Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis

The effect of patients' socioeconomic status in rehabilitation centers on the efficiency and performance

BACKGROUND

Patients' socioeconomic status on hospitals' efficiency in controlling for clinical component characteristics may have a role that has few been studied in rehabilitation centers.

DESIGN

Because of the national health insurance system, rehabilitation centers are free of charge. To answer whether a patient's socioeconomic status (SES) is associated with efficiency and performance, we use a counterfactual analysis to get the patient's SES effect "as if" the patient's case was identical to whatever hospital. We restrained the data to patients from public acute care units where the decision on rehabilitation sector admission is based on availability, limiting bias by confounding factors. Besides, an analysis of six pathologies led to the same results.

SETTING

An exhaustive, detailed administrative database on rehabilitation center stays in France. To define the patients' socioeconomic status, we use two sources of data: the information collected at the time of the patient's entry into rehabilitation care and the information collected during the patient's stay in acute care. This double information avoids possible loss of socio-economic details between the two admissions.

POPULATION

Patients recruited were exhaustively admitted over the year 2018 for stroke, chronic obstructive pulmonary disease, heart failure, or total hip replacement in France in the acute care unit and then in a rehab center. Mainly the elderly population. Information on patients' demography, comorbidities, and SES are coded due to the reimbursement system. Different dimensions controlling for factors (hospital ownership, patient clinical characteristics, rehabilitation care specificities, medical staff detailed information, and patients' socioeconomic status), were progressively added to control for any differences in baseline data between the two groups.

METHODS

We assess rehabilitation centers' efficiency by combining selected outcome quality indicators (Physical score improvement, Cognitive score improvement, Mortality, Return-to-home). The specific Providers' Activity Index is used to get the performance index.

CONCLUSIONS

The performance of healthcare institutions is correlated not only to the case mix of their patients but also to the socioeconomic status of the patients admitted. The performance needs to be seen in light of patients' socioeconomic status.

CLINICAL REHABILITATION IMPACTS

The data reveals that patients' socioeconomic status affects rehabilitation care efficiency and performance. In controlling patients' socioeconomic status, for-profit rehabilitation hospitals seemed more efficient than public ones.

Quality of early stroke care and long-term mortality in patients with acute stroke: A nationwide follow-up study

INTRODUCTION

High quality of early stroke care is essential for optimizing the chance of a good patient outcome. The quality of care may be monitored by process performance measures (PPMs) and previous studies have found an association between fulfilment of PPMs and short-term mortality. However, the association with long-term mortality remains to be determined. We aimed to evaluate the association between fulfilment of PPMs and long-term mortality for patients with acute stroke in Denmark.

PATIENTS AND METHODS

We used data from Danish health care registers between 2008 and 2020 to identify all patients admitted with incident stroke (haemorrhagic (ICH) or ischaemic stroke). The quality of early stroke care was assessed using 10 PPMs. Mortality was compared using Cox proportional hazard ratios, risk ratios computed using Poisson regression, and standardized relative survival.

RESULTS

We included 102,742 patients; 9804 cases of ICH, 88,591 cases of ischaemic stroke, and 4347 cases of unspecified strokes. The cumulative 10-year mortality risk was 56.8%. Fulfilment of the individual PPMs was associated with adjusted hazard rate ratios of death between 0.76 and 0.96. Patients with 100% fulfilment of all PPMs had a lower 10-year post-stroke mortality (adjusted risk ratio 0.90) compared to the patients with 0%-49% fulfilment and a standardized relative survival of 81.3%, compared to the general population.

CONCLUSION

High quality of early stroke care was associated with lower long-term mortality following both ICH and ischaemic stroke, which emphasizes the importance of continued attention on the ability of stroke care providers to deliver high quality of early care.

Clinical and organisational quality indicators for the optimal management of acute ischaemic stroke in the era of thrombectomy: a scoping review and expert consensus study

OBJECTIVE

The purpose of this study is to identify clinical and organisational quality indicators conducive to the optimal interdisciplinary management of acute-phase ischaemic stroke.

METHOD

A scoping review based on the six-step methodological framework of Arksey and O'Malley (2005) was conducted including a Delphi process with an experts committee.

DATA SOURCES

MEDLINE, CINAHL, Academic search complete, Cochrane Library databases, in addition to Google Scholar and Google were searched through January 2015 to February 2023.

ELIGIBILITY CRITERIA

French and English references, dealing with clinical and organisational indicators for the management and optimal care of adults with acute ischaemic stroke.

DATA EXTRACTION AND SYNTHESIS

After duplicate removal, all publications were checked for title and abstract. The full text of articles meeting the inclusion criteria was reviewed. Two independent reviewers performed 10% of the study selection and data extraction. Data collected underwent descriptive statistics.

RESULTS

Of the 4343 references identified, 31 were included in the scoping review. About 360 indicators were identified and preliminary screened by two stroke experts. Fifty-four indicators were evaluated for validity, relevance and feasibility by a committee of experts including a partner patient using a Delphi method. A total of 34 indicators were selected and classified based on dimensions of care performance such as accessibility of services, quality of care and resource optimisation. Safety accounted for about one-third of the indicators, while there were few indicators for sustainability, equity of access and responsiveness.

CONCLUSION

This scoping review shows there are many clinical and organisational indicators in the literature that are relevant, valid and feasible for improving the quality of care in the acute phase of ischaemic stroke. Future research is essential to highlight clinical and organisational practices in the acute phase.

