Development and Implementation of Evidence-Based Indicators for Measuring Quality of Acute Stroke Care

COVID-19 Pandemic and Stroke Care in Patients with Dementia Compared to Other Stroke Patients

OBJECTIVES

The primary objective of this study was to examine the impact of the COVID-19 pandemic on the quality of stroke care for patients with preexisting dementia, compared with patients who had only stroke. The secondary aim was to investigate how the quality of stroke care changed during the pandemic and post-pandemic periods compared with the pre-pandemic period in patients with preexisting dementia.

DESIGN

A registry-based, nationwide cohort study in Sweden.

SETTING AND PARTICIPANTS

We included patients with a first stroke between 2019 and 2022, both with and without dementia. The study periods were defined as follows: pre-pandemic (January 1, 2019, to February 29, 2020), COVID-19 pandemic (March 1, 2020, to February 24, 2022), and post-COVID-19 pandemic period (February 25, 2022, to September 19, 2022). The outcomes examined were the following quality indicators of stroke care, suggested by the national guideline of stroke care in Sweden: stroke admission site, performance of swallowing assessment, reperfusion treatment, assessment for rehabilitation, and early supported discharge.

METHODS

The associations were studied through group comparisons and binary logistic regressions.

RESULTS

Of the 21,795 patients with strokes, 1357 had documented preexisting dementia, and 20,438 had stroke without a dementia diagnosis. Throughout all study periods, a significantly lower proportion of patients with stroke with preexisting dementia, compared with stroke-only patients, received reperfusion treatment, assessments for rehabilitation, and early supported discharge from stroke units. In the subgroup of stroke patients with preexisting dementia, no significant associations were found regarding the quality indicators of stroke care before, during, and after the pandemic.

CONCLUSIONS AND IMPLICATIONS

Disparities in quality of stroke care were observed between stroke patients with preexisting dementia and those with only stroke during the COVID-19 pandemic. However, there were no statistically significant differences in stroke care for patients with dementia across the pandemic.

Development and pilot-testing of an evidence-based quality indicator set for home mechanical ventilation care: the OVER-BEAS project

BACKGROUND

The number of patients depending on home mechanical ventilation (HMV) has increased substantially in Germany in recent years. These patients receive long-term care in different nursing facilities (nursing home, shared living community, private home). However, there are limited data available on the quality of care of HMV patients. The aim of the OVER-BEAS project was to identify quality indicators (QIs) of HMV care using an evidence-based approach.

METHODS

A multidisciplinary board consisting of professionals and experts of HMV provision compiled a set of QIs between March and September 2019. In a structured, transparent process a set of QIs covering structures, processes and outcome of HMV patient's care were proposed and evaluated based on the best available evidence. QIs were defined as relevant, reliable and valid measurements of the quality of HMV care and furthermore to be comprehensive and applicable in practice.

RESULTS

The experts proposed 40 QIs and consented a final set of 26 QIs. Based on the final set, questionnaires to document the QIs were developed: (1) to assess the quality and describe the structure of the nursing facility; and (2) to gather information on patient-related processes and outcomes. The feasibility of the questionnaires was tested in 5 nursing facilities treating HMV patients. The remarks from the nursing specialists were categorised in three groups: (1) term missing accuracy, (2) problem of understanding, and (3) not documented or documented elsewhere. Mean documentation time by the nursing specialists for one patient was 15 min. Based on this feedback, the questionnaires were finalised.

CONCLUSIONS

We proposed a set of QIs relating to long-term HMV care and developed two questionnaires to collect this information. In a pilot study, we found the set of questionnaires to be feasible in assessing the quality of HMV care according to current evidence. The development of standardised evidence-based QIs to evaluate HMV care is a step towards implementing a standardised quality assurance program to document the quality of care of HMV patients.

Development of a Set of Indicators for Measuring and Improving Quality of Rehabilitation Care after Ischemic Stroke

Stroke is the leading global cause of permanent disability and the second leading cause of dementia within the first year of the event. Systematic quality improvement interventions such as Audit & Feedback (A&F) can monitor and improve the performance of post-stroke care in conjunction with the use of quality indicators (QIs). The scientific literature shows limited studies on quality improvement and QIs design for poststroke rehabilitation. In Italy, the National Outcomes Evaluation Programme (PNE) annually provides several QIs concerning the acute wards. On the contrary, indicators for quality assessment of post-acute stroke rehabilitation are not available nationwide. In recent years, the Italian Ministry of Health has funded a national network project, the aim of which is to provide and evaluate the effectiveness of A&F strategies in healthcare improvement. Part of this project is the development of a set of IQs for ischemic stroke rehabilitation used to conduct an A&F. In this study, we describe the design and development process of these QIs from administrative databases and report the results of the pilot test conducted on a small sample of Sicilian rehabilitation facilities, comparing them from 2019 to 2021. Feedback from the participating centers was mainly positive, and the quality indicators were found to be comprehensible and appreciated. However, the study highlighted the need for better adherence to indicators measuring processes of rehabilitation care. The set of quality indicators presented in this study, relevant to inpatient settings, could be considered a starting point on which to base quality improvement initiatives both nationally and internationally.

Stroke care during the COVID-19 pandemic: Case numbers, treatments, and mortality in two large German stroke registries

Background and purpose

At the beginning of the SARS-CoV-2 pandemic, an alarming decline in hospitalizations for stroke was reported in several countries, including Germany. We assessed hospitalization numbers and indicators of the quality of stroke care in 2020 during the pandemic containment measures.

Materials and methods

The analysis was based on data of two large stroke quality assurance registries in the north and the south of Germany (Qualitätssicherung Schlaganfall Nordwestdeutschland and Bayerische Arbeitsgemeinschaft für Qualitätssicherung in der stationären Versorgung). We included 395 hospitals with 467,931 documented cases in 2018–2020. The time interval between admission and thrombolysis, frequency of systemic thrombolysis and intra-arterial therapy (IAT), National Institutes of Health Stroke Scale (NIHSS) score on admission and in-hospital mortality were assessed. Changes in the second (Q2) and fourth (Q4) quarters of 2020 were compared to corresponding quarters in 2019 by chi-squared tests.

Results

Hospitalization numbers decreased in the two stroke registries by 8% and 10% in Q2 of 2020 and by 5% and 15% in Q4 of 2020 compared to the same quarters in 2019, respectively. The decline was particularly seen in women and patients with transient ischemic attacks. In cases with cerebral infarction, no increase in NIHSS scores on admission was observed, and the proportion of patients with a time interval between admission and thrombolysis of ≤60 min was unchanged. No clear pattern was found in the frequency of systemic thrombolysis and IAT. In one of the registries, in-hospital mortality of patients with cerebral infarction increased in Q2 of 2020 compared to Q2 of 2019.

Conclusion

Case numbers slightly decreased under pandemic conditions, while our quarterly analysis indicated that the quality of stroke care was largely unchanged throughout the year 2020.

Prediction of Recurrent Ischemic Stroke Using Registry Data and Machine Learning Methods: The Erlangen Stroke Registry

BACKGROUND

There have been multiple efforts toward individual prediction of recurrent strokes based on structured clinical and imaging data using machine learning algorithms. Some of these efforts resulted in relatively accurate prediction models. However, acquiring clinical and imaging data is typically possible at provider sites only and is associated with additional costs. Therefore, we developed recurrent stroke prediction models based solely on data easily obtained from the patient at home.

METHODS

Data from 384 patients with ischemic stroke were obtained from the Erlangen Stroke Registry. Patients were followed at 3 and 12 months after first stroke and then annually, for about 2 years on average. Multiple machine learning algorithms were applied to train predictive models for estimating individual risk of recurrent stroke within 1 year. Double nested cross-validation was utilized for conservative performance estimation and models' learning capabilities were assessed by learning curves. Predicted probabilities were calibrated, and relative variable importance was assessed using explainable artificial intelligence techniques.

RESULTS

The best model achieved the area under the curve of 0.70 (95% CI, 0.64-0.76) and relatively good probability calibration. The most predictive factors included patient's family and housing circumstances, rehabilitative measures, age, high calorie diet, systolic and diastolic blood pressures, percutaneous endoscopic gastrotomy, number of family doctor's home visits, and patient's mental state.

CONCLUSIONS

Developing fairly accurate models for individual risk prediction of recurrent ischemic stroke within 1 year solely based on registry data is feasible. Such models could be applied in a home setting to provide an initial risk assessment and identify high-risk patients early.

