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Mohammed T, Nyante GG, Mothabeng DJ. An evaluation of the structure and process of stroke rehabilitation in primary, secondary and tertiary hospitals in Ghana. SOUTH AFRICAN JOURNAL OF PHYSIOTHERAPY 2022; 78:1637. [PMID: 35747516 PMCID: PMC9210176 DOI: 10.4102/sajp.v78i1.1637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/10/2022] [Indexed: 11/30/2022] Open
Abstract
Background Evidence shows that quality indicators such as the structure and process of stroke rehabilitation can influence patient outcomes. However, not much attention has been paid to the study of these issues in low- and middle-income countries such as Ghana. Objectives Our study evaluated the structure and process of stroke rehabilitation in primary, secondary and tertiary hospitals in the Greater Accra Region of Ghana. Method A cross-sectional survey was conducted involving 111 healthcare professionals. The World Health Organization (WHO) situational analysis and Measure of Processes of Care for Service Providers for Adults (MPOC-SP[A]) questionnaires were administered to gather information on the structure and process of stroke rehabilitation. Descriptive statistics were used to summarise data, and chi-square and Kruskal–Wallis tests were used to establish associations and comparisons, respectively. Results A stroke unit was only available in the tertiary hospital. Although all three hospitals had a multidisciplinary team approach to care, the constituents differed. Length of hospital-stay, duration of treatment and basis for discharge from acute care were not associated with the hospitals. Therapy sessions, access to computed tomography (CT) and magnetic resonance imaging (MRI) scanning were dependent on the hospitals. Conclusion The structure and process of stroke rehabilitation across the three hospitals were similar in some constructs and different in others. Clinical implications Data gathered will help to provide information on the available structure and processes of stroke rehabilitation, which could help assess the quality of care provided.
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Affiliation(s)
- Tawagidu Mohammed
- Department of Physiotherapy, School of Healthcare Sciences, University of Pretoria, Pretoria, South Africa
- Department of Physiotherapy, School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana
| | - Gifty G. Nyante
- Department of Physiotherapy, School of Biomedical and Allied Health Sciences, University of Ghana, Accra, Ghana
| | - Diphale J. Mothabeng
- Department of Physiotherapy, School of Healthcare Sciences, University of Pretoria, Pretoria, South Africa
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2
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Oostendorp RAB, Elvers JWH, van Trijffel E, Rutten GM, Scholten–Peeters GGM, Heijmans M, Hendriks E, Mikolajewska E, De Kooning M, Laekeman M, Nijs J, Roussel N, Samwel H. Relationships Between Context, Process, and Outcome Indicators to Assess Quality of Physiotherapy Care in Patients with Whiplash-Associated Disorders: Applying Donabedian's Model of Care. Patient Prefer Adherence 2020; 14:425-442. [PMID: 32184572 PMCID: PMC7060032 DOI: 10.2147/ppa.s234800] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/28/2020] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Quality indicators (QIs) are measurable elements of practice performance and may relate to context, process, outcome and structure. A valid set of QIs have been developed, reflecting the clinical reasoning used in primary care physiotherapy for patients with whiplash-associated disorders (WAD). Donabedian's model postulates relationships between the constructs of quality of care, acting in a virtuous circle. AIM To explore the relative strengths of the relationships between context, process, and outcome indicators in the assessment of primary care physiotherapy in patients with WAD. MATERIALS AND METHODS Data on WAD patients (N=810) were collected over a period of 16 years in primary care physiotherapy practices by means of patients records. This routinely collected dataset (RCD-WAD) was classified in context, process, and outcome variables and analyzed retrospectively. Clinically relevant variables were selected based on expert consensus. Associations were expressed, using zero-order, as Spearman rank correlation coefficients (criterion: rs >0.25 [minimum: fair]; α-value = 0.05). RESULTS In round 1, 62 of 85 (72.9%) variables were selected by an expert panel as relevant for clinical reasoning; in round 2, 34 of 62 (54.8%) (context variables 9 of 18 [50.0%]; process variables 18 of 34 [52.9]; outcome variables 8 of 10 [90.0%]) as highly relevant. Associations between the selected context and process variables ranged from 0.27 to 0.53 (p≤0.00), between selected context and outcome variables from 0.26 to 0.55 (p≤0.00), and between selected process and outcome variables from 0.29 to 0.59 (p≤0.00). Moderate associations (rs >0.50; p≤0.00) were found between "pain coping" and "fear avoidance" as process variables, and "pain intensity" and "functioning" as outcome variables. CONCLUSION The identified associations between selected context, process, and outcome variables were fair to moderate. Ongoing work may clarify some of these associations and provide guidance to physiotherapists on how best to improve the quality of clinical reasoning in terms of relationships between context, process, and outcome in the management of patients with WAD.
