W. M., Peterson, E. D., Hernandez, A. F., Fonarow, G. C., Schwamm, L. H., & Smith, E. E. (2012). Risk score for intracranial hemorrhage in patients with acute ischemic stroke treated with intravenous tissue type plasminogen activator. Stroke, 43, 1–9.
• Nogueira, R. G., Jadhav, A. P., Haussen, D. C., Bonafe, A., Budzik, R. F., Bhuva, P., et al. (2018). Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. The New England Journal of Medicine, 378 (1), 11–21.
• Powers, W. J., Derdeyn, C. P., Biller, J., Coffey, C. S., Jauch, E. C., Johnston, K. C., Johnston, S. C., Khalessi, A. A., Kidwell, C. S., Meschia, J. F., Ovbiagele, B., & Yavagal, D. R., on behalf of the American Heart Association Stroke Council. (2015). 2015 AHA/ASA focused update of the 2013 guidelines for the early management of patients with acute ischemic stroke regarding endovascular treatment: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 46, 3021–3035.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e26–e30.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.
• Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513
• Pride, G. L., Fraser, J. F., Gupta, R., Alberts, M. J., Rutledge, J. N., Fowler, R., et al. (2016). Prehospital care delivery and triage of stroke with emergent large vessel occlusion (LVO): Report of the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery (SNIS). Journal of NeuroInterventional Surgery, 0, 1–11.
• Saver, J. L., Goyal, M., Bonafe, A., Diener, H.-C., Levy, E. I., Pereira, V. M., et al. (2015). Stent retriever thrombectomy after intravenous t PA vs. t PA alone in stroke. The New England Journal of Medicine, 372 (24), 2285–2295.

Mental health providers that value and respect an individual's autonomy, independence and safety seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003).

To:

The use of restraints is increasingly viewed as an intervention of last resort and growing efforts to reduce the use of restraints emphasize preventing physical or psychological harm as well as ensuring the protection of patient autonomy and dignity (Wasser et al., 2023).

Providers also seek to prevent violence or aggression from occurring in their treatment environments by focusing their attention on prevention activities that have a growing evidence base (Donat, 2003).

To:

In preventing escalations of violence or aggression, providers should employ a comprehensive initial and ongoing assessment including assessing risk for aggression using a standardized tool, ensure active patient participation in developing treatment plans and include interventions that have been successful in preventing escalation in the past (American Psychiatric Nurses Association [APNA], 2022).

(APA, 2022)

To:

(American Psychiatric Association, 2022)

Selected references

To:

To:

Mental health providers that value and respect an individual's autonomy, independence and safety seek to avoid the use of dangerous or restrictive interventions at all times (Donat, 2003).

To:

The use of seclusion is increasingly viewed as an intervention of last resort and reducing the use of seclusion can align inpatient psychiatric care that values and respects patients’ rights and autonomy (Konnyu et al., 2023).

Providers also seek to prevent violence or aggression from occurring in their treatment environments by focusing their attention on prevention activities that have a growing evidence base (Donat, 2003).

To:

In preventing escalations of violence or aggression, providers should employ a comprehensive initial and ongoing assessment including assessing risk for aggression using a standardized tool, ensure active patient participation in developing treatment plans and include interventions that have been successful in preventing escalation in the past (American Psychiatric Nurses Association [APNA], 2022).

(APA, 2022)

To:

(American Psychiatric Association, 2022)

Selected references

To:

To:

Influenza activity most often peaks in February, but can peak rarely as early as November and as late as April.

To:

Influenza activity most often peaks in February, but can peak rarely as early as November and as late as April (Grohskopf et al., 2021).

In order to protect as many people as possible before influenza activity increases, most flu vaccine is administered in September through November, but vaccine is recommended to be administered throughout the influenza season as well.

To:

In order to protect as many people as possible before influenza activity increases, most flu vaccine is administered in September through November, but vaccine is recommended to be administered throughout the influenza season as well (Grohskopf et al., 2025).

Rationale

An estimated 9.3 to 41 million people in the United States get influenza every season.

To:

An estimated 9.3 to 51 million people in the United States get influenza every season (Centers for Disease Control and Prevention [CDC], 2024a).

Each year approximately 120,000 to 710,000 people in the US are hospitalized with complications from influenza and between 6,300 and 52,000 die from the disease and its complications (Center for Disease Control and Prevention [CDC], 2024a).

To:

Each year approximately 120,000 to 710,000 people in the US are hospitalized with complications from influenza and between 6,300 and 52,000 die from the disease and its complications (CDC, 2024a).

Combined with pneumonia, influenza is in the nation’s top 10 leading causes of death for ages 1 through 44 (CDC, 2023).

To:

In 2024, influenza, combined with pneumonia, is in the nation’s top 10 leading causes of death for ages 1 through 44 and those 65 and older (CDC, n.d.).

The Advisory Committee on Immunization Practices (ACIP) recommends seasonal influenza vaccination for all persons 6 months of age and older to highlight the importance of preventing influenza.

To:

The Advisory Committee on Immunization Practices (ACIP) recommends seasonal influenza vaccination for all persons 6 months of age and older to highlight the importance of preventing influenza (Grohskopf et al., 2025).

Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to persons 6 months of age or older.

To:

Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to persons 6 months of age or older (CDC, 2024c).

Selected references

Benowitz I, Esposito DB, Gracey KD, Shapiro ED, Vazquez M. Influenza vaccine given to pregnant women reduces hospitalization due to influenza in their infants.CID. December 2010; 51 (12): 1355-1361.

Carr S, Allison Kim J, et al. Safety and immunogenicity of live attenuated and inactivated influenza vaccines in children with cancer. J Infect Dis.2011:204:1475-1482.

Centers for Disease Control and Prevention. (2013). Estimated Influenza Illnesses and Hospitalizations Averted by Influenza Vaccination — United States,2012–13 Influenza Season. MMWR. 2013;62(49):997-1000.

Centers for Disease Control and Prevention. (2017). Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2017-2018. MMWR, August 17, 2017;62(RR07); 1-20.

To:

To:

To:

To:

Chung EY, Huang L, and Schneider L. Safety of influenza vaccine administration in egg-allergic patients. Pediatrics. 2010 May;125(5):e1024-30. Epub 2010 Apr 5.

Darvishiana M, Gefenaitea G, Turnerc RM, Pechlivanogloua P, Van der HoekeW, Van den Heuvelb ER, Haka E (2014). After adjusting for bias in meta-analysis seasonal influenza vaccine remains effective in community-dwelling elderly. JClin Epidemiol 2014;67:734-744.

To:

Grohskopf, L. A., Alyanak, E., Ferdinands, J. M., Chung, J. R., Broder, K. R., Talbot, H. K., & Fry, A. M. (2021). Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices, United States, 2021–22 influenza season. MMWR Recommendations and Reports, 70(RR 5), 1–28.

Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007 March 1;44 Suppl2:S27-72.

To:

Naquin, A., O’Halloran, A., Ujamaa, D., Sundaresan, D., Masalovich, S., Cummings, C. N., Noah, K., Jain, S., Kirley, P. D., Alden, N. B., Austin, E., Meek, J., Yousey Hindes, K., Openo, K., Witt, L., Monroe, M. L., Henderson, J., Tellez Nunez, V., Lynfield, R., … Bozio, C. H. (2024). Laboratory confirmed influenza associated hospitalizations among children and adults — Influenza Hospitalization Surveillance Network, United States, 2010–2023. MMWR Surveillance Summaries, 73(SS 6), 1–18.

Nichol KL, Nordin J, Mullooly J, et al. Influenza Vaccination and Reduction in Hospitalizations for Cardiac Disease and Stroke among the Elderly. N Engl JMed. 2003;348:1322-1332.

Rubin L, Levin M, Ljungman P, et al. 2013 IDSA clinical practice guideline for vaccination of the immunocompromised host. Clin Infect Dis. 2014;58(3):e44-100. DOI: 10.1093/cid/cit684

The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean birth (CB) rates. Some hospitals’ CB rates were over 50%. Hospitals with CB rates at 15-20% have infant outcomes that are just as good and better maternal outcomes (Symum et al., 2023). There is no data that higher rates improve any outcomes, yet the CB rates continue to rise. This measure seeks to focus attention on the most variable portion of the CB epidemic, the term labor CB in nulliparous women. This population segment accounts for the large majority of the variable portion of the CB rate and is the area most affected by subjectivity.

As compared to other CB measures, what is different about NTSV CB rate (Primary CB in first births with term singleton pregnancies in head down position) is that there are clear cut quality improvement activities that can be done to address the differences. Main et al. (2012) found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates. The results showed if labor was forced when the cervix was not ready the outcomes were poorer. Rosenstein et al. (2021) also showed that labor and delivery guidelines can make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Berkowitz, et al.,1989; Goyert et al., 1989; Luthy et al., 2003, Symum et al., 2021). The dramatic variation in cesarean rates seen in all populations studied is striking. Cesarean rates varied tenfold in US hospitals nationwide across hospitals, from 7.1 % to 69.9 % and there was a 15-fold variation among low-risk women, from 2.4% to 36.5% (Kozhimannil et al., 2013).

A reduction in the number of nulliparous patients with live term singleton newborns in vertex position (NTSV) delivering by cesarean birth will result in increased patient safety, a substantial decrease in maternal and neonatal morbidity and substantial savings in health care costs. Successful quality improvement efforts incorporate audit and feedback strategies combined with provider and nurse education, guidelines and peer review.

The measure will assist health care organizations (HCOs) to track nulliparous patients with live term singleton newborns in vertex position delivering by cesarean birth to reduce the occurrence. Nulliparous women have 4-6 times the cesarean birth rate than multiparous women thus the NTSV population is the largest driver of primary cesarean birth rate (Sakala et al., 2020). NTSV has a large variation among facilities, thus identifying an important population on which to focus quality improvement efforts.

In accordance with the American College of Obstetricians and Gynecologists (ACOG) recommendations (2020), cesarean delivery is indicated for patients with active genital lesions of genital herpes or prodromal symptoms (i.e., vulvar pain or burning at delivery) that may indicate viral shedding. Therefore, the measure will exclude encounters with a diagnosis of active genital herpes.

In addition, the accepted approach to treat placenta accreta spectrum, or the range of pathologic adherence of the placenta that includes placenta increta, placenta percreta, and placenta accreta, as well as placenta previa, is cesarean delivery (ACOG & Society for Maternal-Fetal Medicine (SMFM), 2018). Vasa previa is an indication for cesarean delivery (SMFM Publications Committee, Sinkey, Odibo, & Dashe, 2015). Accordingly, placenta previa, vasa previa, and placenta accreta spectrum are all qualifying conditions to also be excluded from the measure.

Ultimately, a reduction in primary cesarean births will reduce the number of women having repeat cesarean births (almost 90% of mothers who have a primary cesarean birth will have subsequent cesarean birth (CDC, 2020)). Thus, improvement in the rates of cesarean birth for the first birth will reduce the morbidity of all future births and avoid all the controversies with trial of labor after cesarean/elective repeat cesareans.

To:

The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean birth (CB) rates. Some hospitals’ CB rates were over 50%. Hospitals with CB rates at 15% to 20% have infant outcomes that are just as good and better maternal outcomes (Symum & Zayas-Castro, 2023). There is no data that higher rates improve any outcomes, yet the CB rates continue to remain high. This measure seeks to focus attention on the most variable portion of the CB epidemic, the term labor CB in nulliparous patients. This population segment accounts for the large majority of the variable portion of the CB rate and is the area most affected by subjectivity.

As compared to other CB measures, what is different about Nulliparous, Term, Singleton, Vertex (NTSV) CB rate is that there are clear cut quality improvement activities that can be done to address the differences. Main et al. (2012) found that over 60% of the variation among hospitals can be attributed to first birth labor induction rates and first birth early labor admission rates. The results showed that if labor was forced when the cervix was not ready, the outcomes were poorer. Rosenstein et al. (2021) also showed if labor and delivery guidelines can make a difference in labor outcomes. Many authors have shown that physician factors, rather than patient characteristics or obstetric diagnoses are the major driver for the difference in rates within a hospital (Symum & Zayas-Castro, 2023). The dramatic variation in cesarean rates seen in all populations studied is striking. Cesarean rates varied tenfold in US hospitals nationwide across hospitals (Agency for Healthcare Research and Quality [AHRQ], 2002), from 7.1% to 69.9%, and there was a 15-fold variation among low-risk women, from 2.4% to 36.5% (Kozhimannil et al., 2013).

A reduction in the number of NTSV patients delivering by cesarean birth will result in increased patient safety, a substantial decrease in maternal and neonatal morbidity and substantial savings in health care costs (Main et al., 2019). Successful quality improvement efforts incorporate audit and feedback strategies combined with provider and nurse education, guidelines and peer review.

The measure will assist health care organizations to track NTSV patients delivering by cesarean birth to reduce the occurrence. Nulliparous patients have 4-6 times the cesarean birth rate than multiparous patients, thus the NTSV population is the largest driver of primary cesarean birth rate (Sakala et al., 2020). NTSV has a large variation among facilities, thus identifying an important population on which to focus quality improvement efforts.

In accordance with the American College of Obstetricians and Gynecologists (ACOG, 2020) recommendations, cesarean delivery is indicated for patients with active genital lesions of genital herpes or prodromal symptoms (i.e., vulvar pain or burning at delivery) that may indicate viral shedding. Therefore, the measure will exclude encounters with a diagnosis of active genital herpes.

In addition, the accepted approach to treat placenta accreta spectrum, or the range of pathologic adherence of the placenta that includes placenta increta, placenta percreta, and placenta accreta, as well as placenta previa, is cesarean delivery (ACOG & Society for Maternal-Fetal Medicine (SMFM), 2018). Vasa previa is an indication for cesarean delivery (SMFM Publications Committee et al., 2015). Accordingly, placenta previa, vasa previa, and placenta accreta spectrum are all qualifying conditions to also be excluded from the measure.

Ultimately, a reduction in primary cesarean births will reduce the number of patients having repeat cesarean births (almost 90% of mothers who have a primary cesarean birth will have subsequent cesarean birth [Osterman, 2020]). Thus, improvement in the rates of cesarean birth for the first birth will reduce the morbidity of all future births and avoid all the controversies with trial of labor after cesarean/elective repeat cesareans.

Selected References:

• Agency for Healthcare Research and Quality. (2002). AHRQ Quality Indicators Guide to Inpatient Quality Indicators: Quality of Care in Hospitals Volume, Mortality, and Utilization. Revision 4 (December 22, 2004). AHRQ Pub. No. 02-RO204.
• American College of Obstetricians and Gynecologists. (2000). Task Force on Cesarean Delivery Rates. Evaluation of Cesarean Delivery. (Developed under the direction of the Task Force on Cesarean Delivery Rates, Roger K. Freeman, MD, Chair, Arnold W. Cohen, MD, Richard Depp III, MD, Fredric D. Frigoletto Jr, MD, Gary D.V. Hankins, MD, Ellice Lieberman, MD, DrPH, M. Kathryn Menard, MD, David A. Nagey, MD, Carol W. Saffold, MD, Lisa Sams, RNC, MSN and ACOG Staff: Stanley Zinberg, MD, MS, Debra A. Hawks, MPH, and Elizabeth Steele)
• ACOG Practice Bulletin #220, Management of Genital Herpes in Pregnancy, May 2020
• American College of Obstetricians and Gynecologists, & Society for Maternal-Fetal Medicine (2018). Obstetric Care Consensus No. 7: Placenta Accreta Spectrum. Obstetrics and gynecology, 132(6), e259–e275.
• Bailit, J.L., Garrett, J.M., Miller, W.C., McMahon, M.J., & Cefalo, R.C. (2002). Hospital primary cesarean delivery rates and the risk of poor neonatal outcomes. Am J Obstet Gynecol. 187(3):721-7.
• Bailit, J. & Garrett, J. (2003). Comparison of risk-adjustment methodologies. Am J Obstet Gynecol.102:45-51.
• Bailit, J.L., Love, T.E., & Dawson, N.V. (2006). Quality of obstetric care and risk-adjusted primary cesarean delivery rates. Am J Obstet Gynecol.194:402.
• Bailit, J.L. (2007). Measuring the quality of inpatient obstetrical care. Ob Gyn Sur. 62:207-213.
• Berkowitz, G.S., Fiarman, G.S., Mojica, M.A., et al. (1989). Effect of physician characteristics on the cesarean birth rate. Am J Obstet Gynecol. 161:146-9.
• Center for Disease Control (2020). Recent trends in vaginal birth after cesarean delivery: United States, 2016-2018. Retrieved from National Center for Health Statistics: https://www.cdc.gov/nchs/products/databriefs/db359.htm
• Cleary, R., Beard, R.W., Chapple, J., Coles, J., Griffin, M., & Joffe, M. (1996). The standard primipara as a basis for inter-unit comparisons of maternity care. Br J Obstet Gynecol. 103:223-9.
• DiGiuseppe, D.L., Aron, D.C., Payne, S.M., Snow, R.J., Dieker, L., & Rosenthal, G.E. (2001). Risk adjusting cesarean delivery rates: a comparison of hospital profiles based on medical record and birth certificate data. Health Serv Res.36:959-77.
• Goyert, G.L., Bottoms, F.S., Treadwell, M.C., et al. (1989). The physician factor in cesarean birth rates. N Engl J Med.320:706-9.
• Kozhimannil, K. B., Law, M. R., & Virnig, B. A. (2013). Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health affairs (Project Hope), 32(3), 527–535. https://doi.org/10.1377/hlthaff.2012.1030
• Le Ray, C., Carayol, M., Zeitlin, J., Berat, G., & Goffinet, F. (2006). Level of perinatal care of the maternity unit and rate of cesarean in low-risk nulliparas. Am J Obstet Gynecol. 107:1269-77.
• Luthy, D.A., Malmgren, J.A., Zingheim, R.W., & Leininger, C.J. (2003). Physician contribution to a cesarean delivery risk model. Am J Obstet Gynecol.188:1579-85.
• Main E.K., Bloomfield, L., & Hunt, G. (2004). Development of a large-scale obstetric quality-improvement program that focused on the nulliparous patient at term. Am J Obstet Gynecol.190:1747-58.
• Main, E. K., Chang, S. C., Cape, V., Sakowski, C., Smith, H., & Vasher, J. (2019). Safety Assessment of a Large-Scale Improvement Collaborative to Reduce Nulliparous Cesarean Delivery Rates. Obstetrics and gynecology, 133(4), 613–623. https://doi.org/10.1097/AOG.0000000000003109
• Main, E.K., Moore, D., Farrell, B., Schimmel, L.D., Altman, R.J., Abrahams, C., et al., (2006). Is there a useful cesarean birth measure? Assessment of the nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality improvement. Am J Obstet Gynecol. 194:1644-51.
• Main, E. K., Morton, C. H., Melsop, K., Hopkins, D., Giuliani, G., & Gould, J. B. (2012). Creating a public agenda for maternity safety and quality in cesarean delivery. Obstetrics and gynecology, 120(5), 1194–1198. https://doi.org/10.1097/aog.0b013e31826fc13d
• Romano, P.S., Yasmeen, S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M. (2005). Coding of perineal lacerations and other complications of obstetric care in hospital discharge data. Am J Obstet Gynecol.106:717-25.
• Rosenstein, M. G., Chang, S. C., Sakowski, C., Markow, C., Teleki, S., Lang, L., Logan, J., Cape, V., & Main, E. K. (2021). Hospital Quality Improvement Interventions, Statewide Policy Initiatives, and Rates of Cesarean Delivery for Nulliparous, Term, Singleton, Vertex Births in California. JAMA, 325(16), 1631–1639. https://doi.org/10.1001/jama.2021.3816
• Sakala, C., Belanoff, C., & Declercq, E. R. (2020). Factors Associated with Unplanned Primary Cesarean Birth: Secondary Analysis of the Listening to Mothers in California Survey. BMC pregnancy and childbirth, 20(1), 462. https://doi.org/10.1186/s12884-020-03095-4
• Society of Maternal-Fetal (SMFM) Publications Committee, Sinkey, R. G., Odibo, A. O., & Dashe, J. S. (2015). SMFM consult series #37: Diagnosis and management of vasa previa. American Journal of Obstetrics & Gynecology, 213(5), 615-619. https://doi.org/10.1016/j.ajog.2015.08.031
• Symum, H., & Zayas-Castro, J. L. (2021). A Multistate Decomposition Analysis of Cesarean Rate Variations, Associated Health Outcomes, and Financial Implications in the United States. American journal of perinatology, 10.1055/s-0041-1736538. Advance online publication. https://doi.org/10.1055/s-0041-1736538
• U.S. Department of Health and Human Services. (n.d.). Reduce cesarean births among low-risk women with no prior births-MICH-06. Retrieved from Healthy People 2030: https://health.gov/healthypeople/objectives-and-data/browse-objectives/pregnancy-and-childbirth/reduce-cesarean-births-among-low-risk-women-no-prior-births-mich-06
• Yasmeen, S., Romano, P.S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M. (2006). Accuracy of obstetric diagnoses and procedures in hospital discharge data. Am J Obstet Gynecol. 194:992-1001.