Changes of Health-Related Quality of Life Within the 1st Year After Stroke-Results From a Prospective Stroke Cohort Study

Introduction: As prospective data on long-term patient-reported outcome measures (PROMs) to assess Health related Quality of Life (HRQoL) after stroke are still scarce, this study examined the long-term course of PROMs and investigated influential factors such as recanalization therapies. Materials and Methods: A total of 945 (mean age 69 years; 56% male) stroke patients were enrolled with a personal interview and chart review performed at index event. One hundred forty (15%) patients received thrombolysis (IVT) and 53 (5%) patients received endovascular therapy (ET) or both treatments as bridging therapy (BT). After 3 and 12 months, a follow-up was conducted using a postal questionnaire including subjective quality of life EQ-5D-5L (European Quality of Life 5 Dimensions). At all time-points, Modified Rankin Scale (mRS) was additionally used to quantify functional stroke severity. Differences between therapy groups were identified using post-hoc-tests. Linear and logistic regression analyses were used to identify predictors of outcomes. Results: Recanalization therapies were associated with significant improvements of NIHSS (National Institutes of Health Stroke Scale [regression coefficient IVT 1.21 (p = 0.01) and ET/BT 7.6; p = 0.001] and mRS (modified Rankin Scale) [regression coefficient IVT 0.83; p = 0.001 and ET/BT 2.0; p = 0.001] between admission and discharge compared to patients with stroke unit therapy only, with a trend toward improvement of EQ-5D after 12 months [regression coefficient 4.67 (p = 0.17)] with IVT. HRQoL was considerably impaired by stroke and increased steadily in 3- and 12-months follow-up in patients with (mean EQ-5D from 56 to 68) and without recanalization therapy (mean EQ-5D from 62 to 68). In severe strokes a major and significant improvement was only detected during period of 3 to 12 months (p = 0.03 in patients with and p = 0.005 in patients without recanalization therapy). Conclusions: Despite significant and continuous improvements after stroke the HRQoL after 12 months remained below the age-matched general population, but was still unexpectedly high in view of the accumulation of permanent disabilities in up to 30% of the patients. Especially in severe strokes, it is important to evaluate HRQoL beyond a 3-months follow-up as improvements became significant only between 3 months and 1 year.

Ten Years of Improving Acute Stroke Management in a Metropolitan Area: A Population-Based Quantification of Quality Indicators

BACKGROUND AND PURPOSE

Rapid access to acute stroke treatment improves clinical outcomes in patients with ischemic stroke. We aimed to shorten the time to admission and to acute stroke treatment for patients with acute stroke in the Hamburg metropolitan area by collaborative multilevel measures involving all hospitals with stroke units, the Emergency Medical Services (EMS), and health-care authorities.

METHODS

In 2007, an area-wide stroke care quality project was initiated. The project included mandatory admission of all stroke patients in Hamburg exclusively to hospitals with stroke units, harmonized acute treatment algorithms among all hospitals, repeated training of the EMS staff, a multimedia educational campaign, and a mandatory stroke care quality monitoring system based on structured data assessment and quality indicators for procedural measures. We analyzed data of all patients with acute stroke who received inhospital treatment in the city of Hamburg during the evaluation period from the quality assurance database data and evaluated trends of key quality indicators over time.

RESULTS

From 2007 to 2016, a total of 83,395 patients with acute stroke were registered. During this period, the proportion of patients admitted within ≤3 h from symptom onset increased over time from 27.8% in 2007 to 35.2% in 2016 (p < 0.001). The proportion of patients who received rapid thrombolysis (within ≤30 min after admission) increased from 7.7 to 54.1% (p < 0.001).

CONCLUSIONS

Collaborative stroke care quality projects are suitable and effective to improve acute stroke care.

Organization and Implementation of a Stroke Center in Panamá, a Model for Implementation of Stroke Centers in Low and Middle Income Countries

Background: Stroke is the second leading cause of death and disability worldwide. Stroke centers have become a central component of modern stroke services in many high-income countries, but their feasibility and efficacy in low, middle, and emerging high-income countries are less clear. Also, despite the availability of international guidelines, many hospitals worldwide do not have organized clinical stroke care. We present a methodology to help hospitals develop stroke centers and review quality data after implementation.

Objectives: To describe and compare demographics, performance, and clinical outcomes of the Pacífica Salud, Hospital Punta Pacífica (PSHPP) stroke center during its first 3 years 2017–2019.

Methods: Pacífica Salud, Hospital Punta Pacífica was organized to implement protocols of care based on the best practices by international guidelines and a quality improvement process. The methodology for implementation adapts a model for translating evidence into practice for implementation of evidence-based practices in medicine. This is a retrospective study of prospectively collected quality data between March of 2017 to December of 2019 for patients admitted to PSHPP with primary diagnosis stroke. Data collected include demographics, clinical data organized per the Joint Commission's STK Performance Measures, door to needle, door to groin puncture, 90 day modified Rankin Score, and hemorrhagic complications from IV thrombolysis and mechanical thrombectomy (MT). Primary outcome: year over year proficiency in documenting performance measures. Secondary outcome: year over year improvement.

Results: A total of 143 patients were admitted for acute ischemic stroke, TIA, or hemorrhagic stroke. Of these, 36 were admitted in 2017, 50 in 2018, and 57 in 2019. Performance measure proficiency increased in the year-over-year analysis as did the total number of patients and the number of patients treated with IV thrombolysis and MT.

Conclusions: We present the methodology and results of a stroke program implementation in Panamá. This program is the first in the country and in Central America to achieve Joint Commission International (JCI) certification as a Primary Stroke Center (PSC). We postulate that the dissemination of management guidelines is not sufficient to encourage the development of stroke centers. The application of a methodology for translation of evidence into practice with mentorship facilitated the success of this program.

Quality of Care for Patients With Multiple Sclerosis-A Review of Existing Quality Indicators

Background: The care of patients with multiple sclerosis (MS) calls for a lifelong guidance and treatment and results in a high resource utilization. Therefore, strategies for the assessment and improvement of the care process are crucial. Quality indicators have become a widely used instrument to determine quality in many areas of the healthcare system. The currently available sets of indicators for the quality of MS care are summarized in this review.

Methods: A literature search was conducted for reports that include statements on quality indicators for the care of people with MS. For the determination of the strength of the underlying evidence of the identified publications appropriate criteria of the PRISMA and AGREE-Statements were used. A further prioritization of the eligible indicators was based on the internal grading by the initial authors.

Results: Of the 465 included records in the search, 6 sources were finally identified, 3 demonstrating a high and the others a medium strength of evidence. In total, these six reports described 226 quality indicators for the treatment of MS. Of them, 147 were further included in the assessment due to the scope of this article. Among the 101 indicators that originated from reports with a high strength of evidence, 6 also had a high initial internal grading. These six identified quality indicators describe five important characteristics of a high-quality care of MS.

Conclusion: The search led to a scientifically evident set of six quality indicators for the assessment of care for patients with MS. These should be seen as starting points in the development of comprehensive sets of quality indicators in MS that addresses the individual objective of their use.

EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients (EVA-TRISP) registry: basis and methodology of a pan-European prospective ischaemic stroke revascularisation treatment registry

PURPOSE

The Thrombolysis in Ischemic Stroke Patients (TRISP) collaboration was a concerted effort initiated in 2010 with the purpose to address relevant research questions about the effectiveness and safety of intravenous thrombolysis (IVT). The collaboration also aims to prospectively collect data on patients undergoing endovascular treatment (EVT) and hence the name of the collaboration was changed from TRISP to EVA-TRISP. The methodology of the former TRISP registry for patients treated with IVT has already been published. This paper focuses on describing the EVT part of the registry.

PARTICIPANTS

All centres committed to collecting predefined variables on consecutive patients prospectively. We aim for accuracy and completeness of the data and to adapt local databases to investigate novel research questions. Herein, we introduce the methodology of a recently constructed academic investigator-initiated open collaboration EVT registry built as an extension of an existing IVT registry in patients with acute ischaemic stroke (AIS).

FINDINGS TO DATE

Currently, the EVA-TRISP network includes 20 stroke centres with considerable expertise in EVT and maintenance of high-quality hospital-based registries. Following several successful randomised controlled trials (RCTs), many important clinical questions remain unanswered in the (EVT) field and some of them will unlikely be investigated in future RCTs. Prospective registries with high-quality data on EVT-treated patients may help answering some of these unanswered issues, especially on safety and efficacy of EVT in specific patient subgroups.