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Affiliation(s)
- Rob A B Oostendorp
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
- Department of Manual Therapy, Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Brussels, Belgium
- Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- Practice Physiotherapy and Manual Therapy, Heeswijk-Dinther, the Netherlands
| | - J W Hans Elvers
- Department of Public Health and Research, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
- Methodological Health-Skilled Institute, Beuningen, the Netherlands
| | - Emiel van Trijffel
- SOMT University of Physiotherapy, Amersfoort, the Netherlands
- Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Geert M Rutten
- Institute of Health Studies, Faculty of Health and Social Studies, HAN University of Applied Science, Nijmegen, the Netherlands
- Faculty of Science and Engineering, Maastricht University, Maastricht, the Netherlands
| | - Gwendolyne G M Scholten–Peeters
- Department of Human Movement Sciences, Faculty of Behavioral and Movement Sciences, Vrije Universiteit Free University Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Marcel Heijmans
- Practice Physiotherapy and Manual Therapy, Heeswijk-Dinther, the Netherlands
| | - Erik Hendriks
- Department of Epidemiology, Center of Evidence Based Physiotherapy, Maastricht University, Maastricht, the Netherlands
- Practice Physiotherapy ‘Klepperheide’, Druten, the Netherlands
| | - Emilia Mikolajewska
- Department of Physiotherapy, Ludwik Rydygier Collegium Medicum in Bydgoszcz, Nicolaus Copernicus Univerisity, Toruń, Poland
- Neurocognitive Laboratory, Centre for Modern Interdisciplinary Technologies, Nicolaus Copernicus University, Toruń, Poland
| | - Margot De Kooning
- Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium
| | - Marjan Laekeman
- Department of Nursing Sciences, Ph.D.-Kolleg, Faculty of Health, University Witten/Herdecke, Witten, Germany
| | - Jo Nijs
- Pain in Motion International Research Group, Department of Physiotherapy, Human Physiology and Anatomy, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- Department of Physical Medicine and Physiotherapy, University Hospital Brussels, Brussels, Belgium
| | - Nathalie Roussel
- Department of Physiotherapy and Rehabilitation Sciences (MOVANT), Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Han Samwel
- Revalis Pain Rehabilitation Centre, ‘s Hertogenbosch, the Netherlands
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3
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The Complex Association of Race/Ethnicity With Pain Treatment Quality in an Urban Medical Center With 2 Pediatric Emergency Departments. Pediatr Emerg Care 2019; 35:815-820. [PMID: 29346231 DOI: 10.1097/pec.0000000000001401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE This study aimed to explore racial differences in analgesia quality. METHODS A retrospective cross-sectional study of 24,733 visits by individuals 21 years or younger with pain scores of 4 to 10 was performed using electronic medical records. We compared 2 process metrics, treatment with any analgesics within 60 minutes and treatment with opioids within 60 minutes, and one outcome metric, a reduction in pain score by 2 or more points within 90 minutes. Multivariable logistic regression adjusted for the effects of patient characteristics and health status. We also determined variations in analgesia quality among those with severe pain. RESULTS When compared with white children, black children were more likely to receive any analgesia (adjusted odds ratio [aOR], 1.94; 95% confidence interval, 1.71-2.21), but both blacks (aOR, 0.66; 0.51-0.85) and Hispanics (aOR, 0.56; 0.39-0.80) were less likely to receive opioids. Blacks were more likely to reduce their pain score (aOR, 1.50; 1.28-1.76).Among children with severe pain, both blacks and Hispanics were more likely to receive any analgesia (black: aOR, 2.05 [1.71-2.46]; Hispanic: aOR, 1.29 [1.05-1.59]), and Hispanic children were less likely to receive opioids (aOR, 0.58; 0.37-0.91). Again, black children were more likely to reduce their pain score (aOR, 1.42; 1.13-1.79). CONCLUSIONS The relationship between race/ethnicity and analgesia is complex. Although minority children were less likely to receive opioids, black children had better treatment outcomes. Future studies should explore clinical response to analgesia in addition to process measures to better understand if differential treatment may be justified to achieve equitable care outcomes.