REGISTRATION DETAILS

https://osf.io/qc4mk/.

Pragmatic solutions to reduce the global burden of stroke: a World Stroke Organization-Lancet Neurology Commission

Stroke is the second leading cause of death worldwide. The burden of disability after a stroke is also large, and is increasing at a faster pace in low-income and middle-income countries than in high-income countries. Alarmingly, the incidence of stroke is increasing in young and middle-aged people (ie, age <55 years) globally. Should these trends continue, Sustainable Development Goal 3.4 (reducing the burden of stroke as part of the general target to reduce the burden of non-communicable diseases by a third by 2030) will not be met. In this Commission, we forecast the burden of stroke from 2020 to 2050. We project that stroke mortality will increase by 50%—from 6·6 million (95% uncertainty interval [UI] 6·0 million–7·1 million) in 2020, to 9·7 million (8·0 million–11·6 million) in 2050—with disability-adjusted life-years (DALYs) growing over the same period from 144·8 million (133·9 million–156·9 million) in 2020, to 189·3 million (161·8 million–224·9 million) in 2050. These projections prompted us to do a situational analysis across the four pillars of the stroke quadrangle: surveillance, prevention, acute care, and rehabilitation. We have also identified the barriers to, and facilitators for, the achievement of these four pillars. DISABILITY-ADJUSTED LIFE-YEARS (DALYS): The sum of the years of life lost as a result of premature mortality from a disease and the years lived with a disability associated with prevalent cases of the disease in a population. One DALY represents the loss of the equivalent of one year of full health On the basis of our assessment, we have identified and prioritised several recommendations. For each of the four pillars (surveillance, prevention, acute care, and rehabilitation), we propose pragmatic solutions for the implementation of evidence-based interventions to reduce the global burden of stroke. The estimated direct (ie, treatment and rehabilitation) and indirect (considering productivity loss) costs of stroke globally are in excess of US$891 billion annually. The pragmatic solutions we put forwards for urgent implementation should help to mitigate these losses, reduce the global burden of stroke, and contribute to achievement of Sustainable Development Goal 3.4, the WHO Intersectoral Global Action Plan on epilepsy and other neurological disorders (2022–2031), and the WHO Global Action Plan for prevention and control of non-communicable diseases. Reduction of the global burden of stroke, particularly in low-income and middle-income countries, by implementing primary and secondary stroke prevention strategies and evidence-based acute care and rehabilitation services is urgently required. Measures to facilitate this goal include: the establishment of a framework to monitor and assess the burden of stroke (and its risk factors) and stroke services at a national level; the implementation of integrated population-level and individual-level prevention strategies for people at any increased risk of cerebrovascular disease, with emphasis on early detection and control of hypertension; planning and delivery of acute stroke care services, including the establishment of stroke units with access to reperfusion therapies for ischaemic stroke and workforce training and capacity building (and monitoring of quality indicators for these services nationally, regionally, and globally); the promotion of interdisciplinary stroke care services, training for caregivers, and capacity building for community health workers and other health-care providers working in stroke rehabilitation; and the creation of a stroke advocacy and implementation ecosystem that includes all relevant communities, organisations, and stakeholders.

Body Mass Index (BMI) Related Morbidity with Thyroid Surgery

OBJECTIVES

The increase in incidence of thyroid cancer correlates with strict increases in body mass index (BMI) and obesity in the United States. Thyroid hormone dysregulation has been shown to precipitate circulatory volume, peripheral resistance, cardiac rhythm, and even cardiac muscle health. Theoretically, thyroid surgery could precipitate injury to the cardiopulmonary system.

METHODS

The American College of Surgery National Quality Improvement Program database was queried for thyroidectomy cases in the 2007-2020 Participant User files. Continuous and categorical associations between BMI and cardiopulmonary complications were investigated as reported in the database.

RESULTS

The query resulted 186,095 cases of thyroidectomy procedures in which the mean age was 51.3 years and sample was 79.3% female. No correlation was evident in univariate and multivariate analyses between BMI and the incidence of postoperative stroke or myocardial infarction. The incidence of complications was extremely low. However, risk of deep venous thrombosis correlated with BMI in the categorical, univariate, and multivariate (OR 1.036, CI 1.014-1.057, p < 0.01) regression analysis. Additionally, increased BMI was associated with increased risk of pulmonary embolism (PE) (OR 1.050 (1.030, 1.069), p < 0.01), re-intubation (OR 1.012 (1.002, 1.023), p = 0.02), and prolonged intubation (OR 1.031 (1.017, 1.045), p < 0.01).

CONCLUSION

Despite the rarity of cardiopulmonary complications during thyroid surgery, patients with very high BMI carry a significant risk of deep venous thrombosis, PE, and prolonged intubation.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2823-2830, 2023.

Associations between structure- and process-orientated measures and stroke long term mortality - an observational study based on routine data

OBJECTIVES

Various measures are used to improve the quality of stroke care. In Germany, these include concentrating treatment in specialized facilities (stroke units), mandatory quality comparisons of hospitals in some German states, and treatment according to prespecified structure and process specifications (neurological complex treatment 8-981 or 8-98b). These measures have previously only been analyzed individually and regarding short-term patient outcomes. This study analyzes these measures in combination, considering patients' comorbidities as well as stroke severity in a longitudinal perspective.