FUTURE PLANS

This collaborative effort aims at addressing clinically important questions on safety and efficacy of EVT in conditions not covered by RCTs. The TRISP registry generated substantial novel data supporting stroke physicians in their daily decision making considering IVT candidate patients. While providing observational data on EVT in daily clinical practice, our future findings may likewise be hypothesis generating for future research as well as for quality improvement (on EVT). The collaboration welcomes participation of further centres willing to fulfill the commitment and the outlined requirements.

What makes a good quality indicator set? A systematic review of criteria

BACKGROUND

While single indicators measure a specific aspect of quality (e.g. timely support during labour), users of these indicators, such as patients, providers and policy-makers, are typically interested in some broader construct (e.g. quality of maternity care) whose measurement requires a set of indicators. However, guidance on desirable properties of indicator sets is lacking.

OBJECTIVE

Based on the premise that a set of valid indicators does not guarantee a valid set of indicators, the aim of this review is 2-fold: First, we introduce content validity as a desirable property of indicator sets and review the extent to which studies in the peer-reviewed health care quality literature address this criterion. Second, to obtain a complete inventory of criteria, we examine what additional criteria of quality indicator sets were used so far.

METHODS

We searched the databases Web of Science, Medline, Cinahl and PsycInfo from inception to May 2021 and the reference lists of included studies. English- or German-language, peer-reviewed studies concerned with desirable characteristics of quality indicator sets were included. Applying qualitative content analysis, two authors independently coded the articles using a structured coding scheme and discussed conflicting codes until consensus was reached.

RESULTS

Of 366 studies screened, 62 were included in the review. Eighty-five per cent (53/62) of studies addressed at least one of the component criteria of content validity (content coverage, proportional representation and contamination) and 15% (9/62) addressed all component criteria. Studies used various content domains to structure the targeted construct (e.g. quality dimensions, elements of the care pathway and policy priorities), providing a framework to assess content validity. The review revealed four additional substantive criteria for indicator sets: cost of measurement (21% [13/62] of the included studies), prioritization of 'essential' indicators (21% [13/62]), avoidance of redundancy (13% [8/62]) and size of the set (15% [9/62]). Additionally, four procedural criteria were identified: stakeholder involvement (69% [43/62]), using a conceptual framework (44% [27/62]), defining the purpose of measurement (26% [16/62]) and transparency of the development process (8% [5/62]).

CONCLUSION

The concept of content validity and its component criteria help assessing whether conclusions based on a set of indicators are valid conclusions about the targeted construct. To develop a valid indicator set, careful definition of the targeted construct including its (sub-)domains is paramount. Developers of quality indicators should specify the purpose of measurement and consider trade-offs with other criteria for indicator sets whose application may reduce content validity (e.g. costs of measurement) in light thereof.

Brain circuitry underlying the ABC model of anxiety

Anxiety Disorders are prevalent and often chronic, recurrent conditions that reduce quality of life. The first-line treatments, such as serotonin reuptake inhibitors and cognitive behavioral therapy, leave a significant proportion of patients symptomatic. As psychiatry moves toward targeted circuit-based treatments, there is a need for a theory that unites the phenomenology of anxiety with its underlying neural circuits. The Alarm, Belief, Coping (ABC) theory of anxiety describes how the neural circuits associated with anxiety interact with each other and domains of the anxiety symptoms, both temporally and spatially. The latest advancements in neuroimaging techniques offer the ability to assess these circuits in vivo. Using Neurosynth, a large open-access meta-analytic imaging database, the association between terms related to specific neural circuits was explored within the ABC theory framework. Alarm-related terms were associated with the amygdala, anterior cingulum, insula, and bed nucleus of stria terminalis. Belief-related terms were associated with medial prefrontal cortex, precuneus, bilateral temporal poles, and hippocampus. Coping-related terms were associated with the ventrolateral and dorsolateral prefrontal cortices, basal ganglia, and anterior cingulate. Neural connections underlying the functional neuroanatomy of the ABC model were observed. Additionally, there was considerable interaction and overlap between circuits associated with the symptom domains. Further neuroimaging research is needed to explore the dynamic interaction between the functional domains of the ABC theory. This will pave the way for probing the neuroanatomical underpinnings of anxiety disorders and provide an evidence-based foundation for the development of targeted treatments, such as neuromodulation.

Number of Patients with Ischemic Stroke did not Decline in a Regional Stroke Unit After the Implementation of Mechanical Thrombectomy

OBJECTIVES

Since the implementation of mechanical thrombectomy (MT) in 2015 for patients with ischemic stroke and large-vessel occlusion, the question arose as to whether patients should be primarily admitted to the nearest regional stroke unit (SU) for prompt intravenous thrombolysis (IVT) or to a more distant supraregional SU performing MT, to avoid secondary-transfer delays in MT. Although an evidence-based answer is still lacking, a discrepant discussion with potential consequences for the regional flow of stroke patients arose. We aimed to assess if MT implementation was associated with the number and characteristics of patients with stroke/transient ischemic attack (TIA) admitted to a regional SU not offering endovascular treatment.

MATERIALS AND METHODS

Patients with acute stroke/TIA treated at the Klinikum Main-Spessart Lohr, Germany, in 2013/2014 or 2017/2018 were included in this retrospective study. Data were derived from the clinical information system and mandatory stroke quality assessment. We assessed the catchment area using a region-based approach. For each region, the number of patients treated in our hospital, including data regarding clinical severity, demographic characteristics, and changes over time, were analyzed.

RESULTS

The number of patients with acute stroke/TIA increased from 890 (2013/2014) to 1016 (2017/2018). Aggregated demographic and clinical data of the whole catchment area showed no differences between 2013/2014 and 2017/2018 (P > 0.05) besides duration of hospitalization (P < 0.01), IVT rate (P < 0.01), and secondary transfer for MT. A region-based analysis revealed an increase in younger and more severely affected patients admitted from the periphery of the catchment area between 2013/2014 and 2017/2018.

CONCLUSION

Despite the implementation of MT in the supraregional SUs around our regional SU (not offering MT), more patients with stroke/TIA were admitted to our hospital, especially younger and more severely affected patients, from the border regions of the catchment area.

Association Between Adherence to Quality Indicators and 7-Day In-Hospital Mortality After Acute Ischemic Stroke

Background and Purpose:

Quality indicators (QI) are an accepted tool to measure performance of hospitals in routine care. We investigated the association between quality of acute stroke care defined by overall adherence to evidence-based QI and early outcome in German acute care hospitals.

Methods:

Patients with ischemic stroke admitted to one of the hospitals cooperating within the ADSR (German Stroke Register Study Group) were analyzed. The ADSR is a voluntary network of 9 regional stroke registers monitoring quality of acute stroke care across 736 hospitals in Germany. Quality of stroke care was defined by adherence to 11 evidence-based indicators of early processes of stroke care. The correlation between overall adherence to QI with outcome was investigated by assessing the association between 7-day in-hospital mortality with the proportion of QI fulfilled from the total number of QI the individual patient was eligible for. Generalized linear mixed model analysis was performed adjusted for the variables age, sex, National Institutes of Health Stroke Scale and living will and as random effect for the variable hospital.

Results:

Between 2015 and 2016, 388 012 patients with ischemic stroke were reported (median age 76 years, 52.4% male). Adherence to distinct QI ranged between 41.0% (thrombolysis in eligible patients) and 95.2% (early physiotherapy). Seven-day in-hospital mortality was 3.4%. The overall proportion of QI fulfilled was median 90% (interquartile range, 75%–100%). In multivariable analysis, a linear association between overall adherence to QI and 7-day in-hospital-mortality was observed (odds ratio adherence <50% versus 100%, 12.7 [95% CI, 11.8–13.7]; P <0.001).

Conclusions:

Higher quality of care measured by adherence to a set of evidence-based process QI for the early phase of stroke treatment was associated with lower in-hospital mortality.