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Zhang X, Li Z, Zhao X, Xian Y, Liu L, Wang C, Wang C, Li H, Prvu Bettger J, Yang Q, Wang D, Jiang Y, Bao X, Yang X, Wang Y, Wang Y. Relationship between hospital performance measures and outcomes in patients with acute ischaemic stroke: a prospective cohort study. BMJ Open 2018; 8:e020467. [PMID: 30068610 PMCID: PMC6074631 DOI: 10.1136/bmjopen-2017-020467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Evidence-based performance measures have been increasingly used to evaluate hospital quality of stroke care, but their impact on stroke outcomes has not been verified. We aimed to evaluate the correlations between hospital performance measures and outcomes among patients with acute ischaemic stroke in a Chinese population. METHODS Data were derived from a prospective cohort, which included 120 hospitals participating in the China National Stroke Registry between September 2007 and August 2008. Adherence to nine evidence-based performance measures was examined, and the composite score of hospital performance measures was calculated. The primary stroke outcomes were hospital-level, 30-day and 1-year risk-standardised mortality (RSM). Associations of individual performance measures and composite score with stroke outcomes were assessed using Spearman correlation coefficients. RESULTS One hundred and twenty hospitals that recruited 12 027 patients with ischaemic stroke were included in our analysis. Among 12 027 patients, 61.59% were men, and the median age was 67 years. The overall composite score of performance measures was 63.3%. The correlation coefficients between individual performance measures ranged widely from 0.01 to 0.66. No association was observed between the composite score and 30-day RSM. The composite score was modestly associated with 1-year RSM (Spearman correlation coefficient, 0.34; p<0.05). The composite score explained only 2.53% and 10.18% of hospital-level variation in 30-day and 1-year RSM for patients with acute stroke. CONCLUSIONS Adherence to evidence-based performance measures for acute ischaemic stroke was suboptimal in China. There were various correlations among hospital individual performance measures. The hospital performance measures had no correlations with 30-day RSM rate and modest correlations with 1-year RSM rate.