MATERIALS/METHODS

Analyses were based on data from 243,415 insurees of Germany's biggest health insurance (AOK) admitted to hospitals between 2007 and 2017 with cerebral infarction. Mortality risk was calculated using Cox regressions adjusted for various covariates. Kaplan-Meier analyses were differentiated by treatment site (stroke unit/external quality assurance/ Federal State Consortium of Quality Assurance Hesse - LAGQH) were performed, followed by log-rank tests and p-value adjustment. Trend analyses were performed for treatment types in combination with treatment sites.

RESULTS

All analyses showed significant advantages for patients who received Neurological Complex Treatment, especially when the treatment was performed under external quality assurance conditions and/or in stroke units. There was an increasing frequency of specialized stroke treatment.

CONCLUSIONS

Quality-enhancing structures and processes are associated with a lower mortality risk after stroke. There appears to be evidence of a cascading benefit from the implementation of neurological complex treatment, external quality assurance, and ultimately, stroke units. Consecutively, care should be concentrated in hospitals that meet these specifications. However, since measures are often applied in combination, it remains unclear which specific measures are crucial for patient outcome.

Interventions for the uptake of evidence-based recommendations in acute stroke settings

BACKGROUND

There is a growing body of research evidence to guide acute stroke care. Receiving care in a stroke unit improves access to recommended evidence-based therapies and patient outcomes. However, even in stroke units, evidence-based recommendations are inconsistently delivered by healthcare workers to patients with stroke. Implementation interventions are strategies designed to improve the delivery of evidence-based care.

OBJECTIVES

To assess the effects of implementation interventions (compared to no intervention or another implementation intervention) on adherence to evidence-based recommendations by health professionals working in acute stroke units. Secondary objectives were to assess factors that may modify the effect of these interventions, and to determine if single or multifaceted strategies are more effective in increasing adherence with evidence-based recommendations.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, Joanna Briggs Institute and ProQuest databases to 13 April 2022. We searched the grey literature and trial registries and reviewed reference lists of all included studies, relevant systematic reviews and primary studies; contacted corresponding authors of relevant studies and conducted forward citation searching of the included studies. There were no restrictions on language and publication date.

SELECTION CRITERIA

We included randomised trials and cluster-randomised trials. Participants were health professionals providing care to patients in acute stroke units; implementation interventions (i.e. strategies to improve delivery of evidence-based care) were compared to no intervention or another implementation intervention. We included studies only if they reported on our primary outcome which was quality of care, as measured by adherence to evidence-based recommendations, in order to address the review aim.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, extracted data and assessed risk of bias and certainty of evidence using GRADE. We compared single implementation interventions to no intervention, multifaceted implementation interventions to no intervention, multifaceted implementation interventions compared to single implementation interventions and multifaceted implementation interventions to another multifaceted intervention. Our primary outcome was adherence to evidence-based recommendations.

MAIN RESULTS

We included seven cluster-randomised trials with 42,489 patient participants from 129 hospitals, conducted in Australia, the UK, China, and the Netherlands. Health professional participants (numbers not specified) included nursing, medical and allied health professionals. Interventions in all studies included implementation strategies targeting healthcare workers; three studies included delivery arrangements, no studies used financial arrangements or governance arrangements. Five trials compared a multifaceted implementation intervention to no intervention, two trials compared one multifaceted implementation intervention to another multifaceted implementation intervention. No included studies compared a single implementation intervention to no intervention or to a multifaceted implementation intervention. Quality of care outcomes (proportions of patients receiving evidence-based care) were included in all included studies. All studies had low risks of selection bias and reporting bias, but high risk of performance bias. Three studies had high risks of bias from non-blinding of outcome assessors or due to analyses used. We are uncertain whether a multifaceted implementation intervention leads to any change in adherence to evidence-based recommendations compared with no intervention (risk ratio (RR) 1.73; 95% confidence interval (CI) 0.83 to 3.61; 4 trials; 76 clusters; 2144 participants, I2 =92%, very low-certainty evidence). Looking at two specific processes of care, multifaceted implementation interventions compared to no intervention probably lead to little or no difference in the proportion of patients with ischaemic stroke who received thrombolysis (RR 1.14, 95% CI 0.94 to 1.37, 2 trials; 32 clusters; 1228 participants, moderate-certainty evidence), but probably do increase the proportion of patients who receive a swallow screen within 24 hours of admission (RR 6.76, 95% CI 4.44 to 10.76; 1 trial; 19 clusters; 1,804 participants; moderate-certainty evidence). Multifaceted implementation interventions probably make little or no difference in reducing the risk of death, disability or dependency compared to no intervention (RR 0.93, 95% CI 0.85 to 1.02; 3 trials; 51 clusters ; 1228 participants; moderate-certainty evidence), and probably make little or no difference to hospital length of stay compared with no intervention (difference in absolute change 1.5 days; 95% CI -0.5 to 3.5; 1 trial; 19 clusters; 1804 participants; moderate-certainty evidence). We do not know if a multifaceted implementation intervention compared to no intervention result in changes to resource use or health professionals' knowledge because no included studies collected these outcomes.

AUTHORS' CONCLUSIONS

We are uncertain whether a multifaceted implementation intervention compared to no intervention improves adherence to evidence-based recommendations in acute stroke settings, because the certainty of evidence is very low.