To:

• Agency for Healthcare Research and Quality. (2002). AHRQ quality indicators - Guide to inpatient quality indicators: Quality of care in hospitals - Volume, mortality, and utilization. (AHRQ Publication No. 02-RO204). U.S. Department of Health and Human Services. https://www.ahrq.gov/downloads/pub/inpatqi/iqi_guide.pdf
• American College of Obstetricians and Gynecologists, & Society for Maternal-Fetal Medicine. (2018). Obstetric care consensus no. 7: Placenta accreta spectrum. Obstetrics & Gynecology, 132 (6), e259–e275. https://doi.org/10.1097/AOG.0000000000002983
• American College of Obstetricians and Gynecologists. (2014). ReVITALize: Obstetrics data definitions. https://www.acog.org/practice-management/health-it-and-clinical-informatics/revitalize-obstetrics-data-definitions
• American College of Obstetricians and Gynecologists. (2020). ACOG practice bulletin number 220: Management of genital herpes in pregnancy. Obstetrics & Gynecology, 135 (5), 1236–1238. https://doi.org/10.1097/AOG.0000000000003841
• Kozhimannil, K. B., Law, M. R., & Virnig, B. A. (2013). Cesarean delivery rates vary tenfold among US hospitals; reducing variation may address quality and cost issues. Health Affairs, 32 (3), 527–535. https://doi.org/10.1377/hlthaff.2012.1030
• Main, E. K., Chang, S. C., Cape, V., Sakowski, C., Smith, H., & Vasher, J. (2019). Safety assessment of a large-scale improvement collaborative to reduce nulliparous cesarean delivery rates. Obstetrics and Gynecology, 133 (4), 613–623. https://doi.org/10.1097/AOG.0000000000003109
• Main, E. K., Morton, C. H., Melsop, K., Hopkins, D., Giuliani, G., & Gould, J. B. (2012). Creating a public agenda for maternity safety and quality in cesarean delivery. Obstetrics and Gynecology, 120 (5), 1194–1198. https://doi.org/10.1097/aog.0b013e31826fc13d
• Osterman, M. J. K. (2020). Recent trends in vaginal birth after cesarean delivery: United States, 2016–2018 (NCHS Data Brief No. 359). National Center for Health Statistics. https://www.cdc.gov/nchs/products/databriefs/db359.htm
• Rosenstein, M. G., Chang, S. C., Sakowski, C., Markow, C., Teleki, S., Lang, L., Logan, J., Cape, V., & Main, E. K. (2021). Hospital quality improvement interventions, statewide policy initiatives, and rates of cesarean delivery for nulliparous, term, singleton, vertex births in California. JAMA, 325 (16), 1631–1639. https://doi.org/10.1001/jama.2021.3816
• Sakala, C., Belanoff, C., & Declercq, E. R. (2020). Factors associated with unplanned primary cesarean birth: Secondary analysis of the Listening to Mothers in California Survey. BMC Pregnancy and Childbirth, 20 (1), 462. https://doi.org/10.1186/s12884-020-03095-4
• Society of Maternal-Fetal (SMFM) Publications Committee, Sinkey, R. G., Odibo, A. O., & Dashe, J. S. (2015). #37: Diagnosis and management of vasa previa. American Journal of Obstetrics & Gynecology, 213 (5), 615-619. https://doi.org/10.1016/j.ajog.2015.08.031
• Symum, H., & Zayas-Castro, J. L. (2023). A multistate decomposition analysis of cesarean rate variations, associated health outcomes, and financial implications in the United States. American Journal of Perinatology, 40 (13), 1473-1483. https://doi.org/10.1055/s-0041-1736538

Narrative algorithm:

1. Start Cesarean birth logic. Run cases, which are included in the Perinatal Care Mother Initial Patient Population and pass the edits defined in the Clinical Data Processing Flow, through this measure.

1. Start Cesarean birth logic. Run cases, which are included in the Perinatal Care Mother Initial Patient Population and pass the edits defined in the Clinical Data Processing Flow, through this measure.

Exclusive human milk feeding for the first 6 months of neonatal life has long been the expressed goal of World Health Organization (WHO), Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). ACOG has recently reiterated its position (ACOG, 2018). A Cochrane review substantiates the benefits (Kramer et al., 2012). Much evidence has now focused on the prenatal and intrapartum period as critical for the success of exclusive (or any) human milk feeding (Centers for Disease Control and Prevention [CDC], 2020; CDC, 2013; Petrova et al., 2007; Taveras et al., 2004). Exclusive human milk feeding rate during birth hospital stay has been calculated by the California Department of Public Health for the last several years using newborn genetic disease testing data. Healthy People 2020 and the CDC have also been active in promoting this goal.

To:

Exclusive human milk feeding for the first 6 months of neonatal life has long been the expressed goal of World Health Organization [WHO], 2007, Department of Health and Human Services (DHHS), American Academy of Pediatrics (AAP) and American College of Obstetricians and Gynecologists (ACOG). ACOG has recently reiterated its position (ACOG, 2018). A Cochrane review substantiates the benefits (Kramer & Kakuma, 2012). Much evidence has now focused on the prenatal and intrapartum period as critical for the success of exclusive (or any) human milk feeding (Centers for Disease Control and Prevention [CDC], 2020; McGuire, 2014). Exclusive human milk feeding rate during birth hospital stay has been calculated by the California Department of Public Health (2020) for the last several years using newborn genetic disease testing data. Healthy People 2020 (National Center for Health Statistics, 2021) and the CDC have also been active in promoting this goal.

Selected References

• ACOG Committee Opinion No. 756: Optimizing Support for Breastfeeding as Part of Obstetric Practice. (2018). Obstetrics and gynecology, 132(4), e187–e196. https://doi.org/10.1097/AOG.0000000000002890
• California Department of Public Health. (2017). Division of Maternal, Child and Adolescent Health, Breastfeeding Initiative, In-Hospital Breastfeeding Initiation Data, Hospital of Occurrence: Available at: https://www.cdph.ca.gov/Programs/CFH/DMCAH/Breastfeeding/Pages/In-Hospital-Breastfeeding-Initiation-Data.aspx
• Centers for Disease Control and Prevention. (2020). Division of Nutrition, Physical Activity and Obesity. Breastfeeding Report Card. Available at: https://www.cdc.gov/breastfeeding/data/reportcard.htm
• Centers for Disease Control and Prevention. Strategies to Prevent Obesity and Other Chronic Diseases: The CDC Guide to Strategies to Support Breastfeeding Mothers and Babies. Atlanta: U.S. Department of Health and Human Services; 2013. Available at: https://www.cdc.gov/breastfeeding/pdf/bf-guide-508.pdf

• Kramer, M. S., & Kakuma, R. (2012). Optimal duration of exclusive breastfeeding. The Cochrane database of systematic reviews, 2012(8), CD003517. https://doi.org/10.1002/14651858.CD003517.pub2
• Meek, J.Y., & Noble, L., Section on Breastfeeding; Policy Statement: Breastfeeding and the Use of Human Milk. American Academy of Pediatrics July 2022; 150 (1). https://doi.org/10.1542/peds.2022-057988
• Perrine CG, Chiang KV, Anstey EH, et al. Implementation of Hospital Practices Supportive of Breastfeeding in the Context of COVID-19 — United States, July 15–August 20, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1767–1770. DOI: http://dx.doi.org/10.15585/mmwr.mm6947a3
• Petrova, A., Hegyi, T., & Mehta, R. (2007). Maternal race/ethnicity and one-month exclusive breastfeeding in association with the in-hospital feeding modality. Breastfeeding Medicine. 2(2):92-8.
• Taveras, E.M., Li, R., Grummer-Strawn, L., Richardson, M., Marshall, R., Rego, V.H., Miroshnik, I., & Lieu, T.A. (2004). Opinions and practices of clinicians associated with continuation of exclusive breastfeeding. Pediatrics. 113(4):e283-90.
• US Department of Health and Human Services. (2020). Healthy People 2020 Final Review. Washington, DC: US Department of Health and Human Services. Available at: https://www.cdc.gov/nchs/healthy_people/hp2020-final-review.htm
• World Health Organization. (2007). Indicators for assessing infant and young child feeding practices. Washington, DC, USA: World Health Organization. Available at: http://apps.who.int/iris/bitstream/10665/43895/1/9789241596664_eng.pdf

To:

• ACOG Committee Opinion No. 756 summary: Optimizing support for breastfeeding as part of obstetric practice. (2018). Obstetrics & Gynecology, 132 (4), 1086–1088. https://doi.org/10.1097/AOG.0000000000002891
• California Department of Public Health. (2020). In-hospital breastfeeding initiation data: Hospital of occurrence. https://www.cdph.ca.gov/Programs/CFH/DMCAH/Breastfeeding/Pages/Hospital-of-Occurrence-2020.aspx
• Centers for Disease Control and Prevention, Division of Nutrition, Physical Activity, and Obesity. (2022). Breastfeeding report card. https://www.cdc.gov/breastfeeding-data/media/pdfs/2024/06/2022-Breastfeeding-Report-Card-508.pdf
• Feltner, C., Weber, R. P., Stuebe, A., Grodensky, C. A., Orr, C., & Viswanathan, M. (2018). Breastfeeding programs and policies, breastfeeding uptake, and maternal health outcomes in developed countries. https://www.ncbi.nlm.nih.gov/books/NBK525106/
• Kramer, M. S., & Kakuma, R. (2012). Optimal duration of exclusive breastfeeding. Cochrane Database of Systematic Reviews, 2012 (8). https://doi.org/10.1002/14651858.cd003517.pub2
• McGuire, S. (2014). Centers for Disease Control and Prevention. 2013. Strategies to prevent obesity and other chronic diseases: The CDC guide to strategies to support breastfeeding mothers and babies. Atlanta, GA: U.S. Department of Health and Human Services, 2013. Advances in Nutrition, 5 (3), 291–292. https://doi.org/10.3945/an.114.005900
• Meek, J. Y., & Noble, L. (2022). Section on Breastfeeding. Policy statement: Breastfeeding and the use of human milk. Pediatrics, 150 (1). https://doi.org/10.1542/peds.2022-057988
• National Center for Health Statistics. (2021). Healthy People 2020 final review. Centers for Disease Control and Prevention. https://www.cdc.gov/nchs/healthy_people/hp2020-final-review.htm
• World Health Organization. (2007). Indicators for assessing infant and young child feeding practices. World Health Organization. http://apps.who.int/iris/bitstream/handle/10665/43895/9789241596664_eng.pdf

To:

The most important childbirth outcome for families is bringing home a healthy baby. While there have been measures developed to assess clinical practices and outcomes in preterm infants, there is a lack of metrics that assess the health outcomes of term infants who represent over 90% of all births. This measure addresses this gap and gauges adverse outcomes resulting in severe or moderate morbidity in otherwise healthy term infants without preexisting conditions (Fleischman, Oinuma, & Clark, 2010; Arham et al., 2025). This measure also uses length of stay (LOS) modifiers to guard against overcoding and undercoding of diagnoses. Importantly, this metric also serves as a balancing measure for other maternal measures such as Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean rates and early elective delivery rates. The purpose of a balancing measure is to guard against any unanticipated or unintended consequences of quality improvement activities for these measures.

Selected References

• Martin JA, Hamilton BE, Ventura SJ et al. Births: Final data for 2010. National vital statistics reports; vol 61 no1. Hyattsville, MD: National Center for health Statistics. 2012
• Russo, C. A (Thomson Reuters) and Andrews, R.M (AHRQ). Potentially Avoidable Injuries to mothers and Newborns During Childbirth, 2006. HCUP Statistical Brief # 74. June 2009. Agency for Healthcare Research and Quality. Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statsbriefs/sb74.pdf.
• Gregory KD, Fridman M, Shah S et al. Global measures of quality and patient safety-related childbirth outcomes: should we monitor adverse or ideal rates? Am J Obstet Gynecol 2009;200:681.e1-681.e7.
• Profit J, Zupancic JA, Gould JB et al. Implementing pay-for-performance in the neonatal intensive care unit. Pediatrics 2007;119:975-82
• American College of Obstetricians and Gynecologists. Operative Vaginal Delivery. (2020). Practice Bulletin, Number 219. Obstetrics and gynecology,135(4), e149–e159. https://doi.org/10.1097/AOG.0000000000003764
• Practice Bulletin No 178: Shoulder Dystocia. Obstet Gynecol. 2017 May;129(5):e123-e133. doi: 10.1097/AOG.0000000000002043. PMID: 28426618.
• Puopolo, K.M., Lynfield, R., & Cummings, J.J. (2019). Management of Infants at Risk for Group B Streptococcal Disease.American Academy of Pediatrics, 144 (2). https://doi.org/10.1542/peds.2019-1881
• Teitler, J. O., Plaza, R., Hegyi, T., Kruse, L., & Reichman, N. E. (2019). Elective deliveries and neonatal outcomes in full-term pregnancies. American Journal of Epidemiology, 188(4), 674–683. https://doi.org/10.1093/aje/kwz014
• Wilmink, F. A., Hukkelhoven, C. W., Lunshof, S., Mol, B. W., van der Post, J. A., & Papatsonis, D. N. (2010). Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry. American journal of obstetrics and gynecology, 202(3), 250.e1–250.e2508. https://doi.org/10.1016/j.ajog.2010.01.052
• Tita AT, Landon MB, Spong CY et al. Timing of Elective Repeat Cesarean Delivery at Term and Neonatal Outcomes. N Engl J Med 2009;360(2):111-20
• Hansen AK, Wisborg K, Uldbjerg N. Risk of respiratory morbidity in term infants delivered by elective cesarean section: cohort study. BMJ 2008;336:85
• Spong CY. Defining “Term” pregnancy: Recommendations from the defining “term” pregnancy workgroup. JAMA. 2013 Jun 19;309(23):2445-6.
• Zhang X and Kramer MS. Variations in Mortality and Morbidity by Gestational Age among Infants Born at Term. J Pediatr 2009;154:358-62
• Fleischman AR, Oinuma M and Clark SL. Rethinking the Definition of “Term Pregnancy”. Obstet Gynecol 2010;116(1)136-139
• Clark SL, Miller DD, Belfort MA, et al. Neonatal and maternal outcomes associated with elective term delivery. Am J Obstet Gynecol 2009;200:156.e1-156.e4
• Reddy UM, Bettegowda VR, Dias T et al. Term Pregnancy: A period of Heterogeneous Risk for Infant Mortality. Obstet Gynecol 2011;117:1279-1287
• "Unexpected Complications in Term Newborns.” California Maternal Quality Care Collaborative (CMQCC), 2018, www.cmqcc.org/focus-areas/quality-metrics/unexpected-complications-term-newborns.
  