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Affiliation(s)
- Xinmiao Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Zixiao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Ying Xian
- Department of Neurology, Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chunxue Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Chunjuan Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Hao Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Janet Prvu Bettger
- Department of Neurology, Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
- Duke University School of Nursing, Duke University, Durham, North Carolina, USA
| | - Qing Yang
- Duke University School of Nursing, Duke University, Durham, North Carolina, USA
| | - David Wang
- INI Stroke Network, OSF Healthcare System, University of Illinois College of Medicine, Peoria, Illinois, USA
| | - Yong Jiang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xiaolei Bao
- Statistical Analysis Office, Department of Information, General Hospital of Lanzhou Military Area Command, Lanzhou, Gansu, China
| | - Xiaomeng Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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5
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Hemphill JC, Adeoye OM, Alexander DN, Alexandrov AW, Amin-Hanjani S, Cushman M, George MG, LeRoux PD, Mayer SA, Qureshi AI, Saver JL, Schwamm LH, Sheth KN, Tirschwell D. Clinical Performance Measures for Adults Hospitalized With Intracerebral Hemorrhage: Performance Measures for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2018; 49:e243-e261. [PMID: 29786566 DOI: 10.1161/str.0000000000000171] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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6
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Ali M, Salehnejad R, Mansur M. Hospital heterogeneity: what drives the quality of health care. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:385-408. [PMID: 28439750 PMCID: PMC5978923 DOI: 10.1007/s10198-017-0891-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 03/28/2017] [Indexed: 05/29/2023]
Abstract
A major feature of health care systems is substantial variation in health care quality across hospitals. The quality of stroke care widely varies across NHS hospitals. We investigate factors that may explain variations in health care quality using measures of quality of stroke care. We combine NHS trust data from the National Sentinel Stroke Audit with other data sets from the Office for National Statistics, NHS and census data to capture hospitals' human and physical assets and organisational characteristics. We employ a class of non-parametric methods to explore the complex structure of the data and a set of correlated random effects models to identify key determinants of the quality of stroke care. The organisational quality of the process of stroke care appears as a fundamental driver of clinical quality of stroke care. There are rich complementarities amongst drivers of quality of stroke care. The findings strengthen previous research on managerial and organisational determinants of health care quality.
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Affiliation(s)
- Manhal Ali
- University of Manchester, Manchester, UK
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7
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Nuckols TK, Conlon C, Robbins M, Dworsky M, Lai J, Roth CP, Levitan B, Seabury S, Seelam R, Benner D, Asch SM. Quality of care and patient-reported outcomes in carpal tunnel syndrome: A prospective observational study. Muscle Nerve 2018; 57:896-904. [PMID: 29272038 DOI: 10.1002/mus.26041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Higher quality care for carpal tunnel syndrome (CTS) may be associated with better outcomes. METHODS This prospective observational study recruited adults diagnosed with CTS from 30 occupational health centers, evaluated physicians' adherence to recommended care processes, and assessed results of the Boston Carpal Tunnel Questionnaire (BCTQ) and Short Form Health Survey version 2 (SF-12v2) at recruitment and at 18 months. RESULTS Among 343 individuals, receiving better care (80th vs. 20th percentile for adherence) was associated with greater improvements in BCTQ Symptom Severity scores (-0.18, 95% confidence interval [CI] -0.32 to -0.05), BCTQ Functional Status scores (-0.21, 95% CI -0.34 to -0.08), and SF12-v2 Physical Component scores (1.75, 95% CI 0.33-3.16). Symptoms improved more when physicians assessed and managed activity, patients underwent necessary surgery, and employers adjusted job tasks. DISCUSSION Efforts should be made to ensure that patients with CTS receive essential care processes including necessary surgery and activity assessment and management. Muscle Nerve 57: 896-904, 2018.
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Affiliation(s)
- Teryl K Nuckols
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA.,Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Craig Conlon
- Employee Health, The Permanente Medical Group, Oakland, California, USA
| | - Michael Robbins
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Michael Dworsky
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Julie Lai
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Carol P Roth
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Barbara Levitan
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Seth Seabury
- University of Southern California, USC Schaeffer Center, Los Angeles, California, USA
| | - Rachana Seelam
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | | | - Steven M Asch
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA.,VA Palo Alto Health Care System, Menlo Park, California, USA.,Division of General Medical Disciplines, Stanford University School of Medicine, Palo Alto, California, USA
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8
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Urimubenshi G, Langhorne P, Cadilhac DA, Kagwiza JN, Wu O. Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis. Eur Stroke J 2017; 2:287-307. [PMID: 31008322 DOI: 10.1177/2396987317735426] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/09/2017] [Indexed: 01/09/2023] Open
Abstract
Purpose Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes. Method We sought publications of recent (January 2000-May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up. Findings We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72-0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66-0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50-0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43-0.64), lipid management (odds ratio 0.52; 0.38-0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67-0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43-0.78) and stroke unit admission (odds ratio 0.83; 0.77-0.89). Adherence with several key performance indicators appeared to have an additive benefit. Discussion Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke. Conclusion Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence.