Measuring Quality of Care for Ischemic Stroke Treated With Acute Reperfusion Therapy in Japan - The Close The Gap-Stroke

BACKGROUND

In Japan there is no consensus on how to efficiently measure quality indicators (QIs), defined as a standard of care, for acute ischemic stroke (AIS). Using information from a health insurance claims database and electronic medical records, we evaluated the feasibility and validity of measuring QIs for AIS patients who received intravenous recombinant tissue plasminogen activator (IV rt-PA) or endovascular therapy (EVT).Methods and Results:AIS patients receiving rt-PA or EVT between 2013 and 2015 were identified. We selected 17 AIS QI measures for primary stroke centers (PSCs) and 8 for comprehensive stroke centers (CSCs). Defined QIs were calculated for each hospital and then averaged. In total, the data of 8,206 patients (rt-PA 83.7%, EVT 34.9%) from 172 hospitals were obtained. Median National Institute of Health Stroke Scale score at admission was 14, and 37.7% of the patients were functionally independent at discharge. All target QIs were successfully measured with fewer missing values, and the accuracy of preset data was about 90%. Adherence rates were low (<50%) in 5 QI measures among PSCs, including door-to-needle time ≤1 h, and in 1 QI measure among CSCs (door-to-brain and vascular imaging time ≤30 min).

CONCLUSIONS

Measuring QIs for AIS by this novel approach was feasible and reliable in the provision of a national benchmark.

[Quality of care of acute ischemic stroke in Germany 2018]

In this overview the current quality of acute in-hospital care of stroke patients in Germany in 2018 is described based on standardized and evidence-based quality indicators. For this purpose the reports of the regional quality assurance projects for stroke care, which collaborated within the German-speaking Stroke Registers Study Group (ADSR) were analyzed. Overall, more than 280,000 acute admissions of stroke patients were documented in the included quality assurance projects. The results regarding the defined 16 quality indicators comprising diagnostics, acute treatment, rehabilitation and secondary prevention showed a high level of acute inpatient treatment of stroke in Germany. Only a few quality indicators, such as early transfer for thrombectomy indicated a great necessity for process optimization.

[Care of patients with Parkinson's disease in Germany]

In Germany various concepts for treating patients with Parkinson's disease (PD) are available, e.g. oral medication with levodopa or deep brain stimulation (DBS), depending on the stage and severity of symptoms and also multidisciplinary management up to intersectoral treatment approaches (e.g. complex PD treatment and integrative care concepts). Nevertheless, in the treatment of patients with PD a comprehensive provision of services and a nationwide standardized collation of treatment quality are so far lacking. This is particularly true for technically complicated procedures, which necessitate a high standard of expertise by the treating physician. Some of these challenges could be overcome by expanding digital approaches (e.g. teleneurological consultation and wearables) and by introducing quality assurance initiatives (e.g. comprehensive registries and certification programs).

Evaluation of outcome relevance of quality indicators in the emergency department (ENQuIRE): study protocol for a prospective multicentre cohort study

INTRODUCTION

Quality of emergency department (ED) care affects patient outcomes substantially. Quality indicators (QIs) for ED care are a major challenge due to the heterogeneity of patient populations, health care structures and processes in Germany. Although a number of quality measures are already in use, there is a paucity of data on the importance of these QIs on medium-term and long-term outcomes. The evaluation of outcome relevance of quality indicators in the emergency department study (ENQuIRE) aims to identify and investigate the relevance of QIs in the ED on patient outcomes in a 12-month follow-up.

METHODS AND ANALYSIS

The study is a prospective non-interventional multicentre cohort study conducted in 15 EDs throughout Germany. Included are all patients in 2019, who were ≥18 years of age, insured at the Techniker Krankenkasse (statutory health insurance (SHI)) and gave their written informed consent to the study.The primary objective of the study is to assess the effect of selected quality measures on patient outcome. The data collected for this purpose comprise medical records from the ED treatment, discharge (claims) data from hospitalised patients, a patient questionnaire to be answered 6-8 weeks after emergency admission, and outcome measures in a 12-month follow-up obtained as claims data from the SHI.Descriptive and analytical statistics will be applied to provide summaries about the characteristics of QIs and associations between quality measures and patient outcomes.

ETHICS AND DISSEMINATION

Approval of the leading ethics committee at the Medical Faculty of the University of Magdeburg (reference number 163/18 from 19 November 2018) has been obtained and adapted by responsible local ethics committees.The findings of this work will be disseminated by publication of peer-reviewed manuscripts and presentations as conference contributions (abstracts, poster or oral presentations).Moreover, results will be discussed with clinical experts and medical associations before being proposed for implementation into the quality management of EDs.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00015203); Pre-results.

Long-Term Outcomes in Patients with Stroke after in-Hospital Treatment-Study Protocol of the Prospective Stroke Cohort Augsburg (SCHANA Study)

INTRODUCTION

In Germany, stroke is the third leading cause of death, with more than 60,000 fatalities out of approximately 260,000 cases (first-ever and recurrent strokes) each year. So far, there are only a few long-term studies investigating determinants of the natural course of the disease, especially in the era of mechanical thrombectomy.

MATERIALS AND METHODS

The prospective single-center stroke cohort Augsburg (SCHANA) study will include about 1000 patients treated for stroke in the University Hospital of Augsburg. Patients aged 18 years or older with a confirmed diagnosis of ischemic or hemorrhagic stroke are included in the study. Information on demographic characteristics, onset of symptoms, etiologic factors, comorbidities, quality of life, invasive and non-invasive treatment, complications, and laboratory parameters are collected during a personal interview conducted during the patients' hospital stay and via a medical chart review. About 30 mL of blood is collected from each patient, and after processing and aliquoting, all blood specimens are frozen at -80° C. The study participants will be followed-up via postal questionnaires at three and 12 months after discharge from the hospital. Furthermore, mortality follow-ups will be conducted. Cox-regression analysis will be used to estimate relative risks.

CONCLUSION

The SCHANA study will generate comprehensive data on the long-term course of the disease. In addition to the main outcomes, recurrent events and survival, patient-oriented outcomes such as health-related quality of life and depression are the focus of the study.

Two years' experience of implementing a comprehensive telemedical stroke network comprising in mainly rural region: the Transregional Network for Stroke Intervention with Telemedicine (TRANSIT-Stroke)

Background

Telemedicine improves the quality of acute stroke care in rural regions with limited access to specialized stroke care. We report the first 2 years’ experience of implementing a comprehensive telemedical stroke network comprising all levels of stroke care in a defined region.

Methods

The TRANSIT-Stroke network covers a mainly rural region in north-western Bavaria (Germany). All hospitals providing acute stroke care in this region participate in TRANSIT-Stroke, including four hospitals with a supra-regional certified stroke unit (SU) care (level III), three of those providing teleconsultation to two hospitals with a regional certified SU (level II) and five hospitals without specialized SU care (level I). For a two-year-period (01/2015 to 12/2016), data of eight of these hospitals were available; 13 evidence-based quality indicators (QIs) related to processes during hospitalisation were evaluated quarterly and compared according to predefined target values between level-I- and level-II/III-hospitals.

Results

Overall, 7881 patients were included (mean age 74.6 years ±12.8; 48.4% female). In level-II/III-hospitals adherence of all QIs to predefined targets was high ab initio. In level-I-hospitals, three patterns of QI-development were observed: a) high adherence ab initio (31%), mainly in secondary stroke prevention; b) improvement over time (44%), predominantly related to stroke specific diagnosis and in-hospital organization; c) no clear time trends (25%). Overall, 10 out of 13 QIs reached predefined target values of quality of care at the end of the observation period.

Conclusion

The implementation of the comprehensive TRANSIT-Stroke network resulted in an improvement of quality of care in level-I-hospitals.

Adherence to 20 Emergency General Surgery Best Practices: Results of a National Survey

OBJECTIVE

To examine national adherence to emergency general surgery (EGS) best practices.

BACKGROUND

There is a national crisis in access to high-quality care for general surgery emergencies. Acute care surgery (ACS), a specialty leveraging strengths of trauma systems, may ameliorate this crisis. A critical component of trauma care is adherence to clinical guidelines. We previously established best practices for EGS using RAND Appropriateness Methodology and pilot data.

METHOD

A hybrid (postal/electronic) questionnaire measuring adherence to 20 EGS best practices was administered to respondents overseeing EGS at all eligible adult acute care general hospitals across the US (N = 2811). Questionnaire responses were analyzed using bivariate methods and multiple logistic regression.

RESULTS

The response rate was 60.1%. Adherence ranged from 8.5% for having an EGS registry to 86.2% for auditing 30-day postoperative readmissions. Adherence was higher for practices not restricted to EGS (eg, auditing readmissions) compared to EGS-specific practices (eg, registry, activation system). Adopting an ACS model of care increased adherence to practices for deferring elective cases; tiering urgent operations; following National Comprehensive Cancer Network guidelines; reversing anticoagulants; auditing returns to intensive care, time to evaluation, time to operation, and time to source control; and having transfer agreements to receive patients, ICU admission protocols, as well as EGS-specific activation systems, outpatient clinics, morbidity and mortality conferences, and registries.