To:

• American College of Obstetricians and Gynecologists. (2017). Practice Bulletin No. 178: Shoulder dystocia. Obstetrics & Gynecology, 129 (5), e123–e133. https://doi.org/10.1097/AOG.0000000000002043
• American College of Obstetricians and Gynecologists. (2020). Operative vaginal delivery (Practice Bulletin No. 219). Obstetrics & Gynecology, 135 (4), e149–e159. https://doi.org/10.1097/AOG.0000000000003764
• Arham, M., & Wróblewska Seniuk, K. (2025). Short and long term consequences of late preterm and early term birth. Children, 12 (7), 907. https://doi.org/10.3390/children12070907
• California Maternal Quality Care Collaborative. (n.d.). Unexpected complications in term newborns. Retrieved March 30, 2026, from https://www.cmqcc.org/focus-areas/quality-metrics/unexpected-complications-term-newborns
• Clark, S. L., Miller, D. D., Belfort, M. A., Dildy, G. A., Frye, D. K., & Meyers, J. A. (2009). Neonatal and maternal outcomes associated with elective term delivery. American Journal of Obstetrics and Gynecology, 200 (2), 156.e1–156.e6. https://doi.org/10.1016/j.ajog.2008.08.068
• Fleischman, A. R., Oinuma, M., & Clark, S. L. (2010). Rethinking the definition of “term pregnancy.” Obstetrics & Gynecology, 116 (1), 136–139. https://doi.org/10.1097/AOG.0b013e3181e24f28
• Gregory, K. D., Fridman, M., Shah, S., & Korst, L. M. (2009). Global measures of quality and patient safety related childbirth outcomes: Should we monitor adverse or ideal rates? American Journal of Obstetrics and Gynecology, 200 (6), 681.e1–681.e7. https://doi.org/10.1016/j.ajog.2009.02.033
• Hansen, A. K., Wisborg, K., Uldbjerg, N., & Henriksen, T. B. (2008). Risk of respiratory morbidity in term infants delivered by elective cesarean section: Cohort study. BMJ, 336 (7635), 85–87. https://doi.org/10.1136/bmj.39405.539282.be
• Martin, J. A., Hamilton, B. E., Ventura, S. J., Osterman, M. J. K., Wilson, E. C., & Mathews, T. J. (2012). Births: Final data for 2010. National Vital Statistics Reports, 61 (1), 1–72.
• Profit, J., Zupancic, J. A., Gould, J. B., & Petersen, L. A. (2007). Implementing pay for performance in the neonatal intensive care unit. Pediatrics, 119 (5), 975–982. https://doi.org/10.1542/peds.2006-1565
• Puopolo, K. M., Lynfield, R., Cummings, J. J., Committee on Fetus and Newborn, & Committee on Infectious Diseases. (2019). Management of infants at risk for group B streptococcal disease. Pediatrics, 144 (2). https://doi.org/10.1542/peds.2019-1881
• Reddy, U. M., Bettegowda, V. R., Dias, T., Yamada Kushnir, T., Ko, C. W., & Willinger, M. (2011). Term pregnancy: A period of heterogeneous risk for infant mortality. Obstetrics & Gynecology, 117 (6), 1279–1287. https://doi.org/10.1097/AOG.0b013e3182179e28
• Spong, C. Y. (2013). Defining “term” pregnancy: Recommendations from the Defining “Term” Pregnancy Workgroup. Journal of the American Medical Association, 309 (23), 2445–2446. https://doi.org/10.1001/jama.2013.6235
• Teitler, J. O., Plaza, R., Hegyi, T., Kruse, L., & Reichman, N. E. (2019). Elective deliveries and neonatal outcomes in full-term pregnancies. American Journal of Epidemiology, 188 (4), 674–683. https://doi.org/10.1093/aje/kwz014
• Tita, A. T. N., Landon, M. B., Spong, C. Y., Lai, Y., Leveno, K. J., Varner, M. W., Moawad, A. H., Caritis, S. N., Meis, P. J., Wapner, R. J., Sorokin, Y., Miodovnik, M., Carpenter, M., Peaceman, A. M., O’Sullivan, M. J., Sibai, B. M., Langer, O., Thorp, J. M., Ramin, S. M., & Mercer, B. M. (2009). Timing of elective repeat cesarean delivery at term and neonatal outcomes. New England Journal of Medicine, 360 (2), 111–120. https://doi.org/10.1056/NEJMoa0803267
• Wilmink, F. A., Hukkelhoven, C. W., Lunshof, S., Mol, B. W., van der Post, J. A., & Papatsonis, D. N. (2010). Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: A 7 year retrospective analysis of a national registry. American Journal of Obstetrics & Gynecology, 202 (3), 250.e1–250.e8. https://doi.org/10.1016/j.ajog.2010.01.052
• Zhang, X., & Kramer, M. S. (2009). Variations in mortality and morbidity by gestational age among infants born at term. Journal of Pediatrics, 154 , 358–362. https://doi.org/10.1016/j.jpeds.2008.09.013

In patients with acute ischemic stroke (AIS) and impaired mobility, intermittent pneumatic compression (IPC) or prophylactic low-dose subcutaneous heparin (UFH or LMWH) are recommended options to reduce the risk of deep vein thrombosis (DVT), unless contraindications exist. Elastic compression stockings or graduated compression stockings (GCS) are not recommended and may be harmful, resulting in skin breakdown, ulceration, and tissue necrosis (Prabhakaran, S., et al., 2026). Mechanical or pharmacological VTE prophylaxis are also recommended for patients with spontaneous intracerebral hemorrhage (ICH), (Greenberg, S., et al.,2022), and aneurysmal subarachnoid hemorrhage (aSAH) whose aneurysm has been repaired (Hoh, B., et al., 2023). Aspirin alone is not recommended as an agent to prevent VTE.

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Approximately two thirds of stroke survivors require rehabilitation (Winstein, C., et al., 2016); however, many patients never receive these services. High priorities include early mobilization and resumption of self-care activities as soon as possible after stroke. A considerable body of evidence indicates better clinical outcomes when patients with stroke are treated in a setting that provides coordinated, interdisciplinary stroke-related evaluation and services. Evaluation of a stroke survivor’s rehabilitation needs is best performed by a team that can include a physician with expertise in rehabilitation, nurses, physical therapists, occupational therapists, speech/language therapists, psychologists, and orthotists, (Ibid., 2016)). Assessment using a comprehensive, standardized tool, such as the Barthel Index or the Functional Independence Measure (FIM), is recommended. A post-acute care assessment is also beneficial when determining long-term functional outcomes, (Ibid., 2016). Effective rehabilitation interventions initiated early following stroke can enhance the recovery process and minimize functional disability. The primary goal of rehabilitation is to prevent complications, minimize impairments, and maximize function.

In patients with acute ischemic stroke (AIS), a formal, individualized, interdisciplinary assessment of the patient’s rehabilitation needs should be completed during the inpatient hospitalization, (Prabhakaran, S., et al., 2026). Early assessment and implementation of mild activity, such as range of motion (ROM), within 24-48 hours is recommended for patients with moderate ICH, but aggressive mobilization should be avoided and could worsen 14-day mortality, (Greenberg, S., et al., 2022). Validated scoring tools or patient-reported outcome measures can screen for physical, cognitive, behavioral, and quality of life (QOL) deficits prior to discharge, (Hoh, B., et al., 2023).

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For patients with a stroke due to a cardioembolic source (e.g., atrial fibrillation, mechanical heart valve), warfarin is recommended unless contraindicated. In recent years, novel oral anticoagulants (NOACs) have been developed and approved by the U.S. Food and Drug Administration (FDA) for stroke prevention, and may be considered as an alternative to warfarin for select patients. Anticoagulation therapy is not generally recommended for secondary stroke prevention in patients presumed to have a non-cardioembolic stroke.

Anticoagulants at doses to prevent venous thromboembolism are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or TIA.

There are separate guideline recommendations for venous thromboembolism (VTE) prevention after acute ischemic stroke, including extended deep vein thrombosis (DVT) prophylaxis for select patients. (Prabhakaran, S., et al., 2026). Anticoagulants such as enoxaparin and unfractionated heparin (UFH) at doses to prevent DVT are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or TIA.

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• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
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• Kleindorfer, D. O., Towfighi, A, Chaturvedi, S., Cockroft, K. M., Gutierrez, J., Lombardi-Hill, D., Kamel, H., Kernan, W. N., Kittner, S. J., Leira, E. C., Lennon, O., Meschia, J. F., Nguyen, T. N., Pollak, P. M., Santangeli, P., Sharrief, A. Z., Smith, S. C., Jr., Turan, T. N., & Williams, L. S. (2021). Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline from the American Heart Association/American Stroke Association. Stroke, 52 (7), e364–e467.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e26–e30.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.
• Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513

Furthermore, a prior stroke or transient ischemic attack (TIA) are among a limited number of predictors of high stroke risk within the population of patients with atrial fibrillation. Nonparoxysmal AF compared to paroxysmal AF has been associated with a higher risk of stroke in this patient population. Therefore, much emphasis has been placed on identifying methods for preventing recurrent ischemic stroke as well as preventing first stroke. Prevention strategies focus on the modifiable risk factors such as hypertension, smoking, and atrial fibrillation.

Anticoagulation therapy is recommended for secondary stroke prevention for ischemic stroke patients with AF, unless contraindicated. Globally, the use of direct oral anticoagulant medications has continued to increase since 2018 and the prevalence of vitamin K antagonist use decreased. However, about 10% of patients are still treated with antiplatelet medications only.

AF is also an important risk factor for stroke. Furthermore, a prior stroke or transient ischemic attack (TIA) are among a limited number of predictors of high stroke risk within the population of patients with atrial fibrillation. Nonparoxysmal AF compared to paroxysmal AF has been associated with a higher risk of stroke in this patient population. Therefore, much emphasis has been placed on identifying methods for preventing recurrent ischemic stroke as well as preventing first stroke. Prevention strategies focus on the modifiable risk factors such as hypertension, smoking, and atrial fibrillation.

• Berge, E., M. Abdelnoor, P. H. Nakstad, and P. M. Sandset. "Low Molecular-Weight Heparin Versus Aspirin in Patients with Acute Ischaemic Stroke and Atrial Fibrillation: A Double-Blind Randomised Study. Haest Study Group. Heparin in Acute Embolic Stroke Trial." [In eng]. Lancet 355, no. 9211 (Apr 8 2000): 1205-10.
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• Fuster, V., L. E. Ryden, D. S. Cannom, H. J. Crijns, A. B. Curtis, K. A. Ellenbogen, J. L. Halperin, et al. "Acc/Aha/Esc 2006 Guidelines for the Management of Patients with Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients with Atrial Fibrillation): Developed in Collaboration with the European Heart Rhythm Association and the Heart Rhythm Society." [In eng]. Circulation 114, no. 7 (Aug 15 2006): e257-354.
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• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e31-e32.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
• Saxena, R., and P. J. Koudstaal. "Anticoagulants for Preventing Stroke in Patients with Nonrheumatic Atrial Fibrillation and a History of Stroke or Transient Ischemic Attack (Review). ." Cochrane Database Syst Rev, no. 4 (2011): CD000185.
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• Campbell, L. A., Ammon, J. P., Kombathula, R., Muhammad, N., & Jackson, C. D. (2025). New atrial fibrillation guideline: Modify risk, control rhythm, prevent progression. Cleveland Clinic Journal of Medicine, 92 (5), 291–296. https://doi.org/10.3949/ccjm.92a.24067
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• Kornej, J., Börschel, C. S., Benjamin, E. J., & Schnabel, R. B. (2020). Epidemiology of atrial fibrillation in the 21st century: Novel methods and new insights. Circulation Research, 127 (1), 4–20.
• Martin, S. S., Aday, A. W., Allen, N. B., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., … Palaniappan, L. P. (2025). 2025 heart disease and stroke statistics: A report of US and global data from the American Heart Association. Circulation, 151, e333–e334.
• Palaniappan, L. P., Allen, N. B., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., Avery, C. L., Baker-Smith, C. M., Bansal, N., Currie, M. E., Earlie, R. S., Fan, W., Fetterman, J. L., Barone Gibbs, B., Heard, D. G., Hiremath, S., Hong, H., Hyacinth, H. I., Ibeh, C., Jiang, T., … Khan, S. S. (2026). 2026 heart disease and stroke statistics: A report of U.S. and global data from the American Heart Association. Circulation. Advance online publication. https://doi.org/10.1161/CIR.0000000000001412
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e26–e30.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.

The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke; however, as the NINDS investigators concluded, the earlier that IV thrombolytic therapy is initiated, the better the patient outcome. Therefore, the target for IV alteplase initiation remains within 3 hours of time last known well. The administration of IV alteplase beyond 3 hours of stroke symptom onset has not been FDA approved.

Although the benefit of IV alteplase has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for alteplase therapy in recent years. Updated recommendations from the AHA/ASA in 2019 identified IV tenecteplase (TNK) as a reasonable alternative to alteplase. In March, 2025, IV TNK received FDA-approval for the treatment of acute ischemic stroke (AIS) in adults. The approval is based on a large multi-center non-inferiority study demonstrating that the efficacy of TNK and alteplase are comparable. Symptomatic intracranial hemorrhage (ICH) is a potential complication with both agents. However, a systematic review of 26 studies comparing IV TNK with alteplase suggests slightly less risk of an event (RR 0.89, 95% CI, 0.65-1.23) with TNK (Martin, 2025).

The European Cooperative Acute Stroke Study (ECASS) III trial indicated that intravenous r-tPA (alteplase) can be given safely to, and can improve outcomes for, carefully selected patients treated 3 to 4.5 hours after stroke. More recently, guideline recommendations from the American Heart Association/American Stroke Association provide additional evidence supporting IV thrombolytic therapy initiation in time frames up to 24 hours for certain select acute ischemic stroke (AIS) patients meeting very specific clinical criteria. As the NINDS investigators concluded, guidelines continue to reinforce that patient outcomes are better with faster administration. Physicians with experience and skill in stroke management and the interpretation of CT scans should supervise treatment, (Prabhakaran, S., et al., 2026).

Although the benefit of IV thrombolytics has been well established, only a minority of patients with acute ischemic stroke actually receive this medication across the United States, despite the removal of many previous contraindications and warnings for therapy. In March 2025, IV tenecteplase (TNK) received FDA-approval for the treatment of AIS in adults. The approval is based on a large multi-center non-inferiority study demonstrating that the efficacy of TNK and alteplase are comparable. Symptomatic intracranial hemorrhage (ICH) is a potential complication with both agents. However, a systematic review of 26 studies comparing IV TNK with alteplase suggests slightly less risk of an event (RR 0.89, 95% CI, 0.65-1.23) with TNK (Martin, 2025). Either IV TNK at a dose of 0.25mg/kg body weight (max dosage 25 mg) or IV alteplase at 0.9mg/kg body weight are recommended for AIS patients eligible for therapy within 4.5 hours of last known well to improve functional outcomes. However, the single bolus-based approach used with TNK may improve the timeliness of administration and shorten door-to-needle (DTN) and door-in-door-out (DIDO) times (Prabhakaran, S. et al., 2026).

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• Demaerschalk, B. M., Kleindorfer, D. O., Adeoye, O. M., Demchuk, A. M., Fugate, J. E., Grotta, J. C., Khalessi, A. A., Levy, E. I., Palesch, Y. Y., Prabhakaran, S., Saposnik, G., Saver, J. L., & Smith, E. E. (2016). Scientific rationale for the inclusion and exclusion criteria for intravenous alteplase in acute ischemic stroke: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 47 (2), 581–641. https://doi.org/10.1161/STR.0000000000000086
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• Martin, S. S., Aday, A. W., Allen, N. B., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., … Palaniappan, L. P. (2025). 2025 heart disease and stroke statistics: A report of US and global data from the American Heart Association. Circulation, 151, e333–e334.
• Palaniappan, L. P., Allen, N. B., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., Avery, C. L., Baker-Smith, C. M., Bansal, N., Currie, M. E., Earlie, R. S., Fan, W., Fetterman, J. L., Barone Gibbs, B., Heard, D. G., Hiremath, S., Hong, H., Hyacinth, H. I., Ibeh, C., Jiang, T., … Khan, S. S. (2026). 2026 heart disease and stroke statistics: A report of U.S. and global data from the American Heart Association. Circulation. Advance online publication. https://doi.org/10.1161/CIR.0000000000001412.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e26–e30.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.
• Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513
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There are separate guideline recommendations for venous thromboembolism (VTE) prevention after acute ischemic stroke, including extended deep vein thrombosis (DVT) prophylaxis for select patients. (Prabhakaran, S., et al., 2026). Anticoagulants such as enoxaparin and unfractionated heparin (UFH) at doses to prevent DVT are insufficient antithrombotic therapy to prevent recurrent ischemic stroke or TIA.

• Adams, H., R. Adams, G. Del Zoppo, L. B. Goldstein, Association Stroke Council of the American Heart, and Association American Stroke. "Guidelines for the Early Management of Patients with Ischemic Stroke: 2005 Guidelines Update a Scientific Statement from the Stroke Council of the American Heart Association/American Stroke Association." [In eng]. Stroke 36, no. 4 (Apr 2005): 916-23.
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• Eccles, M., N. Freemantle, and J. Mason. "North of England Evidence Based Guideline Development Project: Guideline on the Use of Aspirin as Secondary Prophylaxis for Vascular Disease in Primary Care. North of England Aspirin Guideline Development Group." [In eng]. BMJ 316, no. 7140 (Apr 25 1998): 1303-9.
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• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e30.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
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• Kernan, W. N., Ovbiagele, B., Black, H. R., Bravata, D. M., Chimowitz, M. I., Ezekowitz, M. D., Fang, M. C., Fisher, M., Furie, K. L., Heck, D. V., Johnston, S. C., Kasner, S. E., Kittner, S. J., Mitchell, P. H., Rich, M. W., Richardson, D., Schwamm, L. H., Wilson, J. A., American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, & Council on Peripheral Vascular Disease. (2014). Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 45 (7), 2160–2236. http://doi.org/10.1161/STR.0000000000000024
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e26–e30.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.
• Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513

High-intensity statin therapy should be initiated or continued as first-line therapy in women and men less than or equal to 75 years of age who have clinical ASCVD, unless contraindicated. In patients with clinical ASCVD and a contraindication to high-intensity statin therapy, moderate-intensity therapy should be considered as an alternative if it can be tolerated. In individuals greater than 75 years of age, the potential for ASCVD risk reduction benefits, adverse effects, drug-drug interactions, and patient preferences should be considered, and statin therapy individualized based on these considerations (Stone, N., et al., 2013; Blumenthal, R., et al., 2026).

Previously, a goal of LDL-C <70 mg/dL has been recommended for secondary stroke prevention, (Martin, S., et al., 2025). However, most patients with clinical ASCVD, including those with ischemic stroke, are likely to be at very high risk and have other co-morbidities, such as, a history of hypertension, myocardial infarction, heart failure, or diabetes. A goal of LDL-C <55 mg/dL is now preferred for very high risk patients. In addition to high-intensity statin therapy, ezetimibe and/or a PCSK9 inhibitor may be needed to lower LDL-C and reduce the risk of future ASCVD events, (Blumenthal, R., et al., 2026).