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Affiliation(s)
- Gerard Urimubenshi
- 1Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK.,College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Peter Langhorne
- 1Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Dominique A Cadilhac
- School of Clinical Sciences at Monash Health, Monash University, Clayton, Australia.,The Florey Institute Neuroscience and Mental Health, University of Melbourne, Victoria, Australia
| | - Jeanne N Kagwiza
- College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Olivia Wu
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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9
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Adelman EE, Lisabeth LD, Smith MA, Baek J, Case EC, Sánchez BN, Burke JF, Skolarus LE, Zahuranec DB, Meurer WJ, Brown DL, Kerber KA, Levine DA, Garcia NM, Campbell MS, Morgenstern LB. Stroke Performance Measures Do Not Predict Functional Outcome. Neurohospitalist 2016. [PMID: 28634500 DOI: 10.1177/1941874416675797] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Poststroke functional outcome is critical to stroke survivors. We sought to determine whether adherence to current stroke performance measures is associated with better functional outcome 90 days after an ischemic stroke. METHODS Utilizing the Brain Attack Surveillance in Corpus Christi cohort, we examined adherence to 7 ischemic stroke performance measures from February 2009 to June 2012. Adherence to the measures was analyzed in aggregate using a binary defect-free score and an opportunity score, representing the proportion of eligible measures met. The opportunity score ranges from 0 to 1, with values closer to 1 implying better adherence. Functional outcome, defined by an activities of daily living and instrumental activities of daily living (ADL/IADL) score (range 1-4, higher scores worse), was ascertained at 90 days poststroke. Tobit regression models were fitted to examine the associations between the performance measures and functional outcome, adjusting for demographic and clinical characteristics, including stroke severity. RESULTS There were 565 patients with ischemic stroke included in the analysis. The median ADL/IADL score was 2.32 (interquartile range [IQR]: 1.41-3.41). The median opportunity score was 1 (IQR: 0.8-1), and 58.4% of the patients received defect-free care. After adjustment, the opportunity score (P = .67) and defect-free care (P = .92) were not associated with functional outcome. CONCLUSION In this population, adherence to a composite of current stroke performance measures was not associated with poststroke functional outcome after adjustment for other factors. Performance measures that are associated with improved functional outcome should be developed and incorporated into stroke quality measures.
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Affiliation(s)
- Eric E Adelman
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Lynda D Lisabeth
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Melinda A Smith
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Jonggyu Baek
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Erin C Case
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Brisa N Sánchez
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - James F Burke
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Health Services Research and Development Center of Excellence, Ann Arbor, MI, USA
| | - Lesli E Skolarus
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Darin B Zahuranec
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - William J Meurer
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Devin L Brown
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Kevin A Kerber
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Deborah A Levine
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Veterans Affairs Health Services Research and Development Center of Excellence, Ann Arbor, MI, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Nelda M Garcia
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | | | - Lewis B Morgenstern
- Stroke Program, Department of Neurology, University of Michigan, Ann Arbor, MI, USA.,Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
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10
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Tung YC, Jeng JS, Chang GM, Chung KP. Processes and outcomes of ischemic stroke care: the influence of hospital level of care. Int J Qual Health Care 2015; 27:260-6. [DOI: 10.1093/intqhc/mzv038] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2015] [Indexed: 11/14/2022] Open
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11
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Chatterjee P, Joynt KE. Do cardiology quality measures actually improve patient outcomes? J Am Heart Assoc 2014; 3:e000404. [PMID: 24510114 PMCID: PMC3959669 DOI: 10.1161/jaha.113.000404] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 12/20/2013] [Indexed: 11/16/2022]
Affiliation(s)
- Paula Chatterjee
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (P.C., K.E.J.)
- Harvard Medical School, VA Boston Healthcare System, Boston, MA (P.C., K.E.J.)
| | - Karen E. Joynt
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA (P.C., K.E.J.)