CONCLUSIONS

There is substantial room for performance improvement, and adopting an ACS model predicts better performance. This novel overview of adherence to EGS best practices will enable surgeons and policymakers to address variations in EGS care nationally.

Methods to measure quality of care and quality indicators through health facility surveys in low- and middle-income countries

Objective

Present methods to measure standardized, replicable and comparable metrics to measure quality of medical care in low- and middle-income countries.

Design

We constructed quality indicators for maternal, neonatal and child care. To minimize reviewer judgment, we transformed criteria from check-lists into data points and decisions into conditional algorithms. Distinct criteria were established for each facility level and type of care. Indicators were linked to discharge diagnoses. We designed electronic abstraction tools using computer-assisted personal interviewing software.

Setting

We present results for data collected in the poorest areas of Belize, Costa Rica, El Salvador, Guatemala, Honduras, Nicaragua, Panama and the state of Chiapas in Mexico (January—October 2014).

Results

We collected data from 12 662 medical records. Indicators show variations of quality of care between and within countries. Routine interventions, such as quality antenatal care (ANC), immediate neonatal care and postpartum contraception, had low levels of compliance. Records that complied with quality ANC ranged from 68.8% [confidence interval (CI):64.5–72.9] in Costa Rica to 5.7% [CI:4.0–8.0] in Guatemala. Less than 25% of obstetric and neonatal complications were managed according to standards in all countries.

Conclusions

Our study underscores that, with adequate resources and technical expertise, collecting data for quality indicators at scale in low- and middle-income countries is possible. Our indicators offer a comparable, replicable and standardized framework to identify variations on quality of care. The indicators and methods described are highly transferable and could be used to measure quality of care in other countries.

Quality Management Program of Stroke Rehabilitation Using Adherence to Guidelines: A Nationwide Initiative in Japan

BACKGROUND AND AIM

In recent years, interest in the quality of medical care has rapidly increased worldwide. However, quality indicators that contribute to establishing standard treatment in stroke medicine, especially rehabilitation, are not well-developed in Japan. Japan has established Kaifukuki (convalescent) rehabilitation wards, and the development of quality indicators for stroke rehabilitation in the convalescent phase is an urgent issue.

METHODS

We first reviewed the literature regarding quality indicators for stroke rehabilitation. Next, we extracted candidate indicators from identified reports and guidelines and surveyed educational hospitals certified by the Japanese Association of Rehabilitation Medicine. On the basis of the survey results, we reevaluated the suitability of the proposed indicators in discussions with an expert panel.

RESULTS

The questionnaire survey highlighted several important items that revealed there is room for improvement in adherence. For stroke rehabilitation in the convalescent phase, we adopted 15 indicators that were feasible as indicators to be used for comparisons between facilities, based on scoring by and opinions of the expert panel. These indicators measured structure (2 indicators), process (5 indicators), and outcome (8 indicators).

CONCLUSION

This is the first study to establish quality indicators to standardize stroke rehabilitation in Japan. We developed this set of 15 indicators using an evidence-based approach. However, many tasks remain for continuous quality improvement.

Development of evidence-based quality indicators for deep brain stimulation in patients with Parkinson's disease and first year experience of implementation of a nation-wide registry

INTRODUCTION

Deep Brain Stimulation (DBS) is a complex, invasive and cost-intensive therapy that requires a high level of expertise. To date, data on quality of DBS in clinical routine in the German health care system are lacking.

METHODS

The development of evidence-based QIs for DBS in PD patients was performed following a standardized process by a multidisciplinary board between 2014 and 2016. The process was initiated by the German Parkinson Society and followed international recommendations for developing QIs including: a systematic literature search; an appraisal of the published evidence; a consensus-based selection of the QI set; and a pilot study to assess the feasibility in implementing the QIs in clinical routine.

RESULTS

A set of 28 QIs for determining the quality of DBS in PD was established by the board covering different dimensions of health care quality (structure, process, and outcome) in different treatment phases of DBS care (pre-operative, peri-operative, and post-operative). Implementation in clinical practice was tested in a pilot study comprising three hospitals delivering DBS care. The feasibility of the QI set was evaluated positively by the participating physicians and hospitals. Mean time to document one patient was 25 min. The German-wide implementation of the defined indicator set within a dedicated quality registry (QualiPa) started in June 2016.

CONCLUSION

QIs are a necessary requirement to monitor hospital performance in DBS care. The evidence-based approach to develop the proposed indicator set is expected to assure transparency, acceptance and long-term applicability of the QI set in Germany.

Are We Delivering Optimal Pulmonary Rehabilitation? The Importance of Quality Indicators in Evaluating Clinical Practice

Pulmonary rehabilitation (PR) is a complex intervention that has been shown to improve exercise capacity and quality of life, reduce dyspnea, and decrease the risk of exacerbations and hospitalization. Although the evidence for PR is strong, the translation of this evidence into clinical practice remains a challenge, and important gaps in care exist. To date, most research in PR has focused on questions related to treatment efficacy. Less attention has been paid to confirming whether the strong evidence base of PR has been effectively translated to this complex clinical setting. Policy makers and other stakeholders in PR are calling for the establishment of core standards and quality indicators in PR to evaluate existing programs and improve patient care. However, what are quality indicators, and how are they used? This Perspective explores quality assurance in the context of PR and introduces the concepts and uses of quality indicators that can be used to evaluate and improve the quality of care.

Stroke in-hospital survival and its predictors: the first results from Tabriz Stroke Registry of Iran

OBJECTIVE

The aim of this study was to determine the in-hospital survival of patients referred to the 2 stroke centers in North-West of Iran during a full seasonal year from April 2015.

METHODS

All the consecutive patients with stroke admitted to the 2 main stroke centers at Tabriz (Imam Reza University Hospital and Razi University Hospital) were recruited in this study. Stroke patients from both ischemic and hemorrhagic subtypes were selected based on the registry data and International Classification of Diseases, 10th edition. At admission, details of examination including vital signs, neurologic and systemic examination, Modified Rankin Scale, and Glasgow Coma Scale were recorded. Baseline hematological and biochemical parameter assessments as well as computerized tomographic scanning were conducted. Cox regression was used to investigate and detect potential predictors of in-hospital survival.

RESULTS

A total of 1,990 patients with stroke were studied. Males comprised 52.1% (1,036) of the subjects. The mean age of the patients was 65.8 years. Three hundred and fifty-seven (17.9%) patients had hemorrhagic stroke vs 1,633 (82.1%) with ischemic stroke. In-hospital case-fatality proportion was 12.5% (95% CI: 11.1-14). Based on modified Rankin Scale score at admission, 1,377 of 1,990 patients (69.2%) had a poor outcome (modified Rankin Scale score ≥3) at the admission time. The regression analysis showed that at least 7 variables could independently predict hospital survival of patients with stroke including age ≥65 years, higher admission modified Rankin Scale score, lower admission Glasgow Coma Scale score, hemorrhagic stroke nature, diabetes, having valvular heart disease, and having aspiration pneumonia.

CONCLUSION

The case-fatality of stroke in the present study setting is high and needs to be appropriately addressed through prevention or management of some of these factors such as diabetes, pneumonia, and valvular heart diseases.

[Telemedicine in stroke care]

Telemedicine is already widely used in many telestroke networks and ensures stroke treatment close to the patient's home in rural and medically underserved areas. This is particularly effective when telemedicine is integrated into a stroke unit concept. While telemedically based thrombolysis therapy has become routine practice for many years, practical implementation of comprehensive mechanical thrombectomy and the related processes remains challenging. The main tasks for the future further include development of a structured stroke aftercare system in neurologically underserved areas and permanent assurance of high-quality stroke care in telemedically connected sites.

Key performance indicators for stroke from the Ministry of Health of Brazil: benchmarking and indicator parameters

Methods

All 16 KPIs were analyzed, including the percentage of patients admitted to the stroke unit, venous thromboembolism prophylaxis in the first 48 hours after admission, pneumonia and hospital mortality due to stroke, and hospital discharge on antithrombotic therapy in patients without cardioembolic mechanism.