• Amarenco, P., J. Bogousslavsky, A. Callahan, 3rd, L. B. Goldstein, M. Hennerici, A. E. Rudolph, H. Sillesen, et al. "High-Dose Atorvastatin after Stroke or Transient Ischemic Attack." [In eng]. N Engl J Med 355, no. 6 (Aug 10 2006): 549-59.
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• Kernan, W.N., B. Ovbiagele, H. R. Black, D. M. Bravata, M. I. Chimowitz, M. D. Ezekowitz, M. C. Fang, M. Fisher, K. L. Furie, D. V. Heck, S. C. Johnston, S. E. Kasner, S. J. Kittner, P. H. Mitchell, M. W. Rich, D. Richardson, L. H. Schwamm, J. A. Wilson. “Guidelines for the Prevention of Stroke in Patients with Stroke and Transient Ischemic Attack: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association.” [in eng.] Stroke 45, no. 7 (May 2014): 2160-223.
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• Martin, S.S., Aday, A.W., Allen, N.B., Almarzooq, Z.I., Anderson, C.A.M., Arora, P.,…Palaniappan, L.P. “2025 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association.” [In eng]. Circulation 151, (Feb 25 2025): e334.
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• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e44, e47.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
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• Schellinger, P. D., R. N. Bryan, L. R. Caplan, J. A. Detre, R. R. Edelman, C. Jaigobin, C. S. Kidwell, et al. "Evidence-Based Guideline: The Role of Diffusion and Perfusion MRI for the Diagnosis of Acute Ischemic Stroke: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology." [In eng]. Neurology 75, no. 2 (Jul 13 2010): 177-85.
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• Blumenthal, R. S., Morris, P. B., Gaudino, M., Johnson, H. M., Anderson, T. S., Bittner, V. A., Blankstein, R., Brewer, L. C., Cho, L., de Ferranti, S. D., Gianos, E., Gluckman, T. J., Gradney, K. F., Isiadinso, I., Lloyd-Jones, D. M., Marrs, J. C., Martin, S. S., McLain, K. H., Mehta, L. S., … Wilkins, J. T. (2026). 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 153 (17), e1154–e1276. https://doi.org/10.1161/CIR.0000000000001423.
• Culver, A. L., Ockene, I. S., Balasubramanian, R., Olendzki, B. C., Sepavich, D. M., Wactawski-Wende, J., Manson, J. E., … (2012). Statin use and risk of diabetes mellitus in postmenopausal women in the Women's Health Initiative. Archives of Internal Medicine, 172 (2), 144–152.
• Grundy, S. M., Stone, N. J., Bailey, A. L., Beam, C., Birtcher, K. K., Blumenthal, R. S., … (2018). 2018 guideline on the management of blood cholesterol: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology. https://doi.org/10.1016/j.jacc.2018.11.003.
• Kleindorfer, D. O., Towfighi, A, Chaturvedi, S., Cockroft, K. M., Gutierrez, J., Lombardi-Hill, D., Kamel, H., Kernan, W. N., Kittner, S. J., Leira, E. C., Lennon, O., Meschia, J. F., Nguyen, T. N., Pollak, P. M., Santangeli, P., Sharrief, A. Z., Smith, S. C., Jr., Turan, T. N., & Williams, L. S. (2021). Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline from the American Heart Association/American Stroke Association. Stroke, 52 (7), e364–e467.
• Kostis, W. J., Cheng, J. Q., Dobrzynski, J. M., Cabrera, J., & Kostis, J. B. (2012). Meta-analysis of statin effects in women versus men. Journal of the American College of Cardiology, 59 (6), 572–582.
• Martin, S. S., Aday, A. W., Allen, N. B., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., … Palaniappan, L. P. (2025). 2025 heart disease and stroke statistics: A report of US and global data from the American Heart Association. Circulation, 151, e333–e334.
• Palaniappan, L. P., Allen, N. B., Almarzooq, Z. I., Anderson, C. A. M., Arora, P., Avery, C. L., Baker-Smith, C. M., Bansal, N., Currie, M. E., Earlie, R. S., Fan, W., Fetterman, J. L., Barone Gibbs, B., Heard, D. G., Hiremath, S., Hong, H., Hyacinth, H. I., Ibeh, C., Jiang, T., … Khan, S. S. (2026). 2026 heart disease and stroke statistics: A report of U.S. and global data from the American Heart Association. Circulation. Advance online publication. https://doi.org/10.1161/CIR.0000000000001412.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e26–e30.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.
• Stone, N. J., Robinson, J. G., Lichtenstein, A. H., Bairey Merz, C. N., Blum, C. B., Eckel, R. H., Goldberg, A. C., Gordon, D., Levy, D., Lloyd-Jones, D. M., McBride, P., Schwartz, J. S., Shero, S. T., Smith, S. C., Watson, K., & Wilson, P. W. F. (2013). Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular disease in adults: A report of the American College of Cardiology/American Heart Association task force on practice guidelines. Circulation, 11, 1–84.

Stroke education starts with information about key warning signs and symptoms, as well as, steps to activate the emergency medical system (EMS) if and when stroke signs and symptoms occur. Early recognition can decrease arrival times to the emergency department, hasten stroke diagnosis, increase treatment times for patients eligible for reperfusion therapies, and ultimately improve outcomes for more patients, (Prabhakaran, S., et al., 2026). Education can be reinforced during an inpatient admission for an acute stroke event but should begin sooner to improve stroke knowledge and awareness across a population and potentially prevent first-time strokes.

• Anderson, R. T., F. Camacho, A. I. Iaconi, C. H. Tegeler, and R. Balkrishnan. "Enhancing the Effectiveness of Community Stroke Risk Screening: A Randomized Controlled Trial." [In eng]. J Stroke Cerebrovasc Dis 20, no. 4 (Jul-Aug 2011): 330-5.
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• Centers for Disease Control and Prevention. "Prevalence and Most Common Causes of Disability among Adults--United States, 2005." [In eng]. MMWR Morb Mortal Wkly Rep 58, no. 16 (May 1 2009): 421-6.
• Chan, Y. F., R. Lavery, N. Fox, R. Kwon, S. Zinzuwadia, R. Massone, and D. Livingston. "Effect of an Educational Video on Emergency Department Patient Stroke Knowledge." [In eng]. J Emerg Med 34, no. 2 (Feb 2008): 215-20.
• Davis, S. M., D. Martinelli, B. Braxton, K. Kutrovac, and T. Crocco. "The Impact of the Extended Parallel Process Model on Stroke Awareness: Pilot Results from a Novel Study." [In eng]. Stroke 40, no. 12 (Dec 2009): 3857-63.
• Dromerick, A. W., M. C. Gibbons, D. F. Edwards, D. E. Farr, M. L. Giannetti, B. Sanchez, N. M. Shara, et al. "Preventing Recurrence of Thromboembolic Events through Coordinated Treatment in the District of Columbia." [In eng]. Int J Stroke 6, no. 5 (Oct 2011): 454-60.
• Duncan, P. W., R. Zorowitz, B. Bates, J. Y. Choi, J. J. Glasberg, G. D. Graham, R. C. Katz, K. Lamberty, and D. Reker. "Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline." [In eng]. Stroke 36, no. 9 (Sep 2005): e100-43.
• Eames, S., T. Hoffmann, L. Worrall, and S. Read. "Delivery Styles and Formats for Different Stroke Information Topics: Patient and Carer Preferences." [In eng]. Patient Educ Couns 84, no. 2 (Aug 2011): e18-23.
• Eames, S., T. Hoffmann, L. Worrall, and S. Read. "Stroke Patients' and Carers' Perception of Barriers to Accessing Stroke Information." [In eng]. Top Stroke Rehabil 17, no. 2 (Mar-Apr 2010): 69-78.
• Evans, R. L., A. L. Matlock, D. S. Bishop, S. Stranahan, and C. Pederson. "Family Intervention after Stroke: Does Counseling or Education Help?" [In eng]. Stroke 19, no. 10 (Oct 1988): 1243-9.
• Furie, K. L., S. E. Kasner, R. J. Adams, G. W. Albers, R. L. Bush, S. C. Fagan, J. L. Halperin, et al. "Guidelines for the Prevention of Stroke in Patients with Stroke or Transient Ischemic Attack: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association." [In eng]. Stroke 42, no. 1 (Jan 2011): 227-76.
• Goldstein, L. B., C. D. Bushnell, R. J. Adams, L. J. Appel, L. T. Braun, S. Chaturvedi, M. A. Creager, et al. "Guidelines for the Primary Prevention of Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association." [In eng]. Stroke 42, no. 2 (Feb 2011): 517-84.
• Greenberg, S. M., Ziai, W. C., Cordonnier, C., Dowlatshahi, D., Francis, B., Goldstein, J. N., Hemphill, J. C. III, Johnson, R., Keigher, K. M., Mack, W.J., Mocco, J., Newton, E. J., Ruff, I. M., Sansing, L. H., Schulman, S., Selim, M. H., Sheth, K. N., Sprigg, N., Sunnerhagen, K. S. "2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline from the American Heart Association/American Stroke Association." [In Eng]. Stroke 53, no. 7 (Jul 2022): e282-e361.
• Gresham, G. E., P. W. Duncan, W. B. Stason, H. P. Adams, A. M. Adelman, D. N. Alexander, D. S. Bishop et al. "Post-stroke rehabilitation. Clinical practice guideline, no. 16. Rockville, MD: US Department of Health and Human Services." Public Health Service, Agency for Health Care Policy and Research (1995): 95-0062.
• Hafsteinsdottir, T. B., M. Vergunst, E. Lindeman, and M. Schuurmans. "Educational Needs of Patients with a Stroke and Their Caregivers: A Systematic Review of the Literature." [In eng]. Patient Educ Couns 85, no. 1 (Oct 2011): 14-25.
• Harrington, R., G. Taylor, S. Hollinghurst, M. Reed, H. Kay, and V. A. Wood. "A Community-Based Exercise and Education Scheme for Stroke Survivors: A Randomized Controlled Trial and Economic Evaluation." [In eng]. Clin Rehabil 24, no. 1 (Jan 2010): 3-15.
• "Kaiser Permanente Clinical Practice Guidelines for Acute Stroke Quartet III Inpatient Management." The Permanente Medical Group, http://www.kaiserpapers.org/cajud/acutestroke/inpaman.html.
• Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al. "Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association." [In Eng]. Stroke (Jan 31 2013).
• Lindsay, M. P., G. Gubitz, M. Bayley, M. D. Hill, C. Davies-Schinkel, S. Singh, and S. Phillips. "Canadian Best Practice Recommendations for Stroke Care (Update 2010)." In, The Canadian Stroke Strategy (2010): 17-20, 129-50. http://www.strokebestpractices.ca/wp-content/uploads/2011/04/2010BPR_ENG.pdf
• Lorig, K. R., D. S. Sobel, A. L. Stewart, B. W. Brown, Jr., A. Bandura, P. Ritter, V. M. Gonzalez, D. D. Laurent, and H. R. Holman. "Evidence Suggesting That a Chronic Disease Self-Management Program Can Improve Health Status While Reducing Hospitalization: A Randomized Trial." [In eng]. Med Care 37, no. 1 (Jan 1999): 5-14.
• Maasland, L., D. Brouwer-Goossensen, H. M. den Hertog, P. J. Koudstaal, and D. W. Dippel. "Health Education in Patients with a Recent Stroke or Transient Ischaemic Attack: A Comprehensive Review." [In eng]. Int J Stroke 6, no. 1 (Feb 2011): 67-74.
• Ostwald, S. K., S. Davis, G. Hersch, C. Kelley, and K. M. Godwin. "Evidence-Based Educational Guidelines for Stroke Survivors after Discharge Home." [In eng]. J Neurosci Nurs 40, no. 3 (Jun 2008): 173-9, 91.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e48.
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al. Guidelines for the Early Management of Patients with Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2019 Dec;50(12):e344-e418.
• Roger, V. L., A. S. Go, D. M. Lloyd-Jones, E. J. Benjamin, J. D. Berry, W. B. Borden, D. M. Bravata, et al. "Heart Disease and Stroke Statistics--2012 Update: A Report from the American Heart Association." [In eng]. Circulation 125, no. 1 (Jan 3 2012): e2-e220.
• Smith, J., A. Forster, A. House, P. Knapp, J. Wright, and J. Young. "Information Provision for Stroke Patients and Their Caregivers." [In eng]. Cochrane Database Syst Rev, no. 2 (2008): CD001919.
• Yvonne Chan, Y. F., R. Nagurka, L. D. Richardson, S. B. Zaets, M. B. Brimacombe, and S. R. Levine. "Effectiveness of Stroke Education in the Emergency Department Waiting Room." [In eng]. J Stroke Cerebrovasc Dis 19, no. 3 (May 2010): 209-15.

• Greenberg, S. M., Ziai, W. C., Cordonnier, C., Dowlatshahi, D., Francis, B., Goldstein, J. N., Hemphill, J. C., III, Johnson, R., Keigher, K. M., Mack, W. J., Mocco, J., Newton, E. J., Ruff, I. M., Sansing, L. H., Schulman, S., Selim, M. H., Sheth, K. N., Sprigg, N., & Sunnerhagen, K. S. (2022). 2022 guideline for the management of patients with spontaneous intracerebral hemorrhage: A guideline from the American Heart Association/American Stroke Association. Stroke, 53 (7), e325–e326.
• Hoh, B. L., Ko, N. U., Amin-Hanjani, S., Chou, S. H.-Y., Cruz-Flores, S., Dangayach, N. S., Derdeyn, C. P., Du, R., Hänggi, D., Hetts, S. W., Ifejika, N. L., Johnson, R., Keigher, K. M., Leslie-Mazwi, T. M., Lucke-Wold, B., Rabinstein, A. A., Robicsek, S. A., Stapleton, C. J., Suarez, J. I., … Welch, B. G. (2023). 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage: A guideline from the American Heart Association/American Stroke Association. Stroke, 54, e321. https://doi.org/10.1161/STR.000000000000043.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e26–e30.
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al. (2019). Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke—A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 50 (12), e344–e418.
• Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513.

The benefits of both IV altelplase and mechanical thrombectomy for the treatment of acute ischemic stroke are time dependent. The earlier the treatment within the time window, the greater the benefit to patients. Initiation of IV alteplase at a primary stroke center (PSC) and rapid transport to an advanced center capable of performing endovascular treatment may lead to faster and more complete reperfusion for certain patients eligible for these treatments (Powers, 2018).

In 2013, The Brain Attack Coalition recommended that stroke transfers occur within 2 hours of patient arrival at the referring stroke center (Alberts, 2013). Since that time, faster door-in-door-out (DIDO) times have been reported for specific groups of stroke patients. For hospitals without an on-site mechanical thrombectomy (MT) service, shorter door-in-door-out (DIDO) times should be the goal. Choi and colleagues recently reported a median DIDO time of 86 minutes (IQR, 65–111) for acute ischemic stroke patients transferred out for potential MT. During working hours (0800–1700 hours), a median DIDO time of 59 minutes (IQR, 51–80) was achieved (Choi, 2019). Prolonged transfer times may result in worse outcomes for MT-eligible patients with evolving large vessel occlusion (ELVO) who are without successful reperfusion. Higher NIHSS scores have been noted at discharge and 90 days (McTaggert, 2018).

Reducing the time stroke patients remain in the emergency department (ED) can improve access to a higher-level of stroke care, surgical intervention, or advanced intra-arterial endovascular treatments, and increase quality of care. For those stroke patients who are not transferred to a TSC or CSC, inpatient admission within 3 hours, preferably to a formal stroke unit, is recommended (Jauch, 2013).

The benefits of both IV thrombolytics and mechanical thrombectomy for the treatment of acute ischemic stroke are time dependent. The earlier the treatment within the time window, the greater the benefit to patients. Initiation of IV alteplase or tenecteplase at an acute stroke ready hospital (ASRH) or primary stroke center (PSC) and rapid transport to an advanced center capable of performing endovascular treatment may lead to faster and more complete reperfusion for certain patients eligible for these treatments (Powers, W.J., et al., 2018).

The American Heart Association® Target Stroke Phase III goals include a door-in-door-out time (DIDO) of < 90 minutes for acute ischemic stroke patients eligible for mechanical thrombectomy (AHA, 2018). Rapid patient transfer is often a first step towards meeting target times for thrombolytic and/or endovascular therapy initiation when the hospital is unable to initiate treatment. For hospitals without an on-site mechanical thrombectomy (MT) service, shorter door-in-door-out (DIDO) times should be the goal. Choi and colleagues reported a median DIDO time of 86 minutes (IQR, 65–111) for acute ischemic stroke patients transferred out for potential MT. During working hours (0800–1700 hours), a median DIDO time of 59 minutes (IQR, 51–80) was achieved (Choi, P.M.C., et al., 2019). However, a recent large U.S. study reported a median DIDO of 174 minutes with only 27.3% of stroke patients transferred under 120 minutes. A significant performance improvement gap of a median 132 minutes was reported for EVT-eligible AIS patients (Stamm, B., et al., 2023). Prolonged transfer times may result in worse outcomes for MT-eligible patients with evolving large vessel occlusion (ELVO) who are without successful reperfusion. Higher NIHSS scores have been noted at discharge and 90 days (McTaggert, R.A., at al., 2018).

Reducing the time stroke patients remain in the emergency department (ED) can improve access to a higher-level of stroke care, surgical intervention, or advanced endovascular treatments, and increase quality of care. EMS pre-notification and the bundling of imaging services (e.g., CT/CTA) can reduce DIDO times (Royan, R., et al., 2026). Agreements with local EMS resources and interhospital transfer protocols for patients requiring higher-level stroke care are a top priority for a stroke system of care and can reduce DIDO times (Prabhakaran, S., et al., 2026).

• Alberts MJ, Wechsler LR, Jensen MEL, Lachtaw RE, Crocco TJ, George MG, Baranski J, Bass RR, et al. “Formation and Function of Acute Stroke-Ready Hospitals Within a Stroke System of Care Recommendations From the Brain Attack Coalition” [In Eng]. Stroke (Nov 12 2013).
• Albright KC, Branas CC, Meyer BC, Matherne-Meyer DE, Zivin JA, Lyden PD, Carr BG. “Acute Cerebrovascular Care in Emergency Stroke Systems.” [In Eng]. Arch Neurol (Oct 2010).
• American Heart Association. Acute Stroke Ready Hospital, 2015.
• Choi PMC, Tsoi AH, Pope AL, Leung S, Frost T, Loh PS, Chandra RV, Ma T, Parsons M, Mitchell P, Dewey HM. “Door-in-Door-Out Time of 60 Minutes for Stroke With Emergent Large Vessel Occlusion at a Primary Stroke Center.” [In Eng]. Stroke (Aug 29 2019).
• Jauch, E. C., J. L. Saver, H. P. Adams, Jr., A. Bruno, J. J. Connors, B. M. Demaerschalk, P. Khatri, et al. "Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association." [In Eng]. Stroke (Jan 31 2013).
• Lyerly MJ, Albright KC, Boehme AK, Shahripour RB, Donnelly JP, Houston JT, Rawal PV, Kapoor N, Alvi M, Sisson A, Alexandrov AW, Alexandrov AV. “Patient Selection for Drip and Ship Thrombolysis in Acute Ischemic Stroke”. [In Eng]. South Med J (Jul 2015).
• McTaggert RA, Moldovan K, Oliver LA, Dibiasio EL, Baird GL, Hemendinger ML, Haas RA, Goyal M, Wang TY, Jayaraman MV. “Door-in-Door-Out Time at Primary Stroke Centers May Predict Outcome for Emergent Large Vessel Occlusion Patients.” [In Eng]. Stroke (Nov 8 2018).
• Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, Biller J, et al; on behalf of the American Heart Association Stroke Council. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018 Jan;49:e8, e10.
• Sheth KN, Smith EE, Grau-Sepulveda MV, Kleindorfer D, Fonarow GC, Schwamm LH. "Drip and Ship Thrombolytic Therapy for Acute Ischemic Stroke: Use, Temporal Trends, and Outcomes.” [In Eng]. Stoke (Mar 2015).