- Cardiovascular Division, Brigham & Women's Hospital, Boston, MA (K.E.J.)
- Harvard Medical School, VA Boston Healthcare System, Boston, MA (P.C., K.E.J.)
- Cardiology Service, VA Boston Healthcare System, Boston, MA (K.E.J.)
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Phipps MS, Jia H, Chumbler NR, Li X, Castro JG, Myers J, Williams LS, Bravata DM. Rural-urban differences in inpatient quality of care in US Veterans with ischemic stroke. J Rural Health 2013; 30:1-6. [PMID: 24383479 DOI: 10.1111/jrh.12029] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE Differences in stroke care quality for patients in rural and urban locations have been suggested, but whether differences exist across Veteran Administration Medical Centers (VAMCs) is unknown. This study examines whether rural-urban disparities exist in inpatient quality among veterans with acute ischemic stroke. METHODS In this retrospective study, inpatient stroke care quality was assessed in a national sample of veterans with acute ischemic stroke using 14 quality indicators (QIs). Rural-Urban Commuting Areas codes defined each VAMC's rural-urban status. A hierarchical linear model assessed the rural-urban differences across the 14 QIs, adjusting for patient and facility characteristics, and clustering within VAMCs. FINDINGS Among 128 VAMCs, 18 (14.1%) were classified as rural VAMCs and admitted 284 (7.3%) of the 3,889 ischemic stroke patients. Rural VAMCs had statistically significantly lower unadjusted rates on 6 QIs: Deep vein thrombosis (DVT) prophylaxis, antithrombotic at discharge, antithrombotic at day 2, lipid management, smoking cessation counseling, and National Institutes of Health Stroke Scale completion, but they had higher rates of stroke education, functional assessment, and fall risk assessment. After adjustment, differences in 2 QIs remained significant-patients treated in rural VAMCs were less likely to receive DVT prophylaxis, but more likely to have documented functional assessment. CONCLUSIONS After adjustment for key demographic, clinical, and facility-level characteristics, there does not appear to be a systematic difference in inpatient stroke quality between rural and urban VAMCs. Future research should seek to understand the few differences in care found that could serve as targets for future quality improvement interventions.
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Affiliation(s)
- Michael S Phipps
- Department of Neurology, University of Connecticut/Hartford Hospital, Hartford, Connecticut; Medical Informatics, Department of Veterans Affairs (VA) Connecticut Healthcare System, West Haven, Connecticut; VA Health Services Research and Development (HSR&D) Stroke Quality Enhancement Research Initiative (QUERI) Program, Indianapolis, Indiana
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Hall WB, Willis LE, Medvedev S, Carson SS. The implications of long-term acute care hospital transfer practices for measures of in-hospital mortality and length of stay. Am J Respir Crit Care Med 2012; 185:53-7. [PMID: 21940788 DOI: 10.1164/rccm.201106-1084oc] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The National Quality Forum recently endorsed in-hospital mortality and intensive care unit length of stay (LOS) as quality indicators for patients in the intensive care unit. These measures may be affected by transferring patients to long-term acute care hospitals (LTACs). OBJECTIVES To quantify the implications of LTAC transfer practices on variation in mortality index and LOS index for patients in academic medical centers. METHODS We used a cross-sectional study design using data reported to the University HealthSystem Consortium from 2008-2009. Data were from patients who were mechanically ventilated for more than 96 hours. MEASUREMENTS AND MAIN RESULTS Using linear regression, we measured the association between mortality index and LTAC transfer rate, with the hospital as the unit of analysis. Similar analyses were conducted for LOS index and cost index. A total of 137 hospitals were analyzed, averaging 534 transfers to LTAC per hospital during the study period. Mean±SD in-hospital mortality was 24±6.4%, and observed LOS was 30.4±8.2 days. The mean LTAC transfer rate was 15.7±13.7%. Linear regression demonstrated a significant correlation between transfer rate and mortality index (R2=0.14; P<0.0001) and LOS index (R2=0.43; P<0.0001). CONCLUSIONS LTAC hospital transfer rate has a significant impact on reported mortality and LOS indices for patients requiring prolonged acute mechanical ventilation. This is an example of factors unrelated to quality of medical care or illness severity that must be considered when interpreting mortality and LOS as quality indicators.