Characteristics of stroke service implementation in Armenia

Background

Acute stroke care service in Armenia was established in 2019 after the implementation of the National Stroke Program (NSP). This study aimed to provide an up-to-date account of the current image and clinical characteristics of acute stroke service implementation at a tertiary hospital in Armenia by analyzing the quality of care and identifying the areas that need improvement.

Methods

We analyzed patient data from a single hospital in 1 year after the establishment of acute stroke care service (February 2021-January 2022). We selected patients who were within 0-24 h from symptom onset at admission and included patients who benefited from reperfusion therapies (intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT)). A favorable outcome was defined as a drop in the National Institutes of Health Stroke Scale (NIHSS) by more than four points at discharge and a modified Rankin score (mRS) of 0-2 at 90 days.

Results

Of the total 385 patients, 155 underwent reperfusion therapies, 91% of patients (141/155) arrived by ambulance, 79.2% (122/155) had neurological improvement at discharge, and 60.6% (94/155) had an mRS of 0-2 at 3 months. Less than 5% of patients had early direct access to the rehabilitation center.

Conclusion

Our study demonstrated that the implementation of NSP with organized protocol-driven inpatient care led to significant advancement in acute stroke service performance. We believe that our report will serve as a model for achieving advanced and structured stroke care in a resource-limited context and contribute to the future development of the healthcare system in our country.

An introduction to key performance indicators for medical physicists

Qualified medical physicists (QMPs) are in a unique position to influence the creation and application of key performance indicators (KPIs) across diverse practices in health care. Developing KPIs requires the involvement of stakeholders in the area of interest. Fundamentally, KPIs should provide actionable information for the stakeholders using or viewing them. During development, it is important to strongly consider the underlying data collection for the KPI, making it automatic whenever possible. Once the KPI has been validated, it is important to setup a review cycle and be prepared to adjust the underlying data or action levels if the KPI is not performing as intended. Examples of specific KPIs for QMPs of common scopes of practice are provided to act as models to aid in implementation. KPIs are a useful tool for QMPs, regardless of the scope of practice or practice environment, to enhance the safety and quality of care being delivered.

Quality of acute ischemic stroke care at a tertiary Hospital in Ghana

Background

Information on the quality of acute ischemic stroke care provided in lower-to-middle income countries is limited.

Objective

This study was undertaken to examine the quality of acute ischemic stroke care provided at Tamale Teaching Hospital in Ghana.

Methods

The medical records of patients admitted into the medical ward of the hospital between January to October 2021 were reviewed retrospectively. Extent of compliance to 15 stroke performance indicators were determined.

Results

Under the study period, 105 patients were admitted at the hospital with acute ischemic stroke. The mean (±SD) age was 65 ± 12 years; 38.1% were males; 65.7% had National Health Insurance Scheme coverage. Glasgow Coma Scale was the only functional stroke rating scale used by physicians to rate stroke severity. About a quarter of the patients had CT scan performed within 24 h of admission. Less than a quarter of the patients had a last known well time documented. Rate of thrombolytic administration was 0%. Less than a quarter of the patients were prescribed venous thromboembolism prophylaxis on the day of admission or day after. Only 13.8% of patients had documented reasons for not being prescribed venous thromboembolism prophylaxis. Antiplatelet therapy was prescribed to 33.3% of the patients by the end of day 2 of admission. Anticoagulation was prescribed to all patients who had comorbid condition of atrial fibrillation as part of the discharge medications. More than half of the patients were discharged to go home with statin medications. Documented stroke education was provided to 31.4% caretakers or patients. Slightly less than half of the patients were assessed for or received rehabilitation. Less than a quarter had documented dysphagia screening within 24 h of admission. None of the patient had their stroke severity rated with National Institutes of Health Stroke Scale on arrival. No patient obtained carotid imaging assessment by end of day 2.

Conclusion

There were several gaps in the quality of acute ischemic stroke care provided to patients at the Tamale Teaching Hospital. With the exception of discharging patients on statin medications, there was poor adherence to all other stroke performance indicators.

Safety climate, leadership and patient views associated with hip fracture care quality and clinician perceptions of hip fracture care performance

BACKGROUND

Hip fracture is a major public health concern for older adults, requiring surgical treatment for patients presenting at hospitals across Australia. Although guidelines have been developed to drive appropriate care of hip fracture patients in hospitals, data on health outcomes suggest these are not well-followed.

OBJECTIVE

This study aims to examine whether clinician measures of safety, teamwork and leadership, and patient perceptions of care are associated with key indicators of hip fracture care and the extent to which there is agreement between clinician perceptions of hip fracture care performance and actual hospital performance of hip fracture care.

METHODS

Retrospective analysis was performed on a series of questionnaires used to assess hospital department- and patient-level measures from the Deepening our Understanding of Quality in Australia study. Data were analysed from 32 public hospitals that encompassed 23 leading hip fracture clinicians, 716 patient medical records and 857 patients from orthopaedic public hospital wards.

RESULTS

Aggregated across all hospitals, only 5 of 12 of the key hip fracture indicators had ≥50% adherence. Adherence to indicators requiring actions to be performed within a recommended time period was poor (7.2-25.6%). No Patient Measure of Safety or clinician-based measures of teamwork, safety climate or leadership were associated with adherence to key indicators of hip fracture care. Simple proportionate agreement between clinician perceptions and actual hospital performance was generally strong, but few agreement coefficients were compelling.