• American Heart Association. (2018). Phase III Target: Stroke: Higher goals for greater good. https://www.stroke.org/-/media/files/professional/quality-improvement/target-stroke/target-stroke-phase-iii/aha-qi-target-stroke-phase-3-brochure.pdf.
• Choi, P. M. C., Tsoi, A. H., Pope, A. L., Leung, S., Frost, T., Loh, P. S., Chandra, R. V., Ma, T., Parsons, M., Mitchell, P., & Dewey, H. M. (2019). Door-in-door-out time of 60 minutes for stroke with emergent large vessel occlusion at a primary stroke center. Stroke. Advance online publication.
• Hoh, B. L., Ko, N. U., Amin-Hanjani, S., Chou, S. H.-Y., Cruz-Flores, S., Dangayach, N. S., Derdeyn, C. P., Du, R., Hänggi, D., Hetts, S. W., Ifejika, N. L., Johnson, R., Keigher, K. M., Leslie-Mazwi, T. M., Lucke-Wold, B., Rabinstein, A. A., Robicsek, S. A., Stapleton, C. J., Suarez, J. I., … Welch, B. G. (2023). 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage: A guideline from[KK3.1] the American Heart Association/American Stroke Association. Stroke, 54, e315, e324-25. https://doi.org/10.1161/STR.000000000000043
• Lyerly, M. J., Albright, K. C., Boehme, A. K., Shahripour, R. B., Donnelly, J. P., Houston, J. T., Rawal, P. V., Kapoor, N., Alvi, M., Sisson, A., Alexandrov, A. W., & Alexandrov, A. V. (2015). Patient selection for drip and ship thrombolysis in acute ischemic stroke. Southern Medical Journal, 108 (7), 393–398. https://doi.org/10.14423/SMJ.0000000000000306
• McTaggart, R. A., Moldovan, K., Oliver, L. A., Dibiasio, E. L., Baird, G. L., Hemendinger, M. L., Haas, R. A., Goyal, M., Wang, T. Y., & Jayaraman, M. V. (2018). Door-in-door-out time at primary stroke centers may predict outcome for emergent large vessel occlusion patients. Stroke, 49 (12), 2969–2974. https://doi.org/10.1161/STROKEAHA.118.021936
• Powers, W. J., Rabinstein, A. A., Ackerson, T., Adeoye, O. M., Bambakidis, N. C., Becker, K., Biller, J., et al., on behalf of the American Heart Association Stroke Council. (2018). 2018 guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 49, e10–e11, e63–e74.
• Prabhakaran, S., Gonzalez, N. R., Zachrison, K. S., Adeoye, O., Alexandrov, A. W., Ansari, S. A., Chapman, S., Czap, A. L., Dumitrascu, O. M., Ishida, K., Jadhav, A. P., Johnson, B., Johnston, K. C., Khatri, P., Kimberly, W. T., Lee, V. H., Leslie-Mazwi, T. M., Mac Grory, B., Madsen, T. E., Menon, B., Mistry, E. A., Park, S., Parker, S., Pérez de la Ossa, N., Reeves, M., Saiz, T., Scott, P. A., Schwartzberg, D., Sheth, S. A., Sporns, P. B., Times, S., Tjoumakaris, S., Wolfe, S. Q., & Yaghi, S.; Peer Review Committee Collaborators. (2026). 2026 guideline for the early management of patients with acute ischemic stroke: A guideline from the American Heart Association/American Stroke Association. Stroke. Advance online publication. https://doi.org/10.1161/STR.0000000000000513
• Royan, R., Stamm, B., Giurcanu, M., Messe, S. R., Jauch, E. C., Saver, J. L., & Prabhakaran, S. (2026). Door-in-door-out times and outcomes in patients with acute ischaemic stroke transferred for endovascular therapy in the USA: A retrospective cohort study. The Lancet Neurology, 25 (2), 160–169. https://doi.org/10.1016/S1474-4422(25)00478-8
• Sheth, K. N., Smith, E. E., Grau-Sepulveda, M. V., Kleindorfer, D., Fonarow, G. C., & Schwamm, L. H. (2015). Drip and ship thrombolytic therapy for acute ischemic stroke: Use, temporal trends, and outcomes. Stroke, 46 (3), 732–739. https://doi.org/10.1161/STROKEAHA.114.007506
• Stamm, B., Royan, R., Giurcanu, M., Messe, S. R., Jauch, E. C., & Prabhakaran, S. (2023). Door-in-door-out times for interhospital transfer of patients with stroke. JAMA, 330 (7), 636–649. https://doi.org/10.1001/jama.2023.12739

The measure is a simple count of the number of MT procedures performed at the PSC each month. Get With The Guidelines®-Stroke users may run reports to identify the number of patients with ischemic stroke who receive mechanical endovascular reperfusion therapy at their facility. Median annual EVT volume varies with more MT procedures reported by higher level stroke centers: 76 for CSCs, 55 for TSCs, and 32 for PSCs, (Raychev, R., et al, 2023).

• American Heart Association / American Stroke Association, Get With The Guidelines®-Stroke, Endovascular Therapy for Acute Ischemic Stroke, September 2020.

• Raychev, R., Sun, J.-L., Schwamm, L., Smith, E. E., Fonarow, G. C., Messé, S. R., Xian, Y., Chiswell, K., Blanco, R., Mac Grory, B., & Saver, J. L. (2023). Performance of thrombectomy-capable, comprehensive, and primary stroke centers in reperfusion therapies for acute ischemic stroke: Report from the Get With The Guidelines–Stroke Registry. Circulation, 148 (25). https://doi.org/10.1161/CIRCULATIONAHA.123.066114

Excessive use of alcohol and drugs has a substantial harmful impact on health and society in the United States. It is a drain on the economy and a source of enormous personal tragedy (The National Quality Forum, A Consensus Report, 2007).

To:

Excessive use of alcohol and drugs has a substantial harmful impact on health and society in the United States.

More than 140,000 people in America die each year due to alcohol-related causes, which is the fourth-leading cause of death in the United States (CDC, 2022, NIAAA, 2023).

To:

About 178,000 people die from excessive alcohol drinking each year and excessive alcohol use is a leading preventable cause of death in the United States (Centers for Disease Control and Prevention [CDC], 2024).

Substance abuse costs the US economy approximately $400 billion dollars each year in lost productivity, crime, and healthcare spending (HHS, 2016). Substance use disorder treatment in US emergency departments and inpatient settings reached more than $13 billion dollars in 2017 (Peterson, 2021).

To:

Excessive alcohol use costs the US economy billions annually in lost productivity, crime, and healthcare spending (CDC, 2024). Substance use disorder treatment in US emergency departments and inpatient settings reached more than $13 billion dollars in 2017 with alcohol related disorders being the most common (Peterson, 2021).

According to the 2020 National Survey on Drug Use and Health (NSDUH), 40.3 million Americans, aged 12 or older, had a substance use disorder (SUD) in the past year (CDC, 2022). As of 2021, 10.6% of the US population age 12 and older (29.5 million people) had an alcohol use disorder in the past year (SAMHSA, 2021).

To:

According to the 2024 National Survey on Drug Use and Health (NSDUH), 48.4 million Americans, aged 12 or older, had a substance use disorder (SUD) in the past year (Substance Abuse and Mental Health Services Administration [SAMHSA], 2025). As of 2024, 9.7% of the US population age 12 and older (27.9 million people) had an alcohol use disorder in the past year (SAMHSA, 2025).

Clinical trials have demonstrated that brief interventions, especially prior to the onset of addiction, significantly improve health and reduce costs, and that similar benefits occur in those with addictive disorders who are referred to treatment (Fleming, 2002, Di Clemente, 2017).

To:

Clinical trials have demonstrated that screening and brief interventions, especially prior to the onset of addiction, results in beneficial reductions in alcohol use and reduces costs, and that similar benefits occur for those who are referred to treatment (Tanner-Smith et al., 2021; Barbosa et al., 2020).

In 2019, 3.6 million people were diagnosed with both a serious mental illness and substance use disorder—which is increasing year over year.

To:

In 2024, among the 14.6 million adults who had a severe mental illness, nearly half (6.9 million people) also had a substance use disorder (SAMHSA, 2025).

While there are substantial evidence-based interventions for substance use, few patients receive substance use care: of the 21.6 million people in 2019 who needed substance use treatment in 2019, 12.2% (or 2.6 million people) received care in a specialty facility (SAMHSA, 2020).

To:

While there are substantial evidence-based interventions for substance use, few patients receive substance use care: among the 52.6 million people in 2024 who reported needing substance use treatment in the past year, 3.5% (or 10.2 million people) received substance use treatment (SAMHSA, 2025).

Selected references

To:

Bernstein J, Bernstein E, Tassiopoulos K, Heren T, Levenson S, Hingson R. Brief motivational interventions at a clinic visit reduces cocaine and heroin use. Drug Alcohol Depend. 2005 Jan 7;77(1):49-59.

DiClemente CC, Corno CM, Graydon MM, Wiprovnick AE, Knoblach DJ. Motivational interviewing, enhancement, and brief interventions over the last decade: A review of reviews of efficacy and effectiveness. Psychol Addict Behav. 2017 Dec;31(8):862-887. doi: 10.1037/adb0000318. PMID: 29199843

Fleming MF, Mundt MP, French MT, Manwell LB, Stauffacher EA, Barry KL. Brief physician advice for problem drinkers: Long-term efficacy and cost-benefit analysis. Alcohol Clin Exp Res. 2002 Jan;26(1):36-43.

Havassy BE, Alvidrez J, Owen KK. Comparisons of patients with comorbid psychiatric and substance use disorders: implications for treatment and service delivery. Am J Psychiatry. 2004 Jan;161(1):139-45.

Kirchner JE, Owen RR, Nordquist C, Fischer EP. Diagnosis and management of substance use disorders among inpatients with schizophrenia. Psychiatr Serv. 1998 Jan;49(1):82-5.

Peterson C, Li M, Xu L, Mikosz CA, Luo F. Assessment of Annual Cost of Substance Use Disorder in US Hospitals. JAMA Netw Open. 2021;4(3):e210242. doi:10.1001/jamanetworkopen.2021.0242

To:

Prochaska JJ, Gill PH, Stephen E, Hall SM. Identification and Treatment of Substance Misuse on an Inpatient Psychiatry Unit. Psychiatr Serv. 2005 Mar;56(3):347-9.

SAMHSA, Center for Behavioral Health Statistics and Quality. 2021 National Survey on Drug Use and Health. Table 5.6A—Alcohol use disorder in past year: among people aged 12 or older; by age group and demographic characteristics, numbers in thousands, 2021.

To:

The National Quality Forum, National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices; A Consensus Report; 2007.

U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016.

To:

Regional anesthesia for primary elective total hip arthroplasty is associated with lower rates of postoperative complications compared with general anesthesia. Specifically, regional anesthesia has been linked to decreased odds of adverse events, including prolonged ventilator dependence, unplanned intubation, and select postoperative complications such as urinary tract infection and pneumonia (Basques et al., 2015). Additional studies have also demonstrated lower rates of blood transfusion with regional compared to general anesthesia (Basques et al., 2015; Bourget-Murray et al., 2022; Illescas et al., 2025).

The American Academy of Orthopaedic Surgeons (AAOS) Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guideline (2023) suggests that regional anesthesia may be used to reduce adverse events in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty. Further, the 2020 Enhanced Recovery After Surgery (ERAS®) Society consensus statement for perioperative care in total hip replacement and total knee replacement surgery concluded that both regional anesthesia and modern general anesthesia may be used as part of a multimodal anesthetic regimen (Wainwright et al., 2020).

According to The American Joint Replacement Registry 2024 Annual Report, the use of general anesthesia alone for primary total hip arthroplasty has steadily decreased from 48.8% in 2017 to 36.4% in 2024 (AJRR, 2024). Similarly, the use of general anesthesia alone for total knee arthroplasty decreased from 40.6% in 2017 to 22.7% in 2023 (AJRR, 2024). This decline aligns with growing evidence supporting the benefits of regional anesthesia, such as spinal anesthesia and PNB combinations, which are associated with better postoperative outcomes, including reduced opioid use, quicker recovery times, and fewer complications (AJRR, 2024).

Selected References

• ¹ Memtsoudis SG, Xuming S.; Ya-Lin Chiu, et al. Perioperative Comparative Effectiveness of Anesthetic Technique in Orthopedic Patients, Anesthesiology 05 2013, Vol.118, 1046-1058.
• ² Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a metaanalysis. Anesth. Analg. 2006; 103: 1018–25.
• ³ Hu S, Zhang Z-Y, Hua Y-Q, Li J, Cai Z-D. A comparison of regional and general anaesthesia for total replacement of the hip or knee: a metaanalysis. J. Bone Joint Surg. Br. 2009; 91: 935–42.
• ⁴ Zorrilla-Vaca A, Grant MC, Mathur V, Li J, Wu CL. The Impact of Neuraxial Versus General Anesthesia on the Incidence of Postoperative Surgical Site Infections Following Knee or Hip Arthroplasty: A Meta-Analysis. Regional Anesthesia & Pain Medicine: September/October 2016 - Volume 41 - Issue 5 - p 555–563.
• ⁵ Kim JH, Cho MR, et al. A comparison of femoral/sciatic nerve block with lateral femoral cutaneous nerve block and combined spinal epidural anesthesia for total knee replacement arthroplasty. Korean J Anesthesiol 2012 May 62(5): 448-453.
• ⁶ Liu JL, Yuan WX, et al. Peripheral nerve blocks versus general anesthesia for total knee replacement in elderly patients on the postoperative quality of recovery. Clinical Interventions in Aging 2014:9 341-350.
• ⁷ Surgical Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guideline. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, 12/4/2015.
• ⁸ Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guideline. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, 3.13.17.
• ⁹ Memtsoudis SG, Thomas Danninger, Rehana Rasul, Jashvant Poeran, Philipp Gerner, Ottokar Stundner, Edward R. Mariano, Madhu Mazumdar. Inpatient Falls after Total Knee Arthroplasty. Anesthesiology, 2014; 120 (3): 551-563.
• Nielsen PT, Jørgensen LN, Albrecht-Beste E, LeffersA, RasmussenLS. Lower thrombosis risk with epidural blockade in knee arthroplasty. Acta Orthopaedica Scandinavica, 1990,61:1, 29-31
• Mitchell D, Friedman, RJ, Baker DJ, Cooke JE, Darcy, MD, Miller MC. Prevention of thromboembolic disease following total knee arthroplasty: Epidural versus general anesthesia. Clinical Orthopaedics & Related Research, August 1991; 269:109-112.
• Jorgensen LN, Rasmussen LS, Nielsen PT, Leffers A, Albrecht-Beste E. Antithrombotic efficacy of continuous extradural analgesia after knee replacement. Br J Anaesth. 1991/1; 1: 8-12
• Soohoo NF, Lieberman JR, et al. Development of Quality of Care Indicators for Patients Undergoing THR/TKR. BMJ Qual Saf 2011;20:153-157
• Basques BA, Toy JO, Bohl, DD, Golinvaux, NS, Grauer, JN. General Compared with Spinal Anesthesia for Total Hip Arthroplasty. The Journal of Bone and Joint Surgery 2015;97:455-61
• Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, Tobias JH, Vernon K, Blom AW. 90 day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis, Lancet. 2013 Sep 28;382(9898):1097-104
• Premier-IHI Integrated Care Pathway for Total Joint Arthroplasty (April 2013)
• Williams-Russo P, Sharrock NE, Haas SB, et al. Randomized Trial of Epidural Versus General Anesthesia: Outcomes After Primary Total Knee Replacement. Clinical Orthopaedics & Related Research. 331:199-208, October, 1996.
• National Surgical Quality Improvement Project database
• FORCE-Total Joint Registry database
• Warren, F., Sundaram, A., Anis, A., Kamath, S., Mont, S., Higuera, S., & Piuzzi, S. (2020). Spinal Anesthesia Is Associated With Decreased Complications After Total Knee and Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons, 28(5), e213–e221.

• American Academy of Orthopaedic Surgeons. (2023). Management of osteoarthritis of the hip evidence-based clinical practice guideline. https://www.aaos.org/globalassets/quality-and-practice-resources/osteoarthritis-of-the-hip/oah-cpg.pdf
• American Joint Replacement Registry (AJRR). (2024). 2024 annual report. American Academy of Orthopaedic Surgeons. https://communications.aaos.org/download-the-ajrr-2024-annual-report
• American Joint Replacement Registry (AJRR). (2025). AJRR 2025 annual report. American Academy of Orthopaedic Surgeons. https://communications.aaos.org/download-the-ajrr-2025-annual-report?_ga=2.211965012.1959132436.1785171229-1269128503.1758898877
• Basques, B. A., Toy, J. O., Bohl, D. D., Golinvaux, N. S., & Grauer, J. N. (2015). General compared with spinal anesthesia for total hip arthroplasty. The Journal of Bone & Joint Surgery, 97 (6), 455–461. https://doi.org/10.2106/JBJS.N.00662
• Bourget-Murray, J., Halpenny, D., Mahdavi, S., Piroozfar, S. G., & Sharma, R. (2022). Perioperative outcomes associated with general and spinal anesthesia after total joint arthroplasty for osteoarthritis: A large, Canadian, retrospective cohort study. Canadian Journal of Surgery, 65 (4), E460–E467. https://doi.org/10.1503/cjs.008821
• Illescas, A., Cozowicz, C., Zhong, H., Reisinger, L., Liu, J., Poeran, J., & Memtsoudis, S. G. (2025). Comparative effectiveness of neuraxial versus general anesthesia in total joint replacement surgery: An updated retrospective analysis using more recent data. Regional Anesthesia & Pain Medicine, 50 (11), 891–900. https://doi.org/10.1136/rapm-2024-105438
• Wainwright, T. W., Gill, M., McDonald, D. A., Middleton, R. G., Reed, M., Sahota, O., Yates, P., & Ljungqvist, O. (2020). Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthopaedica, 91 (1), 3–19. https://doi.org/10.1080/17453674.2019.1683790

To:

Early postoperative mobilization is a core component of high-quality care for total hip replacement and total knee replacement surgery. The 2020 Enhanced Recovery After Surgery (ERAS®) Society consensus statement on perioperative care for total hip replacement and total knee replacement surgery recommends that patients be mobilized as early as they are able to support functional recovery and facilitate early achievement of discharge criteria. Early mobilization is also recommended to mitigate adverse physiologic effects of postoperative immobility and bed rest, including insulin resistance, muscle atrophy, venous thromboembolism, and postoperative pulmonary complications (Wainwright et al., 2020; Alsuwaylihi et al., 2026).

Evidence supports the safety and effectiveness of early mobilization following total hip and knee arthroplasty. Mobilization within the first 24 hours after surgery is associated with a reduction in hospital length of stay without an increase in the rate of in hospital postoperative adverse events (Guerra et al., 2015). Additionally, evidence from a large multicenter study demonstrates that early mobilization is independently associated with a significant reduction in postoperative complications occurring within 30 days following total hip and knee arthroplasty (Ripollés-Melchor et al., 2020).

Based on recommendations from a Technical Advisory Panel and public comment, this measure was refined to focus on early postoperative ambulation as a more clinically meaningful indicator of mobilization.