Results

Both centers admitted over 80% of the patients in their stroke unit. The incidence of venous thromboembolism prophylaxis was > 85%, that of in-hospital pneumonia was < 13%, the hospital mortality for stroke was < 15%, and the hospital discharge on antithrombotic therapy was > 70%.

Conclusion

Our results suggest using the parameters of all of the 16 KPIs required by the Ministry of Health of Brazil, and the present results for the two stroke units for future benchmarking.

[Topic identification for cross-sectoral quality assurance in stroke and TIA treatment]

The development of cross-sectoral quality assurance programs usually requires extensive topic identification. Illustrated by the complex processes of care for stroke and transient ischemic attacks (TIAs), a method for comprehensive topic identification is presented. The first step involves a thorough literature search in terms of systematic reviews, health technology assessments, guidelines, studies into healthcare delivery and the use of specific instruments. Routine data as well as epidemiologic studies are used to analyze the reality of service provision. In addition, experts are consulted to gain expertise concerning deficits of care, approaches to quality assurance and experience with existing quality assurance programs. Furthermore individual patient experiences are collected to add the patients' perceptions of care. Because of the limitation on the regulatory scope of Book V of the German Social Code, which, in this case, was necessary, another source of information was the legal framework and its impact on rescue chain, acute treatment and rehabilitation. Existent quality management systems, accreditations and quality assurance programs in prevention, acute treatment and rehabilitation have been searched in order to avoid any overlap with existing measures. After identifying a total of 71 quality targets according to deficits of care, recommendations for care and expert opinions in primary and secondary prevention, rescue chain, acute treatment, rehabilitation and supply of assistive equipment and therapies, respectively, the usability of instruments was tested. These instruments included case documentation, patient surveys and routine data. 14 quality targets proved to be reproducible by these instruments and were included in the recommendations for a cross-sectoral quality assurance program for stroke and TIA.

Accuracy of Administrative Data for the Coding of Acute Stroke and TIAs

Objective: Administrative data validation is essential for identifying biases and misclassification in research. The objective of this study was to determine the accuracy of diagnostic codes for acute stroke and transient ischemic attack (TIA) using the Ontario Stroke Registry (OSR) as the reference standard. Methods: We identified stroke and TIA events in inpatient and emergency department (ED) administrative data from eight regional stroke centres in Ontario, Canada, from April of 2006 through March of 2008 using ICD–10–CA codes for subarachnoid haemorrhage (I60, excluding I60.8), intracerebral haemorrhage (I61), ischemic (H34.1 and I63, excluding I63.6), unable to determine stroke (I64), and TIA (H34.0 and G45, excluding G45.4). We linked administrative data to the Ontario Stroke Registry and calculated sensitivity and positive predictive value (PPV). Results:: We identified 5,270 inpatient and 4,411 ED events from the administrative data. Inpatient administrative data had an overall sensitivity of 82.2% (95% confidence interval [CI95%]=81.0, 83.3) and a PPV of 68.8% (CI95%=67.5, 70.0) for the diagnosis of stroke, with notable differences observed by stroke type. Sensitivity for ischemic stroke increased from 66.5 to 79.6% with inclusion of I64. The sensitivity and PPV of ED administrative data for diagnosis of stroke were 56.8% (CI95%=54.8, 58.7) and 59.1% (CI95%=57.1, 61.1), respectively. For all stroke types, accuracy was greater in the inpatient data than in the ED data. Conclusion: The accuracy of stroke identification based on administrative data from stroke centres may be improved by including I64 in ischemic stroke type, and by considering only inpatient data.

The Role of the Endoscopist in the Stroke Unit

BACKGROUND

Acute cerebral stroke is a common problem that is frequently associated with dysphagia resulting in an increased risk of aspiration pneumonia, complication, and mortality.

METHODS

A literature review was carried out using the search terms 'stroke unit and endoscopy', 'stroke unit and dysphagia', and 'stroke unit and gastroenterology'.

RESULTS

Only few papers focus on the role of endoscopy in stroke units. One major role is the early detection of dysphagia by flexible endoscopic evaluation of swallowing (FEES). FEES appears to have a higher sensitivity and specificity compared to bedside tests and challenges videofluoroscopy. In contrast, other stroke-associated gastrointestinal complications requiring endoscopic diagnostic or therapeutic intervention, such as gastrointestinal bleeding, abdominal pain, or stasis, and the need to provide fluid and food via gastrostomy or jejunostomy are rarely seen in stroke units and become relevant during and after the rehabilitation phase.

CONCLUSION

FEES should involve an interdisciplinary team comprising neurologists, speech and language pathologists and/or therapists, as well as gastroenterologic endoscopists.

Temporal Changes in the Quality of Acute Stroke Care in Five National Audits across Europe

Background. Data on potential variations in delivery of appropriate stroke care over time are scarce. We investigated temporal changes in the quality of acute hospital stroke care across five national audits in Europe over a period of six years. Methods. Data were derived from national stroke audits in Germany, Poland, Scotland, Sweden, and England/Wales/Northern Ireland participating within the European Implementation Score (EIS) collaboration. Temporal changes in predefined quality indicators with comparable information between the audits were investigated. Multivariable logistic regression analyses were performed to estimate adherence to quality indicators over time. Results. Between 2004 and 2009, individual data from 542,112 patients treated in 538 centers participating continuously over the study period were included. In most audits, the proportions of patients who were treated on a SU, were screened for dysphagia, and received thrombolytic treatment increased over time and ranged from 2-fold to almost 4-fold increase in patients receiving thrombolytic therapy in 2009 compared to 2004. Conclusions. A general trend towards a better quality of stroke care defined by standardized quality indicators was observed over time. The association between introducing a specific measure and higher adherence over time might indicate that monitoring of stroke care performance contributes to improving quality of care.

The quality of acute stroke care- an analysis of evidence-based indicators in 260 000 patients

BACKGROUND

Stroke patients should be cared for in accordance with evidence-based guidelines. The extent of implementation of guidelines for the acute care of stroke patients in Germany has been unclear to date.

METHODS

The regional quality assurance projects that cooperate in the framework of the German Stroke Registers Study Group (Arbeitsgemeinschaft Deutscher Schlaganfall-Register, ADSR) collected data on the care of stroke patients in 627 hospitals in 2012. The quality of the acute hospital care of patients with stroke or transient ischemic attack (TIA) was assessed on the basis of 15 standardized, evidence-based quality indicators and compared across the nine participating regional quality assurance projects.

RESULTS

Data were obtained on more than 260 000 patients nationwide. Intravenous thrombolysis was performed in 59.7% of eligible ischemic stroke patients patients (range among participating projects, 49.7-63.6%). Dysphagia screening was documented in 86.2% (range, 74.8-93.1%). For the following indicators, the defined targets were not reached for all of Germany: anti-aggregation within 48 hours, 93.4% (range, 86.6-96.4%); anticoagulation for atrial fibrillation, 77.6% (range, 72.4-80.1%); standardized dysphagia screening, 86.2% (range, 74.8-93.1%); oral and written information of the patients or their relatives, 86.1% (range, 75.4-91.5%). The rate of patients examined or treated by a speech therapist was in the target range.

CONCLUSION

The defined targets were reached for most of the quality indicators. Some indicators, however, varied widely across regional quality assurance projects. This implies that the standardization of care for stroke patients in Germany has not yet been fully achieved.

Cross-National Key Performance Measures of the Quality of Acute Stroke Care in Western Europe

BACKGROUND AND PURPOSE

There are no agreed measures of stroke care quality that enable the standardized comparison of stroke care between countries. We aimed to develop a set of measures of quality of acute stroke care involving stroke quality registers in Western Europe.

METHODS

A multinational working group identified 6 regional or national stroke quality registers in Europe and reviewed their data sets, performance measures, and the method by which these had been developed. Measures used in the registers were presented for discussion to a consensus group of representatives from the quality registers identified, as well as other stroke experts, and the final set of common performance measures was agreed through majority consensus.

RESULTS

Thirty final performance measures were agreed by the European consensus group, encompassing the domains of coordination of care (stroke unit-based care), diagnosis (brain imaging, vascular imaging, cardiac arrhythmia detection, and therapy assessment), preservation of neural tissue (thrombolytic therapy and door-to-needle time), prevention of complications (dysphagia screening), initiation of secondary prevention (antiplatelet, anticoagulation, lipid lowering, blood pressure lowering, carotid surgery, time from vascular imaging to carotid surgery, and smoking cessation), survival (90-day poststroke mortality), and functional outcomes (90-day modified Rankin Scale).