CONCLUSION

The development of strong quality management processes requires ongoing effort. The findings of this study provide important insights into the relationship between hospital care and outcomes for hip fracture patients and could drive the design of targeted interventions for improved quality assurance of hip fracture care.

The Stroke Unit Story: Where Have We Been and Where Are We Going?

BACKGROUND

The concept of stroke unit care has been discussed for over 50 years, but it is only in the last 25 years that clear evidence of its effectiveness has emerged to inform these discussions.

SUMMARY

This review outlines the history of the concept of stroke units to improve recovery after stroke and their evaluation in clinical trials. It describes the first systematic review of stroke unit trials published in 1993, the establishment of a collaborative research group (the Stroke Unit Trialists' Collaboration), the subsequent analyses and updates of the evidence base, and the efforts to implement stroke unit care in routine settings. The final section considers some of the remaining challenges in this area of research and clinical practice. Key Messages: Good quality evidence confirms that stroke patients who are looked after in a stroke unit are more likely to survive and be independent and living at home 1 year after their stroke. The apparent benefits are independent of patient age, sex, stroke type, or initial stroke severity. The benefits are most obvious in units based in a discrete ward (stroke ward). The current challenges include integrating effective stroke units with more recent systems to deliver hyper-acute stroke interventions and implementing stroke units in lower resource regions.

Stroke 20 20: Implementation goals for intravenous thrombolysis

Introduction

Knowledge of the implementation gap would facilitate the use of intravenous thrombolysis in stroke, which is still low in many countries. The study was conducted to identify national implementation targets for the utilisation and logistics of intravenous thrombolysis.

Material and Method

Multicomponent interventions by stakeholders in health care to optimise prehospital and hospital management with the goal of fast and accessible intravenous thrombolysis for every candidate. Implementation results were documented from prospectively collected cases in all 45 stroke centres nationally. The thrombolytic rate was calculated from the total number of all ischemic strokes in the population of the Czech Republic since 2004.

Results

Thrombolytic rates of 1.3 (95%CI 1.1 to 1.4), 5.4 (95%CI 5.1 to 5.7), 13.6 (95%CI 13.1 to 14.0), 23.3 (95%CI 22.8 to 23.9), and 23.5% (95%CI 23.0 to 24.1%) were achieved in 2005, 2009, 2014, 2017, and 2018, respectively. National median door-to-needle times were 60-70 minutes before 2012 and then decreased progressively every year to 25 minutes (IQR 17 to 36) in 2018. In 2018, 33% of both university and non-university hospitals achieved median door-to-needle time ≤20 minutes. In 2018, door-to-needle times ≤20, ≤45, and ≤60 minutes were achieved in 39, 85, and 93% of patients.

Discussion

Thrombolysis can be provided to ≥ 20% of all ischemic strokes nationwide and it is realistic to achieve median door-to-needle time 20 minutes.

Conclusion

Stroke 20-20 could serve as national implementation target for intravenous thrombolysis and country specific implementation policies should be applied to achieve such target.

Delayed Comprehensive Stroke Unit Care Attributable to the Evolution of Infection Protection Measures across Two Consecutive Waves of the COVID-19 Pandemic

We aimed to assess how evidence-based stroke care changed over the two waves of the COVID-19 pandemic. We analyzed acute stroke patients admitted to a tertiary care hospital in Germany during the first (2 March 2020–9 June 2020) and second (23 September 2020–31 December 2020, 100 days each) infection waves. Stroke care performance indicators were compared among waves. A 25.2% decline of acute stroke admissions was noted during the second (n = 249) compared with the first (n = 333) wave of the pandemic. Patients were more frequently tested SARS-CoV-2 positive during the second than the first wave (11 (4.4%) vs. 0; p < 0.001). There were no differences in rates of reperfusion therapies (37% vs. 36.5%; p = 1.0) or treatment process times (p > 0.05). However, stroke unit access was more frequently delayed (17 (6.8%) vs. 5 (1.5%); p = 0.001), and hospitalization until inpatient rehabilitation was longer (20 (1, 27) vs. 12 (8, 17) days; p < 0.0001) during the second compared with the first pandemic wave. Clinical severity, stroke etiology, appropriate secondary prevention medication, and discharge disposition were comparable among both waves. Infection control measures may adversely affect access to stroke unit care and extend hospitalization, while performance indicators of hyperacute stroke care seem to be untainted.

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.

Enhancing and accelerating stroke treatment in Eastern European region: Methods and achievement of the ESO EAST program

INTRODUCTION

Despite the availability of prevention and therapies of stroke, their implementation in clinical practice, even of low-cost ones, remains poor. In 2015, the European Stroke Organisation (ESO) initiated the ESO Enhancing and Accelerating Stroke Treatment (EAST) program, which aims to improve stroke care quality, primarily in Eastern Europe. Here, we describe its methods and milestones.

PATIENTS AND METHODS

The ESO EAST program is using an implementation strategy based on a 'detecting-understanding-reducing disparities' conceptual framework: stroke care quality is first measured (after developing a platform for data collection), gaps are identified in the current service delivery, and ultimately feedback is provided to participating hospitals, followed by the application of interventions to reduce disparities. The ESO EAST program is carried out by establishing a stroke quality registry, stroke management infrastructure, and creating education and training opportunities for healthcare professionals.