Selected References:

• ¹Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: A systematic review. Clin Rehabil. 2014 Dec 1.
• ²Tayrose G, Newman D, Slover J, Jaffe F, Hunter T, Bosco J. Rapid Mobilization Decreases Length of Stay in Joint Replacement Patients. Bulletin of the Hospital for Joint Diseases 2013;71(3):222-6.
• AAOS Guidelines on Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty”, AAOS.
• Premier-IHI Integrated Care Pathway for Total Joint Arthroplasty (April 2013)
• Soohoo NF, Lieberman JR, et al. Development of Quality of Care Indicators for Patients Undergoing THR/TKR. BMJ Qual Saf 2011;20:153-157
• Larsen K, Sorensen, O, Hansen T, Thomsen P, Soballe K. Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: A randomized clinical trial involving 87 patients with 3 months of followup. Acta Orthopaedica 79:2, 149-159.
• den Hertog A, Gliesche K, Timm J, Mühlbauer B, Zebrowski. Pathway-controlled fast-track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating the recovery pattern, drug consumption, and length of stay. Arch Orthop Trauma Surg. 2012 Aug; 132(8):1153-63.
• Smith TO, McCabe C, Lister Set al Rehabilitation implications during the development of the Norwich Enhanced Recovery Programme (NERP) for patients following total knee and total hip arthroplasty. Orthop Traumatol Surg Res 2012; 98: 499–505.
• Raut S, Mertes SC, Muniz-Terrera G, Khanduja V. Factors associated with prolonged length of stay following a total knee replacement in patients aged over 75. Int Orthop 2012; 36: 1,601–1,608.
• Raphael M, Jaeger M, van Vlymen J. Easily adoptable total joint arthroplasty program allows discharge home in two days. Can J Anaesth 2011; 58: 902–910
• Pua YH, Ong PH. Association of early ambulation with length of stay and costs in total knee arthroplasty: retrospective cohort study. Am J Phys Med Rehabil 2014; 93:962-970.
• Chen AF, Stewart MK, Heyl AE, Klatt BA. Effect of Immediate Postoperative Physical Therapy on Length of Stay for Total Joint Arthroplasty Patients. The Journal of Arthroplasty 2012;Vol.27 No. 6
• Wellman SS, Murphy AC, Gulcynski D, Murphy SB. Implementation of an accelerated mobilization protocol following primary total hip arthroplasty: impact on length of stay and disposition. Current Reviews in Musculoskeletal Medicine Volume 4(3); 2011 Sep
• Renkawitz T, Rieder T, Handel M. Comparison of two accelerated clinical pathways – after total knee replacement how fast can we really go? Clinical Rehabilitation 2010; 24:230-239
• Labraca,NS, Castro-Sanchez,AM, Mataran-Penarrocha,G, Arroyo-Morales,M, Sanchez-Joya,M, Moreno-Lorenzo C. Benefits of starting rehabilitation within 24 hours of primary total knee arthroplasty: randomized clinical trial. Clin Rehabil. 2011/25(6):557-566
• Surgical Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guideline. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, 12/4/2015.

To:

• Alsuwaylihi, A., O'Connor, D., Joshi, G. P., Kehlet, H., and Lobo, D. N. (2026). Importance of early postoperative mobilization: Comprehensive review. BJS Open, 10 (2), zrag016. https://doi.org/10.1093/bjsopen/zrag016
• Guerra, M. L., Singh, P. J., and Taylor, N. F. (2015). Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: A systematic review. Clinical Rehabilitation, 29 (9), 844–854. https://doi.org/10.1177/0269215514558641
• Ripollés-Melchor, J., Abad-Motos, A., Díez-Remesal, Y., Aseguinolaza-Pagola, M., Padin-Barreiro, L., Sánchez-Martín, R., Logroño-Egea, M., García-Orallo, S., Ramirez-Rodriguez, J. M., and POWER2 Study Investigators Group. (2020). Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2). JAMA Surgery, 155 (4), e196024. https://doi.org/10.1001/jamasurg.2019.6024
• Wainwright, T. W., Gill, M., McDonald, D. A., Middleton, R. G., Reed, M., Sahota, O., Yates, P., & Ljungqvist, O. (2020). Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthopaedica, 91 (1), 3–19. https://doi.org/10.1080/17453674.2019.1683790

According to 2012 Medicare claims data, 49% of patients undergoing hip and knee replacements were discharged to an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) for rehabilitation. Therefore, only 51% of patients were discharged to home.

To:

High-quality care for total hip and total knee replacement procedures is designed to promote early functional recovery and enable safe discharge to the patient’s home. The 2020 Enhanced Recovery After Surgery (ERAS®) Society consensus statement on perioperative care for total hip and knee replacement recommends the use of objective discharge criteria to facilitate direct discharge to home (Wainwright et al., 2020).

Home-based rehabilitation is increasingly used following total hip and knee replacement procedures. The American Academy of Orthopaedic Surgeons (AAOS) 2022 Surgical Management of Osteoarthritis of the Knee Evidence Based Clinical Practice Guideline reports that discharge to home, with or without home services, is associated with fewer adverse events compared to discharge to an acute rehabilitation facility or skilled nursing facility (American Academy of Orthopaedic Surgeons, 2022). Additionally, the 2023 Management of Osteoarthritis of the Hip Evidence Based Clinical Practice Guideline reports high-quality evidence supporting either formal physical therapy or unsupervised home exercise following total hip arthroplasty (American Academy of Orthopaedic Surgeons, 2023). Analyses of large national datasets indicate that rates of discharge to home following total hip and knee arthroplasty have notably increased over the past decade (American Joint Replacement Registry, 2025; DeMik et al., 2021), although meaningful variation in discharge practices persist (DeMik et al., 2021).

Selected References

• ¹Mahomed NN, Davis AM, Hawker G, Badley E, Davey JR, Syed KA. et al. Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial. J Bone Joint Surg Am. 2008;90(8):1673–1680.
• ²Padgett DE, et al. Study: Patients Who Go Home After Knee Replacement Do As Well as Those Discharged to Rehab Facility. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 24-28, 2015; Las Vegas.
• Inpatient Rehabilitation Facility Services: Assessing payment adequacy and updating payments - Report to the Congress: Medicare Payment Policy March 2014
• Mallinson TR, Bateman J, Tseng HY, Manheim L, et al. A Comparison of Discharge Functional Status After Rehabilitation in Skilled Nursing, Home Health, and Medical Rehabilitation Settings for Patients After Lower-Extremity Joint Replacement Surgery. Arch Phys Med Rehabil Vol 92, May 2011.
• Fleischman A, Austin, M, Purtill JJ, Parvizi J, Hozack WJ, The Rothman Institute Study: Even if you live alone, there is no place like home after total joint arthroplasty. Presented at American Academy of Orthopaedic Surgeons Annual Meeting; March 14, 2017; San Diego, CA.
• McLawhorn AS, Fu, MC, Schairer WW, Sculco PK, MacLeanCH,Padgett DE. Continued Inpatient Care After Primary Total Knee Arthroplasty Increases 30-Day Post-Discharge Complications: A Propensity Score-Adjusted Analysis. The Journal of Arthroplasty. January 31, 2017 (http://dx.doi.org/10.1016/j.arth.2017.01.039).
• Ramos NL, Karia RJ, Hutzler LH, Brandt AM, Slover JD, Bosco JA. The effect of discharge disposition on 30-day readmission rates after total joint arthroplasty. J Arthroplasty. 2014 Apr;29(4):674-7. doi: 10.1016/j.arth.2013.09.010. Epub 2013 Oct 30.

To:

• American Academy of Orthopaedic Surgeons. (2022). Surgical management of osteoarthritis of the knee evidence-based clinical practice guideline. https://www.aaos.org/quality/quality-programs/surgical-management-of-osteoarthritis-of-the-knee/
• American Academy of Orthopaedic Surgeons. (2023). Management of osteoarthritis of the hip evidence-based clinical practice guideline. https://www.aaos.org/quality/quality-programs/osteoarthritis-of-the-hip/
• American Joint Replacement Registry. (2025). AJRR 2025 annual report. American Academy of Orthopaedic Surgeons. https://communications.aaos.org/download-the-ajrr-2025-annual-report?_ga=2.211965012.1959132436.1785171229-1269128503.1758898877
• DeMik, D. E., Carender, C. N., Glass, N. A., Callaghan, J. J., & Bedard, N. A. (2021). Home discharge has increased after total hip arthroplasty; however, rates vary between large databases. The Journal of Arthroplasty, 36 (2), 586–592.e1. https://doi.org/10.1016/j.arth.2020.08.039
• Wainwright, T. W., Gill, M., McDonald, D. A., Middleton, R. G., Reed, M., Sahota, O., Yates, P., & Ljungqvist, O. (2020). Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthopaedica, 91 (1), 3–19. https://doi.org/10.1080/17453674.2019.1683790

Patients who completed the general health and joint specific functional status assessments within 90 days prior to surgery as specified below:

Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)]

Knees: [VR-12 or PROMIS-Global] AND [KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)]

To:

Patients who completed the general health and joint specific functional status assessments within 90 days prior to surgery as specified below:

Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)]

Knees: [VR-12 or PROMIS-Global] AND [KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)]

The assessment tool must reflect the status of the patient’s health condition, health behavior, or experience with health care from the patient’s perspective, without interpretation of the patient’s response by a clinician or anyone else. The assessment can be completed by phone, mail, email, or in-person.

Rationale

The Veterans RAND 12 Item Health Survey (VR-12) is a generic patient reported outcome (PRO) instrument used to measure health related quality of life. This tool, which measures physical function and health status, is widely used and is well validated in the total hip and total knee population. Additionally, the Patient Reported Outcomes Measurement Information System (PROMIS) Global-10 instrument, funded by the National Institute of Health, is increasingly used in the United States. PROMIS instruments use modern measurement theory to assess patient–reported health status for physical, mental, and social well–being to reliably and validly measure patient reported outcomes (PROs) for clinical research and practice. PROMIS instruments measure concepts such as pain, fatigue, physical function, depression, anxiety and social function. Hip disability and Osteoarthritis Outcome Score (HOOS) and Knee injury and Osteoarthritis Outcome Score (KOOS) are well validated and widely used instruments for measuring joint-specific pain and physical function before and after joint replacement. While the full HOOS and KOOS surveys are lengthy, the orthopedic community prefers an abbreviated survey that captures a subset of items referred to as HOOS JR/KOOS JR.

To:

Elective total hip and knee replacement procedures seek to relieve pain and improve function, underscoring the importance of evaluating these outcomes pre and post surgery (Ayers, 2017). Patient-reported outcome measures (PROMs) are standardized instruments that capture a patient’s perspective on their health status including symptoms, physical function, and quality of life.

The Centers for Medicare & Medicaid Services (CMS) has finalized policies to expand the collection and reporting of patient-reported outcomes (PROs) for total hip and total knee arthroplasty across multiple programs (CMS, 2025, 2026a, 2026b, 2026c). This expansion reflects a national strategy to capture meaningful pre and postoperative PROMs to support clinical care, shared decision-making, and hospital-level quality assessment for elective total hip and knee replacement procedures (Ayers, 2017; CMS, 2021; Pasqualini et al., 2026).

Informed by the recommendations of the 2015 Patient Reported Outcomes Summit for Total Joint Arthroplasty (American Association of Hip and Knee Surgeons, 2015), this measure aims to advance preoperative PROM collection for total hip and knee arthroplasty procedures while accounting for the administrative burden associated with PRO data capture.

Selected References

• ¹ Cella D, Hahn EA, Jensen SE, Patient-Reported Outcomes in Performance Measurement, ©2015 Research Triangle Institute.
• ² Ayers DC, Zheng H, Franklin PD. Integrating Patient-reported Outcomes Into Orthopaedic Clinical Practice: Proof of Concept From FORCE-TJR. Clinical Orthopaedics and Related Research. 2013;471(11):3419-3425. doi:10.1007/s11999-013-3143-z.
• ³ Patient-Reported Outcomes Following Elective Primary Total Hip and/or Total Knee Arthroplasty: Hospital-Level Performance Measure(s), Phase 3 Measure Methodology Report, Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE), May 2015.
• ⁴ AAOS letter to Andy Slavitt, Acting Administrator/CMS dated April 3, 2015. Re.: Response during public comment on “Proposed Electronic Clinical Quality Measures for Functional Status Assessment and Improvement for Patients who received a Total Hip Replacement and Functional Status Assessment and Improvement for Patients who received a Total Knee Replacement.”
• ⁵ AAHKS letter to Andy Slavitt, Acting Administrator/CMS dated March 30, 2015. Re.: Response during public comment on “Proposed Electronic Clinical Quality Measures for Functional Status Assessment and Improvement for Patients who received a Total Hip Replacement and Functional Status Assessment and Improvement for Patients who received a Total Knee Replacement.”

• ⁶ Patient Reported Outcomes Summit for Total Joint Arthroplasty Report, August 31, 2015.
• AAHKS sponsored Patient Reported Outcomes Summit for Total Joint Arthroplasty Report. August 31, 2015.
• FORCE-TJR letter to CMS dated September 3, 2015. Response during public comment on CMS-5516-Proposal for Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services.
• AAHKS, AAOS, AJRR letter to Andy Slavitt, Acting Administrator/CMS dated September 8, 2015. Response during public comment on CMS-5516-Proposal for Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services.
• AAHKS letter to Andy Slavitt, Acting Administrator/CMS dated September 8, 2015. Response during public comment on CMS-5516-Proposal for Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services.

To:

• American Association of Hip and Knee Surgeons. (2015). Patient reported outcomes summit for total joint arthroplasty report. https://www.aahks.org/wp-content/uploads/2015/09/AAHKS-2015-Outcomes-Summit-Report.pdf
• Ayers, D. C. (2017). Implementation of patient-reported outcome measures in total knee arthroplasty. Journal of the American Academy of Orthopaedic Surgeons, 25 (Suppl. 1), S48–S50. https://doi.org/10.5435/JAAOS-D-16-00631
• Centers for Medicare & Medicaid Services. (2021). Hospital-level total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) patient-reported outcome-based performance measure (PRO-PM): Measure methodology report. Yale New Haven Health Services Corporation, Center for Outcomes Research and Evaluation. https://qualitynet.cms.gov/files/683f4bc8a07e87562c82d220?filename=THA_TKA-PRO-PM_MeasMthdlgy.pdf
• Centers for Medicare & Medicaid Services. (2025). Hospital inpatient quality reporting program. https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/inpatient-reporting-program
• Centers for Medicare & Medicaid Services. (2026a). Ambulatory surgical center quality reporting program. https://www.cms.gov/medicare/quality/initiatives/asc-quality-reporting
• Centers for Medicare & Medicaid Services. (2026b). Hospital outpatient quality reporting program. https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/hospital-outpatient-quality-reporting-program
• Centers for Medicare & Medicaid Services. (2026c). TEAM (Transforming episode accountability model). CMS Innovation Center. https://www.cms.gov/priorities/innovation/innovation-models/team-model
• Pasqualini, I., Elmenawi, K. A., Khan, S. T., Gudapati, L. S., & Piuzzi, N. S. (2026). Implementing the total hip and knee arthroplasty patient-reported outcome-based performance measure in outpatient and ambulatory surgical center settings: A practical review of new Centers for Medicare and Medicaid Services policies. The Journal of Arthroplasty, 41 (3), 668–673. https://doi.org/10.1016/j.arth.2025.10.023

Patients who completed the general health and joint specific functional status assessments at 1 year (300-425 days) after surgery, as specified below:

Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)]

Knees: [VR-12 or PROMIS-Global] and {KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)]

The assessment tool must reflect the status of the patient’s health condition, health behavior, or experience with health care from the patient’s perspective, without interpretation of the patient’s response by a clinician or anyone else (Cella et al. 2015). The assessment can be completed by phone, mail, email, or in-person.

To:

Patients who completed the general health and joint specific functional status assessments at 1 year (300-425 days) after surgery, as specified below:

Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)]

Knees: [VR-12 or PROMIS-Global] and [KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)]

The assessment tool must reflect the status of the patient’s health condition, health behavior, or experience with health care from the patient’s perspective, without interpretation of the patient’s response by a clinician or anyone else. The assessment can be completed by phone, mail, email, or in-person.

Rationale

Good orthopedic care requires knowledge of the patient’s history of musculoskeletal pain and associated limitations in daily function, along with improvements or declines seen after surgery. Standardized measures of patient-reported outcomes (PROs) can provide this information.

The American Association of Hip and Knee Surgeons (AAHKS) convened a Patient Reported Outcomes Summit for Total Joint Arthroplasty in 2015 with the goal of obtaining consensus regarding the patient-reported outcomes and risk variables suitable for total hip and total knee arthroplasty performance measures (Patient Reported Outcomes Summit for Total Joint Arthroplasty Report, 2015). The instruments specified in this measure align with the Summit’s recommendations as well as CMS Comprehensive Care for Joint Replacement legislation.

The Veterans RAND 12 item Health Survey (VR-12) is a generic patient reported outcome (PRO) instrument. It is a well validated and widely used in the hip and knee population to measure health related quality of life by capturing the patient’s physical function and health status. The Patient Reported Outcomes Measurement Information System (PROMIS) Global-10 assess patient-reported health status for physical, mental, and social well-being by measuring a patient’s pain, fatigue, physical function, depression/anxiety status, and social function. Hip disability and Osteoarthritis Outcome Score (HOOS) and Knee injury and Osteoarthritis Outcome Score (KOOS) are well validated and widely used instruments for measuring joint-specific pain and physical function before and after joint replacements. Full HOOS and KOOS surveys are lengthy, however, abbreviated versions are available as HOOS Jr./KOOS Jr.

To:

Elective total hip and knee replacement procedures seek to relieve pain and improve function, underscoring the importance of evaluating these outcomes pre and post surgery (Ayers, 2017). Patient-reported outcome measures (PROMs) are standardized instruments that capture a patient’s perspective on their health status including symptoms, physical function, and quality of life.

The Centers for Medicare & Medicaid Services (CMS) has finalized policies to expand the collection and reporting of patient-reported outcomes (PROs) for total hip and total knee arthroplasty across multiple programs (CMS, 2025, 2026a, 2026b, 2026c). This expansion reflects a national strategy to capture meaningful pre and postoperative PROMs to support clinical care, shared decision-making, and hospital-level quality assessment for elective total hip and knee replacement procedures (Ayers, 2017; CMS, 2021; Pasqualini et al., 2026).

Informed by the recommendations of the 2015 Patient Reported Outcomes Summit for Total Joint Arthroplasty (American Association of Hip and Knee Surgeons, 2015), this measure aims to advance postoperative PROM collection for total hip and knee arthroplasty procedures while accounting for the administrative burden associated with PRO data capture.

Selected References

• Cella, D., Hahn, E., Jensen, S., Butt, Z., Nowinski, C. et al. Patient-Reported Outcomes in Performance Measurement. Research Triangle Park (NC): RTI Press; 2015 Sep.
• Patient Report Outcomes Summit for Total Joint Arthroplasty Report, August 31, 2015.