CONCLUSIONS

On the basis of experience of quality registers in Europe, we have proposed a common set of performance measures that will facilitate the international comparison of acute stroke care quality.

Methods of Implementation of Evidence-Based Stroke Care in Europe: European Implementation Score Collaboration

BACKGROUND AND PURPOSE

Differences in stroke care and outcomes reported in Europe may reflect different degrees of implementation of evidence-based interventions. We evaluated strategies for implementing research evidence into stroke care in 10 European countries.

METHODS

A questionnaire was developed and administered through face-to-face interviews with key informants. Implementation strategies were investigated considering 3 levels (macro, meso, and micro, eg, policy, organization, patients/professionals) identified by the framing analysis, and different settings (primary, hospital, and specialist) of stroke care. Similarities and differences among countries were evaluated using the categorical principal components analysis.

RESULTS

Implementation methods reported by ≥7 countries included nonmandatory policies, public financial incentives, continuing professional education, distribution of educational material, educational meetings and campaigns, guidelines, opinion leaders', and stroke patients associations' activities. Audits were present in 6 countries at national level; national and regional regulations in 4 countries. Private financial incentives, reminders, and educational outreach visits were reported only in 2 countries. At national level, the first principal component of categorical principal components analysis separated England, France, Scotland, and Sweden, all with positive object scores, from the other countries. Belgium and Lithuania obtained the lowest scores. At regional level, England, France, Germany, Italy, and Sweden had positive scores in the first principal component, whereas Belgium, Lithuania, Poland, and Scotland showed negative scores. Spain was in an intermediate position.

CONCLUSIONS

We developed a novel method to assess different domains of implementation in stroke care. Clear variations were observed among European countries. The new tool may be used elsewhere for future contributions.

In-hospital stroke recurrence and stroke after transient ischemic attack: frequency and risk factors

BACKGROUND AND PURPOSE

We aimed to assess the risk of recurrent ischemic events during hospitalization for stroke or transient ischemic attack (TIA) with optimal current management and to identify associated risk factors.

METHODS

We performed a retrospective analysis of all patients treated for acute ischemic stroke or TIA in 3 stroke units between 2010 and 2013. Recurrent stroke was defined as new persisting (≥24 hours) neurological deficit occurring >24 hours after the index event and not attributable to other causes of neurological deterioration. Cox proportional hazard regression identified risk factors associated with recurrent stroke.

RESULTS

The study included 5106 patients. During a median length of stay of 5 days (interquartile range, 4-8), stroke recurrence (or stroke after TIA) occurred in 40 patients (0.8%) and was independently associated with history of TIA, symptomatic carotid stenosis (≥70%), or other determined etiology. Patients with recurrent stroke and other determined etiology had cervical arterial dissection (n=2), primary angiitis of the central nervous system (n=1), giant cell arteritis (n=1), and lung cancer with nonbacterial thrombotic endocarditis (n=1). In patients with initial TIA or minor stroke (National Institutes of Health Stroke Scale ≤5) recurrence was associated additionally with pneumonia after the inciting ischemic event but before stroke recurrence. Patients with initial stroke and aphasia had a lower stroke recurrence rate and there were no recurrences in patients with lacunar stroke. Recurrence was associated with significantly higher in-hospital mortality (17.5% versus 3.1%; P<0.001).

CONCLUSIONS

In-hospital stroke recurrence was low with optimal current management. Patients with a history of TIA, severe symptomatic carotid stenosis, or uncommon causes of stroke were at higher risk. Pneumonia was associated with a higher risk of stroke recurrence in patients with initial TIA or minor stroke but not in the overall population studied. Aphasia may bias the detection rate by concealing new neurological symptoms.

TeleStroke units serving as a model of care in rural areas: 10-year experience of the TeleMedical project for integrative stroke care

BACKGROUND AND PURPOSE

Stroke Unit care improves stroke prognosis and is recommended for all patients with stroke. In rural areas, population-wide implementation of Stroke Units is challenging. Therefore, the TeleMedical Project for integrative Stroke Care (TEMPiS) was established in 2003 as a TeleStroke Unit network to overcome this barrier in Southeast Bavaria/Germany. Evaluation of its implementation between 2003 and 2005 had revealed improved process quality and clinical outcomes compared with matched hospitals without TeleStroke Units. Data on sustainability of these effects are lacking.

METHODS

Effects on the stroke care of the local population were analyzed by using data from official hospital reports. Prospective registries from 2003 to 2012 describe processes and outcomes of consecutive patients with stroke and transient ischemic attack treated in TEMPiS hospitals. Quality indicators assess diagnostics, treatment, and outcome. Rates and timeliness of intravenous thrombolysis as well as data on teleconsultations and secondary interhospital transfers were reported over time.

RESULTS

Within the covered area, network implementation increased the number of patients with stroke and transient ischemic attack treated in hospitals with (Tele-)Stroke Units substantially from 19% to 78%. Between February 2003 and December 2012, 54 804 strokes and transient ischemic attacks were treated in 15 regional hospitals, and 31 864 teleconsultations were performed. Intravenous thrombolysis was applied 3331 stroke cases with proportions increasing from 2.6% to 15.5% of all patients with ischemic stroke. Median onset-to-treatment times decreased from 150 (interquartile range, 127-163) to 120 minutes (interquartile range, 90-160) and door-to-needle times from 80 (interquartile range, 68-101) to 40 minutes (interquartile range, 29-59).

CONCLUSIONS

TeleStroke Units can provide sustained high-quality stroke care in rural areas.

Telephone audit for monitoring stroke unit facilities: a post hoc analysis from PROSIT study

BACKGROUND

Although several valid approaches exist to measure the number and the quality of acute stroke units, only few studies tested their reliability. This study is aimed at establishing whether the telephone administration of the PROject of Stroke unIt ITaly (PROSIT) audit questionnaire is reliable compared with direct face-to-face interview.

METHODS

Forty-three medical leaders in charge of in-hospital stroke services were interviewed twice using the same PROSIT questionnaire with 2 different modalities. First, the interviewers approached the medical leaders by telephone. Thereafter, they went to the hospital site and performed a direct face-to-face interview. Six independent couples of trained researchers conducted the audit interviews. The degree of intermodality agreement was measured with kappa statistic.

RESULTS

We found a perfect agreement for stroke units identification between the 2 different audit modalities (K = 1.00; standard error [SE], 1.525). The agreement was also very good for stroke dedicated beds (K = 1.00; SE, 1.525) and dedicated personnel (K = 1.00; SE, 1.525), which are the 2 components of stroke unit definition. The agreement was lower for declared in use process of care and availability of diagnostic investigations.

CONCLUSIONS

The telephone audit can be used for monitoring stroke unit structures. It is more rapid, less expensive, and can repeatedly be used at appropriate intervals. However, a reliable description of the process of care and diagnostic investigations indicators should be obtained by either local site audit visit or prospective stroke register based on individual patient data.

Feasibility of Certified Quality Management in a Comprehensive Stroke Care Network Using Telemedicine: STENO Project

Background

Stroke care networks with and without telemedicine have been established in several countries over the last decade to provide specialized stroke expertise to patients in rural areas. Acute consultation is a first step in the management of stroke, but not the only one. Methods of standardization of care and treatment are much needed. So far, quality management systems have only been used for single stroke units. To the best of our knowledge, we are the first stroke network worldwide to aim for certification of a network-wide quality management system.

Methods

The Stroke Network Using Telemedicine in Northern Bavaria (STENO), currently with 20 associated medical institutions, is one of the world's largest stroke networks, caring for over 5000 stroke patients each year. In 2010, we initiated the implementation of a network-wide ‘total’ quality management system according to ISO standard 9001:2008 in cooperation with the German Stroke Society and a third-party certification organization (LGA InterCert).

Results

Certification according to ISO 9001:2008 was awarded in March 2011 and maintained over a complete certification cycle of 3 years without major deviation from the norm in three external third-party audits. Thrombolysis rate significantly increased from 8·2% (2009) to 12·8% (2012).

Conclusions

Certified quality management within a large stroke network using telemedicine is possible and might improve stroke care procedures and thrombolysis rates. Outcome studies comparing conventional stroke care and telestroke care are inevitable.