RESULTS

Program management and leadership infrastructure has been established in 19 countries (Country Representatives in 22 countries, National Steering Committee in 19 countries). A software platform for data collection and analysis: Registry of Stroke Care Quality was developed, and launched in 2016, and has been used to collect data from over 90,000 patients from >750 hospitals and 56 countries between September 2016 and May 2019. Training in thrombolysis, nursing and research skills has been initiated.

DISCUSSION

ESO EAST is the first pan-Eastern European (and beyond) multifaceted quality improvement intervention putting evidence-informed policies into practice. Continuous monitoring of stroke care quality allows hospital-to-hospital and country-to-country benchmarking and identification of the gaps and needs in health care.

Organised inpatient (stroke unit) care for stroke: network meta-analysis

BACKGROUND

Organised inpatient (stroke unit) care is provided by multi-disciplinary teams that manage stroke patients. This can been provided in a ward dedicated to stroke patients (stroke ward), with a peripatetic stroke team (mobile stroke team), or within a generic disability service (mixed rehabilitation ward). Team members aim to provide co-ordinated multi-disciplinary care using standard approaches to manage common post-stroke problems.

OBJECTIVES

• To assess the effects of organised inpatient (stroke unit) care compared with an alternative service. • To use a network meta-analysis (NMA) approach to assess different types of organised inpatient (stroke unit) care for people admitted to hospital after a stroke (the standard comparator was care in a general ward). Originally, we conducted this systematic review to clarify: • The characteristic features of organised inpatient (stroke unit) care? • Whether organised inpatient (stroke unit) care provide better patient outcomes than alternative forms of care? • If benefits are apparent across a range of patient groups and across different approaches to delivering organised stroke unit care? Within the current version, we wished to establish whether previous conclusions were altered by the inclusion of new outcome data from recent trials and further analysis via NMA.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (2 April 2019); the Cochrane Central Register of Controlled Trials (CENTRAL; 2019, Issue 4), in the Cochrane Library (searched 2 April 2019); MEDLINE Ovid (1946 to 1 April 2019); Embase Ovid (1974 to 1 April 2019); and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 2 April 2019). In an effort to identify further published, unpublished, and ongoing trials, we searched seven trial registries (2 April 2019). We also performed citation tracking of included studies, checked reference lists of relevant articles, and contacted trialists.

SELECTION CRITERIA

Randomised controlled clinical trials comparing organised inpatient stroke unit care with an alternative service (typically contemporary conventional care), including comparing different types of organised inpatient (stroke unit) care for people with stroke who are admitted to hospital.

DATA COLLECTION AND ANALYSIS

Two review authors assessed eligibility and trial quality. We checked descriptive details and trial data with co-ordinators of the original trials, assessed risk of bias, and applied GRADE. The primary outcome was poor outcome (death or dependency (Rankin score 3 to 5) or requiring institutional care) at the end of scheduled follow-up. Secondary outcomes included death, institutional care, dependency, subjective health status, satisfaction, and length of stay. We used direct (pairwise) comparisons to compare organised inpatient (stroke unit) care with an alternative service. We used an NMA to confirm the relative effects of different approaches.

MAIN RESULTS

We included 29 trials (5902 participants) that compared organised inpatient (stroke unit) care with an alternative service: 20 trials (4127 participants) compared organised (stroke unit) care with a general ward, six trials (982 participants) compared different forms of organised (stroke unit) care, and three trials (793 participants) incorporated more than one comparison. Compared with the alternative service, organised inpatient (stroke unit) care was associated with improved outcomes at the end of scheduled follow-up (median one year): poor outcome (odds ratio (OR) 0.77, 95% confidence interval (CI) 0.69 to 0.87; moderate-quality evidence), death (OR 0.76, 95% CI 0.66 to 0.88; moderate-quality evidence), death or institutional care (OR 0.76, 95% CI 0.67 to 0.85; moderate-quality evidence), and death or dependency (OR 0.75, 95% CI 0.66 to 0.85; moderate-quality evidence). Evidence was of very low quality for subjective health status and was not available for patient satisfaction. Analysis of length of stay was complicated by variations in definition and measurement plus substantial statistical heterogeneity (I² = 85%). There was no indication that organised stroke unit care resulted in a longer hospital stay. Sensitivity analyses indicated that observed benefits remained when the analysis was restricted to securely randomised trials that used unequivocally blinded outcome assessment with a fixed period of follow-up. Outcomes appeared to be independent of patient age, sex, initial stroke severity, stroke type, and duration of follow-up. When calculated as the absolute risk difference for every 100 participants receiving stroke unit care, this equates to two extra survivors, six more living at home, and six more living independently. The analysis of different types of organised (stroke unit) care used both direct pairwise comparisons and NMA. Direct comparison of stroke ward versus general ward: 15 trials (3523 participants) compared care in a stroke ward with care in general wards. Stroke ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.78, 95% CI 0.68 to 0.91; moderate-quality evidence). Direct comparison of mobile stroke team versus general ward: two trials (438 participants) compared care from a mobile stroke team with care in general wards. Stroke team care may result in little difference in the odds of a poor outcome at the end of follow-up (OR 0.80, 95% CI 0.52 to 1.22; low-quality evidence). Direct comparison of mixed rehabilitation ward versus general ward: six trials (630 participants) compared care in a mixed rehabilitation ward with care in general wards. Mixed rehabilitation ward care showed a reduction in the odds of a poor outcome at the end of follow-up (OR 0.65, 95% CI 0.47 to 0.90; moderate-quality evidence). In a NMA using care in a general ward as the comparator, the odds of a poor outcome were as follows: stroke ward - OR 0.74, 95% CI 0.62 to 0.89, moderate-quality evidence; mobile stroke team - OR 0.88, 95% CI 0.58 to 1.34, low-quality evidence; mixed rehabilitation ward - OR 0.70, 95% CI 0.52 to 0.95, low-quality evidence.