To:

• American Association of Hip and Knee Surgeons. (2015). Patient reported outcomes summit for total joint arthroplasty. https://www.aahks.org/wp-content/uploads/2015/09/AAHKS-2015-Outcomes-Summit-Report.pdf
• Ayers, D. C. (2017). Implementation of patient-reported outcome measures in total knee arthroplasty. Journal of the American Academy of Orthopaedic Surgeons, 25 (Suppl. 1), S48–S50. https://doi.org/10.5435/JAAOS-D-16-00631
• Centers for Medicare & Medicaid Services. (2021). Hospital-level total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) patient-reported outcome-based performance measure (PRO-PM): Measure methodology report. Yale New Haven Health Services Corporation, Center for Outcomes Research and Evaluation.
• Centers for Medicare & Medicaid Services. (2025). Hospital inpatient quality reporting program. https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/inpatient-reporting-program
• Centers for Medicare & Medicaid Services. (2026a). Ambulatory surgical center quality reporting program. https://www.cms.gov/medicare/quality/initiatives/asc-quality-reporting
• Centers for Medicare & Medicaid Services. (2026b). Hospital outpatient quality reporting program. https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/hospital-outpatient-quality-reporting-program
• Centers for Medicare & Medicaid Services. (2026c). TEAM (Transforming episode accountability model). https://www.cms.gov/priorities/innovation/innovation-models/team-model
• Pasqualini, I., Elmenawi, K. A., Khan, S. T., Gudapati, L. S., & Piuzzi, N. S. (2026). Implementing the total hip and knee arthroplasty patient-reported outcome-based performance measure in outpatient and ambulatory surgical center settings: A practical review of new Centers for Medicare and Medicaid Services policies. The Journal of Arthroplasty, 41 (3), 668–673. https://doi.org/10.1016/j.arth.2025.10.023

To:

Regional anesthesia for primary elective total hip arthroplasty is associated with lower rates of postoperative complications compared with general anesthesia. Specifically, regional anesthesia has been linked to decreased odds of adverse events, including prolonged ventilator dependence, unplanned intubation, and select postoperative complications such as urinary tract infection and pneumonia (Basques et al., 2015). Additional studies have also demonstrated lower rates of blood transfusion with regional compared to general anesthesia (Basques et al., 2015; Bourget-Murray et al., 2022; Illescas et al., 2025). The American Academy of Orthopaedic Surgeons (AAOS) Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guideline (2023) suggests that regional anesthesia may be used to reduce adverse events in patients with symptomatic osteoarthritis of the hip undergoing total hip arthroplasty. Further, the 2020 Enhanced Recovery After Surgery (ERAS®) Society consensus statement for perioperative care in total hip replacement and total knee replacement surgery concluded that both regional anesthesia and modern general anesthesia may be used as part of a multimodal anesthetic regimen (Wainwright et al., 2020). According to The American Joint Replacement Registry 2024 Annual Report, the use of general anesthesia alone for primary total hip arthroplasty has steadily decreased from 48.8% in 2017 to 36.4% in 2024 (AJRR, 2025). Similarly, the use of general anesthesia alone for total knee arthroplasty decreased from 40.6% in 2017 to 21.8% in 2024 (AJRR, 2025). This decline aligns with growing evidence supporting the benefits of regional anesthesia, such as spinal anesthesia and PNB combinations, which are associated with better postoperative outcomes, including reduced opioid use, quicker recovery times, and fewer complications (AJRR, 2024).

Selected References

• ¹ Memtsoudis SG, Xuming S.; Ya-Lin Chiu, et al. Perioperative Comparative Effectiveness of Anesthetic Technique in Orthopedic Patients, Anesthesiology 05 2013, Vol.118, 1046-1058.
• ² Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a metaanalysis. Anesth. Analg. 2006; 103: 1018–25.
• ³ Hu S, Zhang Z-Y, Hua Y-Q, Li J, Cai Z-D. A comparison of regional and general anaesthesia for total replacement of the hip or knee: a metaanalysis. J. Bone Joint Surg. Br. 2009; 91: 935–42.
• ⁴ Zorrilla-Vaca A, Grant MC, Mathur V, Li J, Wu CL. The Impact of Neuraxial Versus General Anesthesia on the Incidence of Postoperative Surgical Site Infections Following Knee or Hip Arthroplasty: A Meta-Analysis. Regional Anesthesia & Pain Medicine: September/October 2016 - Volume 41 - Issue 5 - p 555–563.
• ⁵ Kim JH, Cho MR, et al. A comparison of femoral/sciatic nerve block with lateral femoral cutaneous nerve block and combined spinal epidural anesthesia for total knee replacement arthroplasty. Korean J Anesthesiol 2012 May 62(5): 448-453.
• ⁶ Liu JL, Yuan WX, et al. Peripheral nerve blocks versus general anesthesia for total knee replacement in elderly patients on the postoperative quality of recovery. Clinical Interventions in Aging 2014:9 341-350.
• ⁷ Surgical Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guideline. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, 12/4/2015.
• ⁸ Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guideline. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, 3.13.17.
• ⁹ Memtsoudis SG, Thomas Danninger, Rehana Rasul, Jashvant Poeran, Philipp Gerner, Ottokar Stundner, Edward R. Mariano, Madhu Mazumdar. Inpatient Falls after Total Knee Arthroplasty. Anesthesiology, 2014; 120 (3): 551-563.
• Nielsen PT, Jørgensen LN, Albrecht-Beste E, LeffersA, RasmussenLS. Lower thrombosis risk with epidural blockade in knee arthroplasty. Acta Orthopaedica Scandinavica, 1990,61:1, 29-31
• Mitchell D, Friedman, RJ, Baker DJ, Cooke JE, Darcy, MD, Miller MC. Prevention of thromboembolic disease following total knee arthroplasty: Epidural versus general anesthesia. Clinical Orthopaedics & Related Research, August 1991; 269:109-112.
• Jorgensen LN, Rasmussen LS, Nielsen PT, Leffers A, Albrecht-Beste E. Antithrombotic efficacy of continuous extradural analgesia after knee replacement. Br J Anaesth. 1991/1; 1: 8-12
• Soohoo NF, Lieberman JR, et al. Development of Quality of Care Indicators for Patients Undergoing THR/TKR. BMJ Qual Saf 2011;20:153-157
• Basques BA, Toy JO, Bohl, DD, Golinvaux, NS, Grauer, JN. General Compared with Spinal Anesthesia for Total Hip Arthroplasty. The Journal of Bone and Joint Surgery 2015;97:455-61
• Hunt LP, Ben-Shlomo Y, Clark EM, Dieppe P, Judge A, MacGregor AJ, Tobias JH, Vernon K, Blom AW. 90 day mortality after 409,096 total hip replacements for osteoarthritis, from the National Joint Registry for England and Wales: a retrospective analysis, Lancet. 2013 Sep 28;382(9898):1097-104
• Premier-IHI Integrated Care Pathway for Total Joint Arthroplasty (April 2013)
• Williams-Russo P, Sharrock NE, Haas SB, et al. Randomized Trial of Epidural Versus General Anesthesia: Outcomes After Primary Total Knee Replacement. Clinical Orthopaedics & Related Research. 331:199-208, October, 1996.
• National Surgical Quality Improvement Project database
• FORCE-Total Joint Registry database
• Warren, F., Sundaram, A., Anis, A., Kamath, S., Mont, S., Higuera, S., & Piuzzi, S. (2020). Spinal Anesthesia Is Associated With Decreased Complications After Total Knee and Hip Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons, 28(5), e213–e221.

To:

• American Academy of Orthopaedic Surgeons. (2023). Management of osteoarthritis of the hip evidence-based clinical practice guideline. https://www.aaos.org/globalassets/quality-and-practice-resources/osteoarthritis-of-the-hip/oah-cpg.pdf
• American Joint Replacement Registry (AJRR). (2024). 2024 annual report. American Academy of Orthopaedic Surgeons. https://communications.aaos.org/download-the-ajrr-2024-annual-report
• American Joint Replacement Registry (AJRR). (2025). AJRR 2025 annual report. American Academy of Orthopaedic Surgeons. https://communications.aaos.org/download-the-ajrr-2025-annual-report?_ga=2.211965012.1959132436.1785171229-1269128503.1758898877
• Basques, B. A., Toy, J. O., Bohl, D. D., Golinvaux, N. S., & Grauer, J. N. (2015). General compared with spinal anesthesia for total hip arthroplasty. The Journal of Bone & Joint Surgery, 97 (6), 455–461. https://doi.org/10.2106/JBJS.N.00662
• Bourget-Murray, J., Halpenny, D., Mahdavi, S., Piroozfar, S. G., & Sharma, R. (2022). Perioperative outcomes associated with general and spinal anesthesia after total joint arthroplasty for osteoarthritis: A large, Canadian, retrospective cohort study. Canadian Journal of Surgery, 65 (4), E460–E467. https://doi.org/10.1503/cjs.008821
• Illescas, A., Cozowicz, C., Zhong, H., Reisinger, L., Liu, J., Poeran, J., & Memtsoudis, S. G. (2025). Comparative effectiveness of neuraxial versus general anesthesia in total joint replacement surgery: An updated retrospective analysis using more recent data. Regional Anesthesia & Pain Medicine, 50 (11), 891–900. https://doi.org/10.1136/rapm-2024-105438
• Wainwright, T. W., Gill, M., McDonald, D. A., Middleton, R. G., Reed, M., Sahota, O., Yates, P., & Ljungqvist, O. (2020). Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthopaedica, 91 (1), 3–19. https://doi.org/10.1080/17453674.2019.1683790

To:

Early postoperative mobilization is a core component of high-quality care for total hip replacement and total knee replacement surgery. The 2020 Enhanced Recovery After Surgery (ERAS®) Society consensus statement on perioperative care for total hip replacement and total knee replacement surgery recommends that patients be mobilized as early as they are able to support functional recovery and facilitate early achievement of discharge criteria (Wainwright et al., 2020). Early mobilization is also recommended to mitigate adverse physiologic effects of postoperative immobility and bed rest, including insulin resistance, muscle atrophy, venous thromboembolism, and postoperative pulmonary complications (Wainwright et al., 2020; Alsuwaylihi et al., 2026).

Evidence supports the safety and effectiveness of early mobilization following total hip and knee arthroplasty. Mobilization within the first 24 hours after surgery is associated with a reduction in hospital length of stay without an increase in the rate of in hospital postoperative adverse events (Guerra et al., 2015). Additionally, evidence from a large multicenter study demonstrates that early mobilization is independently associated with a significant reduction in postoperative complications occurring within 30 days following total hip and knee arthroplasty (Ripollés-Melchor et al., 2020).

Based on recommendations from a Technical Advisory Panel and public comment, this measure was refined to focus on early postoperative ambulation as a more clinically meaningful indicator of mobilization.

Selected References

• ¹Guerra ML, Singh PJ, Taylor NF. Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: A systematic review. Clin Rehabil. 2014 Dec 1.
• ²Tayrose G, Newman D, Slover J, Jaffe F, Hunter T, Bosco J. Rapid Mobilization Decreases Length of Stay in Joint Replacement Patients. Bulletin of the Hospital for Joint Diseases 2013;71(3):222-6.
• AAOS Guidelines on Preventing Venous Thromboembolic Disease in Patients Undergoing Elective Hip and Knee Arthroplasty”, AAOS.
• Premier-IHI Integrated Care Pathway for Total Joint Arthroplasty (April 2013)
• Soohoo NF, Lieberman JR, et al. Development of Quality of Care Indicators for Patients Undergoing THR/TKR. BMJ Qual Saf 2011;20:153-157
• Larsen K, Sorensen, O, Hansen T, Thomsen P, Soballe K. Accelerated perioperative care and rehabilitation intervention for hip and knee replacement is effective: A randomized clinical trial involving 87 patients with 3 months of followup. Acta Orthopaedica 79:2, 149-159.
• den Hertog A, Gliesche K, Timm J, Mühlbauer B, Zebrowski. Pathway-controlled fast-track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating the recovery pattern, drug consumption, and length of stay. Arch Orthop Trauma Surg. 2012 Aug; 132(8):1153-63.
• Smith TO, McCabe C, Lister Set al Rehabilitation implications during the development of the Norwich Enhanced Recovery Programme (NERP) for patients following total knee and total hip arthroplasty. Orthop Traumatol Surg Res 2012; 98: 499–505.
• Raut S, Mertes SC, Muniz-Terrera G, Khanduja V. Factors associated with prolonged length of stay following a total knee replacement in patients aged over 75. Int Orthop 2012; 36: 1,601–1,608.
• Raphael M, Jaeger M, van Vlymen J. Easily adoptable total joint arthroplasty program allows discharge home in two days. Can J Anaesth 2011; 58: 902–910
• Pua YH, Ong PH. Association of early ambulation with length of stay and costs in total knee arthroplasty: retrospective cohort study. Am J Phys Med Rehabil 2014; 93:962-970.
• Chen AF, Stewart MK, Heyl AE, Klatt BA. Effect of Immediate Postoperative Physical Therapy on Length of Stay for Total Joint Arthroplasty Patients. The Journal of Arthroplasty 2012;Vol.27 No. 6
• Wellman SS, Murphy AC, Gulcynski D, Murphy SB. Implementation of an accelerated mobilization protocol following primary total hip arthroplasty: impact on length of stay and disposition. Current Reviews in Musculoskeletal Medicine Volume 4(3); 2011 Sep
• Renkawitz T, Rieder T, Handel M. Comparison of two accelerated clinical pathways – after total knee replacement how fast can we really go? Clinical Rehabilitation 2010; 24:230-239
• Labraca,NS, Castro-Sanchez,AM, Mataran-Penarrocha,G, Arroyo-Morales,M, Sanchez-Joya,M, Moreno-Lorenzo C. Benefits of starting rehabilitation within 24 hours of primary total knee arthroplasty: randomized clinical trial. Clin Rehabil. 2011/25(6):557-566
• Surgical Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guideline. Adopted by the American Academy of Orthopaedic Surgeons Board of Directors, 12/4/2015.

To:

• Alsuwaylihi, A., O'Connor, D., Joshi, G. P., Kehlet, H., and Lobo, D. N. (2026). Importance of early postoperative mobilization: Comprehensive review. BJS Open, 10 (2), zrag016. https://doi.org/10.1093/bjsopen/zrag016
• Guerra, M. L., Singh, P. J., and Taylor, N. F. (2015). Early mobilization of patients who have had a hip or knee joint replacement reduces length of stay in hospital: A systematic review. Clinical Rehabilitation, 29 (9), 844–854. https://doi.org/10.1177/0269215514558641
• Ripollés-Melchor, J., Abad-Motos, A., Díez-Remesal, Y., Aseguinolaza-Pagola, M., Padin-Barreiro, L., Sánchez-Martín, R., Logroño-Egea, M., García-Orallo, S., Ramirez-Rodriguez, J. M., and POWER2 Study Investigators Group. (2020). Association Between Use of Enhanced Recovery After Surgery Protocol and Postoperative Complications in Total Hip and Knee Arthroplasty in the Postoperative Outcomes Within Enhanced Recovery After Surgery Protocol in Elective Total Hip and Knee Arthroplasty Study (POWER2). JAMA Surgery, 155 (4), e196024. https://doi.org/10.1001/jamasurg.2019.6024
• Wainwright, T. W., Gill, M., McDonald, D. A., Middleton, R. G., Reed, M., Sahota, O., Yates, P., & Ljungqvist, O. (2020). Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthopaedica, 91 (1), 3–19. https://doi.org/10.1080/17453674.2019.1683790

According to 2012 Medicare claims data, 49% of patients undergoing hip and knee replacements were discharged to an inpatient rehabilitation facility (IRF) or skilled nursing facility (SNF) for rehabilitation. Therefore, only 51% of patients were discharged to home.

To:

High-quality care for total hip and total knee replacement procedures is designed to promote early functional recovery and enable safe discharge to the patient’s home. The 2020 Enhanced Recovery After Surgery (ERAS®) Society consensus statement on perioperative care for total hip and knee replacement recommends the use of objective discharge criteria to facilitate direct discharge to home (Wainwright et al., 2020).

Home-based rehabilitation is increasingly used following total hip and knee replacement procedures. The American Academy of Orthopaedic Surgeons (AAOS) 2022 Surgical Management of Osteoarthritis of the Knee Evidence Based Clinical Practice Guideline reports that discharge to home, with or without home services, is associated with fewer adverse events compared to discharge to an acute rehabilitation facility or skilled nursing facility (American Academy of Orthopaedic Surgeons, 2022). Additionally, the 2023 Management of Osteoarthritis of the Hip Evidence Based Clinical Practice Guideline reports high-quality evidence supporting either formal physical therapy or unsupervised home exercise following total hip arthroplasty (American Academy of Orthopaedic Surgeons, 2023).

Analyses of large national datasets indicate that rates of discharge to home following total hip and knee arthroplasty have notably increased over the past decade (American Joint Replacement Registry, 2025; DeMik et al., 2021), although meaningful variation in discharge practices persist (DeMik et al., 2021).

Selected References

• ¹Mahomed NN, Davis AM, Hawker G, Badley E, Davey JR, Syed KA. et al. Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial. J Bone Joint Surg Am. 2008;90(8):1673–1680.
• ²Padgett DE, et al. Study: Patients Who Go Home After Knee Replacement Do As Well as Those Discharged to Rehab Facility. Presented at: American Academy of Orthopaedic Surgeons Annual Meeting; March 24-28, 2015; Las Vegas.
• Inpatient Rehabilitation Facility Services: Assessing payment adequacy and updating payments - Report to the Congress: Medicare Payment Policy March 2014
• Mallinson TR, Bateman J, Tseng HY, Manheim L, et al. A Comparison of Discharge Functional Status After Rehabilitation in Skilled Nursing, Home Health, and Medical Rehabilitation Settings for Patients After Lower-Extremity Joint Replacement Surgery. Arch Phys Med Rehabil Vol 92, May 2011.
• Fleischman A, Austin, M, Purtill JJ, Parvizi J, Hozack WJ, The Rothman Institute Study: Even if you live alone, there is no place like home after total joint arthroplasty. Presented at American Academy of Orthopaedic Surgeons Annual Meeting; March 14, 2017; San Diego, CA.
• McLawhorn AS, Fu, MC, Schairer WW, Sculco PK, MacLeanCH,Padgett DE. Continued Inpatient Care After Primary Total Knee Arthroplasty Increases 30-Day Post-Discharge Complications: A Propensity Score-Adjusted Analysis. The Journal of Arthroplasty. January 31, 2017 (http://dx.doi.org/10.1016/j.arth.2017.01.039).
• Ramos NL, Karia RJ, Hutzler LH, Brandt AM, Slover JD, Bosco JA. The effect of discharge disposition on 30-day readmission rates after total joint arthroplasty. J Arthroplasty. 2014 Apr;29(4):674-7. doi: 10.1016/j.arth.2013.09.010. Epub 2013 Oct 30.