Stroke service: how can we improve and measure outcomes? Consensus summary from a global stroke forum

The success of acute stroke treatment is first and foremost time-dependent, and the need for improvement in acute stroke management is demonstrated by the fact that only a minority of patients gain access to treatment - in particular, intravenous recombinant tissue plasminogen activator (IV tPA) - within the necessary time window. Standards of acute stroke care vary widely both regionally and nationally; consequently, various healthcare organizations have undertaken initiatives to measure and improve quality of care. To date, most quality measures have been process-based, focusing primarily on metrics of patient care in the acute hospital-based setting (e.g., time to recombinant tPA administration). Therefore, there remains a need for metrics designed to assess how improvements in process translate into patient outcomes. A global forum was convened to share best practice and provide consensus recommendations on core metrics for measuring improvements in access to care and patient outcomes. Recommendations for core metrics of patient outcomes include hospital-based outcomes (e.g., neurological status at 24 h, ambulatory status at discharge) and post-discharge outcomes (e.g., modified Rankin Scale score at 30 and/or 90 days). Recommendations for best practice relating to aspects of people, process, and technology involved in the stroke treatment pathway that may help provide improvements in these core outcome measures are also outlined.

Similarity of patient characteristics and outcomes in consecutive data collection on stroke admissions over one month compared to longer periods

Background

The usefulness of time-limited consecutive data collection compared to continuous consecutive data collection in conditions which show seasonal variations is unclear. The objective of this study is to assess whether one month of admission data can be representative of data collected over two years in the same hospitals.

Methods

We compared the baseline characteristics and discharge outcomes of stroke patients admitted in the first month (October 2009) of the Anglia Stroke Clinical Network Evaluation Study (ASCNES) with the routinely collected data over 2 years between September 2008 and April 2011 from the same 8 hospital trusts in the Anglia Stroke & Heart Clinical Network (AS&HCN) as well as seasonal cohorts from the same period.

Results

We included a total of 8715 stroke patients (October 2009 cohort of ASCNES (n = 308), full AS&HCN cohort (n = 8407 excluding October 2009)) as well as cohorts from different seasons. All cohorts had a similar median age. No significant differences were observed for pre-stroke residence, pre-stroke modified Rankin, weekend vs. weekday admission, time of admission, patients with atrial fibrillation, type of stroke, admission systolic blood pressure, use of thrombolysis (rTPA), in-patient mortality and discharge destination. There were statistically significant differences between cohorts with regard to Oxfordshire Community Stroke Project Classification.

Conclusions

Stroke patients admitted in one month had largely indistinguishable characteristics and discharge outcomes to those admitted to the same trusts in three separate seasons and also over two years in this cohort.

Quality indicators in acute stroke care: a prospective observational survey in 13 Italian regions

BACKGROUND AND AIMS

Quality monitoring has great relevance in stroke care. The Project "How to guarantee adherence to effective interventions in stroke care" aimed to estimate adherence to acute-phase guidelines in stroke care in Italy.

METHODS

A prospective observational study was performed in 27 hospitals of 13 Italian Regions. Adherence to 15 process indicators was evaluated, comparing also stroke units (SU) with conventional wards. An overall score of care, defined as the sum of achieved indicators, was calculated. A multilevel hierarchical model described performance at patient, hospital and regional level.

RESULTS

Overall, 484 consecutive stroke patients (mean age, 73.4 years; 52.7 % males) were included. Total score ranged from 2 to 15 (mean 8.5 ± 2.4). SU patients were more often evaluated with the National Institutes of Health Stroke Scale (NIHSS) within 24 h, had more frequently an assessment of pre- and post-stroke disability, and a CT scan the same or the day after admission. Regional-hospital- and patient-level variability explained, respectively, 25, 34, and 41 % of total score variance. In multivariate models, patients >80 years vs. younger showed a change in total score of -0.45 (95 % CI -0.79 to -0.12), and those with NIHSS ≥14 vs. ≤5 of -0.92 (95 % CI -1.53 to -0.30). A negative change means a worse adjusted average adherence to process indicators. SU admission increased total score of 1.55 (95 % CI 0.52-2.58).

CONCLUSIONS

Our data confirm the need of quality monitoring in stroke care. Although SU patients showed a better adherence to quality indicators, overall compliance was unsatisfactory.

Benchmarks for acute stroke care delivery

OBJECTIVE

Despite widespread interest in many jurisdictions in monitoring and improving the quality of stroke care delivery, benchmarks for most stroke performance indicators have not been established. The objective of this study was to develop data-derived benchmarks for acute stroke quality indicators.

DESIGN

Nine key acute stroke quality indicators were selected from the Canadian Stroke Best Practice Performance Measures Manual.

PARTICIPANTS

A population-based retrospective sample of patients discharged from 142 hospitals in Ontario, Canada, between 1 April 2008 and 31 March 2009 (N = 3191) was used to calculate hospital rates of performance and benchmarks.

INTERVENTION

The Achievable Benchmark of Care (ABC™) methodology was used to create benchmarks based on the performance of the upper 15% of patients in the top-performing hospitals.

MAIN OUTCOME MEASURES

Benchmarks were calculated for rates of neuroimaging, carotid imaging, stroke unit admission, dysphasia screening and administration of stroke-related medications.

RESULTS

The following benchmarks were derived: neuroimaging within 24 h, 98%; admission to a stroke unit, 77%; thrombolysis among patients arriving within 2.5 h, 59%; carotid imaging, 93%; dysphagia screening, 88%; antithrombotic therapy, 98%; anticoagulation for atrial fibrillation, 94%; antihypertensive therapy, 92% and lipid-lowering therapy, 77%. ABC™ acute stroke care benchmarks achieve or exceed the consensus-based targets required by Accreditation Canada, with the exception of dysphagia screening.

CONCLUSIONS

Benchmarks for nine hospital-based acute stroke care quality indicators have been established. These can be used in the development of standards for quality improvement initiatives.

Quality measures for the care of patients with lateral epicondylalgia

Background

Lateral epicondylalgia (LE) defines a condition of varying degrees of pain near the lateral epicondyle. Studies on the management of LE indicated unexplained variations in the use of pharmacologic, non-pharmacological and surgical treatments.

The main aim of this paper was to develop and evaluate clinical quality measures (QMs) or quality indicators, which may be used to assess the quality of the processes of examination, education and treatment of patients with LE.

Methods

Different QMs were developed by a multidisciplinary group of experts in Quality Management of Health Services during a period of one year. The process was based following a 3-step model: i) review and proportion of existing evidence-based recommendations; ii) review and development of quality measures; iii) pilot testing of feasibility and reliability of the indicators leading to a final consensus by the whole panel.

Results

Overall, a set of 12 potential indicators related to medical and physical therapy assessment and treatment were developed to measure the performance of LE care. Different systematic reviews and randomized control trials supported each of the indicators judged to be valid during the expert panel process. Application of the new indicator set was found to be feasible; only the measurement of two quality measures had light barriers. Reliability was mostly excellent (Kappa > 0.8).

Conclusions

A set of good practice indicators has been built and pilot tested as feasible and reliable. The chosen 3-step standardized evidence-based process ensures maximum clarity, acceptance and sustainability of the developed indicators.

Definition of a core set of quality indicators for the assessment of HIV/AIDS clinical care: a systematic review

Background

Several organizations and individual authors have been proposing quality indicators for the assessment of clinical care in HIV/AIDS patients. Nevertheless, the definition of a consensual core set of indicators remains controversial and its practical use is largely limited. This study aims not only to identify and characterize these indicators through a systematic literature review but also to propose a parsimonious model based on those most used.

Methods

MEDLINE, SCOPUS, Cochrane databases and ISI Web of Knowledge, as well as official websites of organizations dealing with HIV/AIDS care, were searched for articles and information proposing HIV/AIDS clinical care quality indicators. The ones that are on patient’s perspective and based on services set were excluded. Data extraction, using a predefined data sheet based on Cochrane recommendations, was done by one of the authors while a second author rechecked the extracted data for any inconsistency.

Results

A total of 360 articles were identified in our search query but only 12 of them met the inclusion criteria. We also identified one relevant site. Overall, we identified 65 quality indicators for HIV/AIDS clinical care distributed as following: outcome (n=15) and process-related (n=50) indicators; generic (n=36) and HIV/AIDS disease-specific (n=29) indicators; baseline examinations (n=19), screening (n=9), immunization (n=4), prophylaxis (n=5), HIV monitoring (n=16), and therapy (=12) indicators.

Conclusions

There are several studies that set up HIV clinical care indicators, with only a part of them useful to assess the HIV clinical care. More importantly, HIV/AIDS clinical care indicators need to be valid, reliable and most of all feasible.