AUTHORS' CONCLUSIONS

We found moderate-quality evidence that stroke patients who receive organised inpatient (stroke unit) care are more likely to be alive, independent, and living at home one year after the stroke. The apparent benefits were independent of patient age, sex, initial stroke severity, or stroke type, and were most obvious in units based in a discrete stroke ward. We observed no systematic increase in the length of inpatient stay, but these findings had considerable uncertainty.

Impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke

Background:

Stroke is a leading cause of death worldwide. The cases of acute ischemic stroke are on the increase in the Asia Pacific, particularly in Malaysia. Various health organizations have recommended guidelines for managing ischemic stroke, but adherence to key performance indicators (KPI) from the guidelines and impact on patient outcomes, particularly mortality, are rarely explored.

Objective:

This study aims to evaluate the impact of adherence to key performance indicators on mortality among patients managed for ischemic stroke.

Methods:

We included all first-ever ischemic stroke patients enrolled in the multiethnic Malaysian National Neurology Registry (NNeuR) - a prospective cohort study and followed-up for six months. Patients’ baseline clinical characteristics, risk factors, neurological findings, treatments, KPI and mortality outcome were evaluated. The KPI nonadherence (NAR) and relationship with mortality were evaluated. NAR>25% threshold was considered suboptimal.

Results:

A total of 579 first-ever ischemic stroke patients were included in the final analysis. The overall mortality was recorded as 23 (4.0%) in six months, with a median (interquartile) age of 65 (20) years. Majority of the patients (dead or alive) had partial anterior circulation infarct, PACI (43.5%; 34.0%) and total anterior circulation infarct, TACI (26.1%; 8.8%). In addition, DVT prophylaxis (82.8%), anticoagulant for atrial fibrillation (AF) patients (48.8%) and rehabilitation (26.2%) were considered suboptimal. NAR < 2 was significantly associated with a decrease in mortality (odds ratio 0.16; 0.02-0.12) compared to NAR>2. Survival analysis showed that death is more likely in patients with NAR>2 (p=0.05).

Conclusions:

KPI nonadherence was associated with mortality among ischemic stroke patients. The adherence to the KPI was sub-optimal, particularly in DVT prophylaxis, anticoagulant for AF patients and rehabilitation. These findings reflect the importance of continuous quality measurement and implementation of evidence recommendations in healthcare delivery to achieve optimal outcome among stroke patients.

Impact of Evidence-Based Stroke Care on Patient Outcomes: A Multilevel Analysis of an International Study

Background

The uptake of proven stroke treatments varies widely. We aimed to determine the association of evidence‐based processes of care for acute ischemic stroke (AIS) and clinical outcome of patients who participated in the HEADPOST (Head Positioning in Acute Stroke Trial), a multicenter cluster crossover trial of lying flat versus sitting up, head positioning in acute stroke.

Methods and Results

Use of 8 AIS processes of care were considered: reperfusion therapy in eligible patients; acute stroke unit care; antihypertensive, antiplatelet, statin, and anticoagulation for atrial fibrillation; dysphagia assessment; and physiotherapist review. Hierarchical, mixed, logistic regression models were performed to determine associations with good outcome (modified Rankin Scale scores 0–2) at 90 days, adjusted for patient and hospital variables. Among 9485 patients with AIS, implementation of all processes of care in eligible patients, or “defect‐free” care, was associated with improved outcome (odds ratio, 1.40; 95% CI, 1.18–1.65) and better survival (odds ratio, 2.23; 95% CI, 1.62–3.09). Defect‐free stroke care was also significantly associated with excellent outcome (modified Rankin Scale score 0–1) (odds ratio, 1.22; 95% CI, 1.04–1.43). No hospital characteristic was independently predictive of outcome. Only 1445 (15%) of eligible patients with AIS received all processes of care, with significant regional variations in overall and individual rates.

Conclusions

Use of evidence‐based care is associated with improved clinical outcome in AIS. Strategies are required to address regional variation in the use of proven AIS treatments.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique Identifier: NCT02162017.

Predictive Factors of Swallowing Disorders and Bronchopneumonia in Acute Ischemic Stroke

BACKGROUND

In stroke patients, early complications such as swallowing disorders (SD) and bronchopneumonia (BP) are frequent and may worsen outcome. The aim of this study was to evaluate the prevalence of SD in acute ischemic stroke (AIS) and the risk of BP, as well as to identify factors associated with these conditions.

METHODS

We retrospectively studied all AISs over a 12-month period in a single-center registry. We determined the frequency of SD in the first 7 days and of BP over the entire hospital stay. Associations of SD and BP with patient characteristics, stroke features, dental status, and presence of a feeding tube were analyzed in multivariate analyses.