To:

• American Academy of Orthopaedic Surgeons. (2022). Surgical management of osteoarthritis of the knee evidence-based clinical practice guideline. https://www.aaos.org/quality/quality-programs/surgical-management-of-osteoarthritis-of-the-knee/
• American Academy of Orthopaedic Surgeons. (2023). Management of osteoarthritis of the hip evidence-based clinical practice guideline. https://www.aaos.org/quality/quality-programs/osteoarthritis-of-the-hip/
• American Joint Replacement Registry. (2025). AJRR 2025 annual report. American Academy of Orthopaedic Surgeons. https://communications.aaos.org/download-the-ajrr-2025-annual-report?_ga=2.211965012.1959132436.1785171229-1269128503.1758898877
• DeMik, D. E., Carender, C. N., Glass, N. A., Callaghan, J. J., & Bedard, N. A. (2021). Home discharge has increased after total hip arthroplasty; however, rates vary between large databases. The Journal of Arthroplasty, 36 (2), 586–592.e1. https://doi.org/10.1016/j.arth.2020.08.039
• Wainwright, T. W., Gill, M., McDonald, D. A., Middleton, R. G., Reed, M., Sahota, O., Yates, P., & Ljungqvist, O. (2020). Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Acta Orthopaedica, 91 (1), 3–19. https://doi.org/10.1080/17453674.2019.1683790

Patients who completed the general health and joint specific functional status assessments within 90 days prior to surgery as specified below:

Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)]

Knees: [VR-12 or PROMIS-Global] AND [KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)]

To:

Patients who completed the general health and joint specific functional status assessments within 90 days prior to surgery as specified below:

Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)]

Knees: [VR-12 or PROMIS-Global] AND [KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)]

The assessment tool must reflect the status of the patient’s health condition, health behavior, or experience with health care from the patient’s perspective, without interpretation of the patient’s response by a clinician or anyone else. The assessment can be completed by phone, mail, email, or in-person.

Rationale

The Veterans RAND 12 Item Health Survey (VR-12) is a generic patient reported outcome (PRO) instrument used to measure health related quality of life. This tool, which measures physical function and health status, is widely used and is well validated in the total hip and total knee population. Additionally, the Patient Reported Outcomes Measurement Information System (PROMIS) Global-10 instrument, funded by the National Institute of Health, is increasingly used in the United States. PROMIS instruments use modern measurement theory to assess patient–reported health status for physical, mental, and social well–being to reliably and validly measure patient reported outcomes (PROs) for clinical research and practice. PROMIS instruments measure concepts such as pain, fatigue, physical function, depression, anxiety and social function. Hip disability and Osteoarthritis Outcome Score (HOOS) and Knee injury and Osteoarthritis Outcome Score (KOOS) are well validated and widely used instruments for measuring joint-specific pain and physical function before and after joint replacement. While the full HOOS and KOOS surveys are lengthy, the orthopedic community prefers an abbreviated survey that captures a subset of items referred to as HOOS JR/KOOS JR.

To:

Elective total hip and knee replacement procedures seek to relieve pain and improve function, underscoring the importance of evaluating these outcomes pre and post surgery (Ayers, 2017). Patient-reported outcome measures (PROMs) are standardized instruments that capture a patient’s perspective on their health status including symptoms, physical function, and quality of life.

The Centers for Medicare & Medicaid Services (CMS) has finalized policies to expand the collection and reporting of patient-reported outcomes (PROs) for total hip and total knee arthroplasty across multiple programs (CMS, 2025a, 2026a, 2026b, 2026c). This expansion reflects a national strategy to capture meaningful pre and postoperative PROMs to support clinical care, shared decision-making, and hospital-level quality assessment for elective total hip and knee replacement procedures (Ayers, 2017; CMS, 2025b; Pasqualini et al., 2026).

Informed by the recommendations of the 2015 Patient Reported Outcomes Summit for Total Joint Arthroplasty (American Association of Hip and Knee Surgeons, 2015), this measure aims to advance preoperative PROM collection for total hip and knee arthroplasty procedures while accounting for the administrative burden associated with PRO data capture.

Selected References

• ¹ Cella D, Hahn EA, Jensen SE, Patient-Reported Outcomes in Performance Measurement, ©2015 Research Triangle Institute.
• ² Ayers DC, Zheng H, Franklin PD. Integrating Patient-reported Outcomes Into Orthopaedic Clinical Practice: Proof of Concept From FORCE-TJR. Clinical Orthopaedics and Related Research. 2013;471(11):3419-3425. doi:10.1007/s11999-013-3143-z.
• ³ Patient-Reported Outcomes Following Elective Primary Total Hip and/or Total Knee Arthroplasty: Hospital-Level Performance Measure(s), Phase 3 Measure Methodology Report, Yale New Haven Health Services Corporation – Center for Outcomes Research and Evaluation (CORE), May 2015.
• ⁴ AAOS letter to Andy Slavitt, Acting Administrator/CMS dated April 3, 2015. Re.: Response during public comment on “Proposed Electronic Clinical Quality Measures for Functional Status Assessment and Improvement for Patients who received a Total Hip Replacement and Functional Status Assessment and Improvement for Patients who received a Total Knee Replacement.”
• ⁵ AAHKS letter to Andy Slavitt, Acting Administrator/CMS dated March 30, 2015. Re.: Response during public comment on “Proposed Electronic Clinical Quality Measures for Functional Status Assessment and Improvement for Patients who received a Total Hip Replacement and Functional Status Assessment and Improvement for Patients who received a Total Knee Replacement.”

• ⁶ Patient Reported Outcomes Summit for Total Joint Arthroplasty Report, August 31, 2015.
• AAHKS sponsored Patient Reported Outcomes Summit for Total Joint Arthroplasty Report. August 31, 2015.
• FORCE-TJR letter to CMS dated September 3, 2015. Response during public comment on CMS-5516-Proposal for Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services.
• AAHKS, AAOS, AJRR letter to Andy Slavitt, Acting Administrator/CMS dated September 8, 2015. Response during public comment on CMS-5516-Proposal for Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services.
• AAHKS letter to Andy Slavitt, Acting Administrator/CMS dated September 8, 2015. Response during public comment on CMS-5516-Proposal for Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services.

To:

• American Association of Hip and Knee Surgeons. (2015). Patient reported outcomes summit for total joint arthroplasty report. https://www.aahks.org/wp-content/uploads/2015/09/AAHKS-2015-Outcomes-Summit-Report.pdf
• Ayers, D. C. (2017). Implementation of patient-reported outcome measures in total knee arthroplasty. Journal of the American Academy of Orthopaedic Surgeons, 25 (Suppl. 1), S48–S50. https://doi.org/10.5435/JAAOS-D-16-00631
• Centers for Medicare & Medicaid Services. (2025a). Hospital inpatient quality reporting program. https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/inpatient-reporting-program
• Centers for Medicare & Medicaid Services. (2025b). Risk-standardized patient-reported outcome-based performance measure (PRO-PM) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) in the HOPD setting (THA/TKA PRO-PM) (OP-42) (Version 1.0). QualityNet. https://qualitynet.cms.gov/files/6766d395a9dd1a5308128737?filename=HOQR_THATKA_PRO-PM_MIF_v.1.pdf
• Centers for Medicare & Medicaid Services. (2026a). Ambulatory surgical center quality reporting program. https://www.cms.gov/medicare/quality/initiatives/asc-quality-reporting
• Centers for Medicare & Medicaid Services. (2026b). Hospital outpatient quality reporting program. https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/hospital-outpatient-quality-reporting-program
• Centers for Medicare & Medicaid Services. (2026c). TEAM (Transforming episode accountability model). https://www.cms.gov/priorities/innovation/innovation-models/team-model
• Pasqualini, I., Elmenawi, K. A., Khan, S. T., Gudapati, L. S., & Piuzzi, N. S. (2026). Implementing the total hip and knee arthroplasty patient-reported outcome-based performance measure in outpatient and ambulatory surgical center settings: A practical review of new Centers for Medicare and Medicaid Services policies. The Journal of Arthroplasty, 41 (3), 668–673. https://doi.org/10.1016/j.arth.2025.10.023

Patients who completed the general health and joint specific functional status assessments, at 1 year (300-425 days) after surgery, as specified below:

Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)]

Knees: [VR-12 or PROMIS-Global] and [KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)]

The assessment tool must reflect the status of the patient’s health condition, health behavior, or experience with health care from the patient’s perspective, without interpretation of the patient’s response by a clinician or anyone else (Cella et al. 2015). The assessment can be completed by phone, mail, email, or in-person.

To:

Patients who completed the general health and joint specific functional status assessments, at 1 year (300-425 days) after surgery, as specified below:

Hips: [VR-12 or PROMIS-Global] AND [HOOS Jr. (6 questions) or HOOS Pain, Function Daily Living Subscales (27 questions)]

Knees: [VR-12 or PROMIS-Global] and {KOOS Jr. (7 questions) or KOOS Stiffness, Pain, Function Daily Living Subscales (28 questions)]

The assessment tool must reflect the status of the patient’s health condition, health behavior, or experience with health care from the patient’s perspective, without interpretation of the patient’s response by a clinician or anyone else. The assessment can be completed by phone, mail, email, or in-person.

Rationale

Good orthopedic care requires knowledge of the patient’s history of musculoskeletal pain and associated limitations in daily function, along with improvements or declines seen after surgery. Standardized measures of patient-reported outcomes (PROs) can provide this information.

The American Association of Hip and Knee Surgeons (AAHKS) convened a Patient Reported Outcomes Summit for Total Joint Arthroplasty in 2015 with the goal of obtaining consensus regarding the patient-reported outcomes and risk variables suitable for total hip and total knee arthroplasty performance measures (Patient Reported Outcomes Summit for Total Joint Arthroplasty Report, 2015). The instruments specified in this measure align with the Summit’s recommendations as well as CMS Comprehensive Care for Joint Replacement legislation.

The Veterans RAND 12 item Health Survey (VR-12) is a generic patient reported outcome (PRO) instrument. It is a well validated and widely used in the hip and knee population to measure health related quality of life by capturing the patient’s physical function and health status. The Patient Reported Outcomes Measurement Information System (PROMIS) Global-10 assess patient-reported health status for physical, mental, and social well-being by measuring a patient’s pain, fatigue, physical function, depression/anxiety status, and social function. Hip disability and Osteoarthritis Outcome Score (HOOS) and Knee injury and Osteoarthritis Outcome Score (KOOS) are well validated and widely used instruments for measuring joint-specific pain and physical function before and after joint replacements. Full HOOS and KOOS surveys are lengthy, however, abbreviated versions are available as HOOS Jr./KOOS Jr.

To:

Elective total hip and knee replacement procedures seek to relieve pain and improve function, underscoring the importance of evaluating these outcomes pre and post surgery (Ayers, 2017). Patient-reported outcome measures (PROMs) are standardized instruments that capture a patient’s perspective on their health status including symptoms, physical function, and quality of life.

The Centers for Medicare & Medicaid Services (CMS) has finalized policies to expand the collection and reporting of patient-reported outcomes (PROs) for total hip and total knee arthroplasty across multiple programs (CMS, 2025a, 2026a, 2026b, 2026c). This expansion reflects a national strategy to capture meaningful pre and postoperative PROMs to support clinical care, shared decision-making, and hospital-level quality assessment for elective total hip and knee replacement procedures (Ayers, 2017; CMS, 2025b; Pasqualini et al., 2026).

Informed by the recommendations of the 2015 Patient Reported Outcomes Summit for Total Joint Arthroplasty (American Association of Hip and Knee Surgeons, 2015), this measure aims to advance postoperative PROM collection for total hip and knee arthroplasty procedures while accounting for the administrative burden associated with PRO data capture.

Selected References

• Cella, D., Hahn, E., Jensen, S., Butt, Z., Nowinski, C. et al. Patient-Reported Outcomes in Performance Measurement. Research Triangle Park (NC): RTI Press; 2015 Sep.
• Patient Report Outcomes Summit for Total Joint Arthroplasty Report, August 31, 2015.

To:

• American Association of Hip and Knee Surgeons. (2015). Patient reported outcomes summit for total joint arthroplasty. https://www.aahks.org/wp-content/uploads/2015/09/AAHKS-2015-Outcomes-Summit-Report.pdf
• Ayers, D. C. (2017). Implementation of patient-reported outcome measures in total knee arthroplasty. Journal of the American Academy of Orthopaedic Surgeons, 25 (Suppl. 1), S48–S50. https://doi.org/10.5435/JAAOS-D-16-00631
• Centers for Medicare & Medicaid Services. (2025a). Hospital inpatient quality reporting program. https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/inpatient-reporting-program
• Centers for Medicare & Medicaid Services. (2025b). Risk-standardized patient-reported outcome-based performance measure (PRO-PM) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) in the HOPD setting (THA/TKA PRO-PM) (OP-42) (Version 1.0). QualityNet. https://qualitynet.cms.gov/files/6766d395a9dd1a5308128737?filename=HOQR_THATKA_PRO-PM_MIF_v.1.pdf
• Centers for Medicare & Medicaid Services. (2026a). Ambulatory surgical center quality reporting program. https://www.cms.gov/medicare/quality/initiatives/asc-quality-reporting
• Centers for Medicare & Medicaid Services. (2026b). Hospital outpatient quality reporting program. https://www.cms.gov/medicare/quality/initiatives/hospital-quality-initiative/hospital-outpatient-quality-reporting-program
• Centers for Medicare & Medicaid Services. (2026c). TEAM (Transforming episode accountability model). https://www.cms.gov/priorities/innovation/innovation-models/team-model
• Pasqualini, I., Elmenawi, K. A., Khan, S. T., Gudapati, L. S., & Piuzzi, N. S. (2026). Implementing the total hip and knee arthroplasty patient-reported outcome-based performance measure in outpatient and ambulatory surgical center settings: A practical review of new Centers for Medicare and Medicaid Services policies. The Journal of Arthroplasty, 41 (3), 668–673. https://doi.org/10.1016/j.arth.2025.10.023

Documentation of cognitive impairment overrides documentation of an alcohol use screen and therefore would not be considered "conflicting documentation." Even if the family or others tell staff the patient uses alcohol, the patient could not be appropriately screened and subsequently counseled due to cognitive impairment. Select Value “7.”

To:

Documentation of cognitive impairment overrides documentation of an alcohol use screen or BAC 0.08 g/dL or greater and therefore would not be considered "conflicting documentation." Even if the family or others tell staff the patient uses alcohol, the patient could not be appropriately screened and subsequently counseled due to cognitive impairment. Select Value “7.”

Examples:

Discharge summary dictated 2 days after discharge states patient went “home”. Physician note on day of discharge further clarifies that the patient will be going home with hospice”. Select value “2” (“Hospice - Home”).

To:

Examples:

A physical restraint is any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely when it is used as a restriction to manage a patient's behavior or restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychiatric condition.

To:

• Crossed lesion time

A physical restraint is any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely when it is used as a restriction to manage a patient's behavior or restrict the patient's freedom of movement and is not a standard treatment for the patient's medical or psychiatric condition.

To:

A physical restraint is any manual method or physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely when it is used as a restriction to manage a patient's behavior or restrict the patient's freedom of movement.

Manual holds

To:

Manual (physical) holds

Stapling

Jarvis

Leather restraints

To:

Leather/locking restraints

• FAQ: https://www.jointcommission.org/en-us/knowledge-library/support-center/standards-interpretation/standards-faqs/000001363

Exclusion

Devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets

To:

Devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, IV arm board, positioning or securing devices during procedures or anesthesia

Methods that involve the physical holding of a patient to conduct routine physical examinations, tests, or medication administration

To:

Methods that involve the physical holding of a patient to conduct routine physical examinations or tests to which the patient has consented

Restraint uses that are forensic or correctional restrictions applied and used by outside law enforcement

To:

Restraint uses that are correctional restrictions applied and used by outside law enforcement

Restraint uses that are forensic or correctional restrictions applied and used by designated hospital security personnel to transport the patient to court off the locked unit

To:

Restraint uses that are correctional restrictions applied and used by designated hospital security personnel to transport the patient to court off the locked unit

• If reasons are not mentioned in the context of anticoagulation therapy, do not make inferences (e.g., do not assume that anticoagulation therapy was not prescribed because of a bleeding disorder unless documentation explicitly states so).
  • Reasons must be explicitly documented (e.g., “Active GI bleed – anticoagulation therapy contraindicated,” “No warfarin” [no reason given]).
  • Consider the term "blood thinners" synonymous with anticoagulant therapy. Physician/APN/PA or pharmacist documentation, e.g., "no blood thinners", select "Yes".

• If reasons are not mentioned in the context of anticoagulation therapy, do not make inferences (e.g., do not assume that anticoagulation therapy was not prescribed because of a bleeding disorder unless documentation explicitly states so).
  • Reasons must be explicitly documented (e.g., “Active GI bleed – anticoagulation therapy contraindicated,” “No warfarin” [no reason given]).
  • Left atrial appendage (LAA) occlusion or closure device without mention of anticoagulation is not an acceptable reason.
    Examples:
    "X device 20XX," select "No".
    "Patient with H/O AF, S/P X device, no longer on anticoagulation," select "Yes".
  • Consider the term "blood thinners" synonymous with anticoagulant therapy. Physician/APN/PA or pharmacist documentation, e.g., "no blood thinners", select "Yes".

• If regional anesthesia was performed/attempted in combination with a modality listed in the Exclusion Guidelines, select “1” or "2" as appropriate.

• If regional anesthesia was performed/attempted in combination with a modality listed in the Exclusion Guidelines, select “1” or "2" as appropriate.

• Anesthesia start time
• Procedure start time
• Terms other than time of arterial access / puncture

Note

To:

• STK inpatient measures (STK-01, 02, 03, 04, 05, 06, 08 and 10)
• STK outpatient measure (STK-OP-1)
• A patient cannot be an inpatient and outpatient at the same time, therefore the same patient cannot be counted in both the inpatient and outpatient STK measures.

Starting from 3Q2021 discharged data, ASR patient can be inpatient or outpatient.

• ASR inpatient measures (ASR-IP-1, 2 and 3)
• ASR outpatient measure (ASR-OP-1)
• STK Outpatient measure (STK-OP-1)
• A patient cannot be an inpatient and outpatient at the same time, therefore the same patient cannot be counted in both the inpatient and outpatient ASR measures.

To:

• STK inpatient measures (STK-01, 02, 03, 04, 05, 06, 08 and 10)
• STK outpatient measure (STK-OP-1)
• A patient cannot be an inpatient and outpatient at the same time at your hospital, therefore the same patient record cannot be counted in both the inpatient and outpatient STK measure data reported by your site. If the patient is transferred from your hospital ED to another acute care hospital outside of or within your health system, include the case in the count of records reviewed for STK-OP-1. If the patient is admitted to your hospital for inpatient care, count the record in all required STK measures and CSTK-01.

• ASR inpatient measures (ASR-IP-1, 2 and 3)
• ASR outpatient measure (ASR-OP-1)
• STK Outpatient measure (STK-OP-1)
• A patient cannot be an inpatient and outpatient at the same time at your hospital, therefore the same patient record cannot be counted in both the inpatient and outpatient ASR measure data reported by your site. If the patient is transferred from your hospital ED to another acute care hospital outside of or within your health system, include the case in the count of records reviewed for ASR-OP-1 and STK-OP-1. If the patient is admitted to your hospital for inpatient care, count the record in the three ASR-IP measures.