RESULTS

In the 340 consecutive patients, the overall frequency of SD and BP was 23.8% and 11.5%, respectively. The multivariate analyses showed significant associations of SD with NIHSS scores >4, involvement of the medulla oblongata and wearing a dental prosthesis (area under the receiver-operator curve (AUC) of 76%). BP was significantly associated with NIHSS scores >4, male sex, bilateral cerebral lesions, the presence of SD, and the use of an enteral feeding tube (AUC 84%). In unadjusted analysis, unfavorable 12-month outcome and mortality were increased in the presence of SD.

CONCLUSION

In AIS, SD and BP are associated with stroke severity and localization and wearing a dental prosthesis increases the risk of SD. Given that patients with SD have an increased risk of poor outcome and mortality, high-risk patients warrant early interventions, including more randomized trials.

Moving stroke rehabilitation evidence into practice: a systematic review of randomized controlled trials

OBJECTIVE

The aim of this study was to investigate the effectiveness of interventions aimed at moving research evidence into stroke rehabilitation practice through changing the practice of clinicians.

DATA SOURCES

EMBASE, CINAHL, Cochrane and MEDLINE databases were searched from 1980 to April 2019. International trial registries and reference lists of included studies completed our search.

REVIEW METHODS

Randomized controlled trials that involved interventions aiming to change the practice of clinicians working in stroke rehabilitation were included. Bias was evaluated using RevMan to generate a risk of bias table. Evidence quality was evaluated using GRADE criteria.

RESULTS

A total of 16 trials were included (250 sites, 14,689 patients), evaluating a range of interventions including facilitation, audit and feedback, education and reminders. Of which, 11 studies included multicomponent interventions (using a combination of interventions). Four used educational interventions alone, and one used electronic reminders. Risk of bias was generally low. Overall, the GRADE criteria indicated that this body of literature was of low quality. This review found higher efficacy of trials which targeted fewer outcomes. Subgroup analysis indicated moderate-level GRADE evidence (103 sites, 10,877 patients) that trials which included both site facilitation and tailoring for local factors were effective in changing clinical practice. The effect size of these varied (odds ratio: 1.63-4.9). Education interventions alone were not effective.

CONCLUSION

A large range of interventions are used to facilitate clinical practice change. Education is commonly used, but in isolation is not effective. Multicomponent interventions including facilitation and tailoring to local settings can change clinical practice and are more effective when targeting fewer changes.

[Dynamics of mortality rates in different types of stroke in the territories included in the Federal program of reorganization of care for stroke patients]

AIM

To study and analyze the dynamics of one-day, 7-day and 28-day mortality rates in different types of stroke.

MATERIAL AND METHODS

The retrospective study was based on the data of the territorial population register for 2009-2016 from seven territories of the Russian Federation in which the Federal program of reorganization of care for stroke patients came into force in 2009. The study population included men and women, aged 25 years and older, registered in the study area. A total of 29.779 stroke cases were identified. The mortality rate was calculated as the ratio of the number of stroke cases that ended fatally to the number of stroke cases per year. The dynamics of the mortality rate of the following types of stroke was analyzed: subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH) and ischemic stroke (IS).

RESULTS

Between 2009 and 2010, there was an increase in SAH one-day, 7-day and 28-day mortality rates and in ICH one-day, 7-day mortality rates. In the period from 2009 to 2010, the increased ICH 28-day mortality rates tended to increase, while the IS one-day, 7-day and 28-day mortality rates decreased. One-day, 7-day and 28-day mortality rates in SAH, ICH, IS had a declining trend from 2010 to 2016. A slight increase in SAH one-day mortality rate in 2014 and 2015 and SAH 7-day mortality rate in 2013 was observed. The same trend was noted for ICH mortality rates in 2013 and 2016 and in 2013, respectively. The IS one-day, 7-day and 28-day mortality rates slightly increased in 2014.

CONCLUSION

According to the territorial-population register from 2009 to 2016, a significant decrease in one-day, 7-day and 28-day mortality rates in all types of stroke in the studied territories was registered. There is no doubt that this is due to the successful implementation of the Federal program of reorganization of care for stroke patients carried out in this period in the territories included in the study.

Action Plan for Stroke in Europe 2018-2030

Two previous pan-European consensus meetings, the 1995 and 2006 Helsingborg meetings, were convened to review the scientific evidence and the state of current services to identify priorities for research and development and to set targets for the development of stroke care for the decade to follow. Adhering to the same format, the European Stroke Organisation (ESO) prepared a European Stroke Action Plan (ESAP) for the years 2018 to 2030, in cooperation with the Stroke Alliance for Europe (SAFE). The ESAP included seven domains: primary prevention, organisation of stroke services, management of acute stroke, secondary prevention, rehabilitation, evaluation of stroke outcome and quality assessment and life after stroke. Research priorities for translational stroke research were also identified. Documents were prepared by a working group and were open to public comments. The final document was prepared after a workshop in Munich on 21-23 March 2018. Four overarching targets for 2030 were identified: (1) to reduce the absolute number of strokes in Europe by 10%, (2) to treat 90% or more of all patients with stroke in Europe in a dedicated stroke unit as the first level of care, (3) to have national plans for stroke encompassing the entire chain of care, (4) to fully implement national strategies for multisector public health interventions. Overall, 30 targets and 72 research priorities were identified for the seven domains. The ESAP provides a basic road map and sets targets for the implementation of evidence-based preventive actions and stroke services to 2030.