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Affiliation(s)
- William B Hall
- Pulmonary and Critical Care Medicine, University of North Carolina at Chapel Hill, 4134 Bioinformatics Building, CB#7020, Chapel Hill, NC 27599, USA
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Affiliation(s)
- Carol Parker
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Lee H. Schwamm
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Gregg C. Fonarow
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Eric E. Smith
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
| | - Mathew J. Reeves
- From the Department of Epidemiology (C.P., M.J.R.), Michigan State University, East Lansing, MI; Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston, MA; Division of Cardiology (G.C.F.), University of California, Los Angeles, CA; Department of Clinical Neurosciences (E.E.S.), Calgary, Alberta, Canada
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15
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Wang CJ, Kavanagh PL, Little AA, Holliman JB, Sprinz PG. Quality-of-care indicators for children with sickle cell disease. Pediatrics 2011; 128:484-93. [PMID: 21844055 DOI: 10.1542/peds.2010-1791] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE To develop a set of quality-of-care indicators for the management of children with sickle cell disease (SCD) who are cared for in a variety of settings by addressing the broad spectrum of complications relevant to their illness. METHODS We used the Rand/University of California Los Angeles appropriateness method, a modified Delphi method, to develop the indicators. The process included a comprehensive literature review with ratings of the evidence and 2 rounds of anonymous ratings by an expert panel (nominated by leaders of various US academic societies and the National Heart, Lung, and Blood Institute). The panelists met face-to-face to discuss each indicator in between the 2 rounds. RESULTS The panel recommended 41 indicators that cover 18 topics; 17 indicators described routine health care maintenance, 15 described acute or subacute care, and 9 described chronic care. The panel identified 8 indicators most likely to have a large positive effect on improving quality of life and/or health outcomes for children with SCD, which covered 6 topics: timely assessment and treatment of pain and fever; comprehensive planning; penicillin prophylaxis; transfusion; and the transition to adult care. CONCLUSIONS Children with SCD are at risk for serious morbidities and early mortality, yet efforts to assess and improve the quality of their care have been limited compared with other chronic childhood conditions. This set of 41 indicators can be used to assess quality of care and provide a starting point for quality-improvement efforts.
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Affiliation(s)
- C Jason Wang
- Department of Pediatrics, Boston University School of Medicine, Boston, Massachusetts, USA.
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Professionals' views on interprofessional stroke team functioning. Int J Integr Care 2011; 11:e081. [PMID: 23390409 PMCID: PMC3564423 DOI: 10.5334/ijic.657] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2010] [Revised: 05/27/2011] [Accepted: 06/08/2011] [Indexed: 11/20/2022] Open
Abstract
Introduction The quality of integrated stroke care depends on smooth team functioning but professionals may not always work well together. Professionals’ perspectives on the factors that influence stroke team functioning remain largely unexamined. Understanding their experiences is critical to indentifying measures to improve team functioning. The aim of this study was to identify the factors that contributed to the success of interprofessional stroke teams as perceived by team members. Methods We distributed questionnaires to professionals within 34 integrated stroke care teams at various health care facilities in 9 Dutch regions. 558 respondents (response rate: 39%) completed the questionnaire. To account for the hierarchical structure of the study design we fitted a hierarchical random-effects model. The hierarchical structure comprised 558 stroke team members (level 1) nested in 34 teams (level 2). Results Analyses showed that personal development, social well-being, interprofessional education, communication, and role understanding significantly contributed to stroke team functioning. Team-level constructs affecting interprofessional stroke team functioning were communication and role understanding. No significant relationships were found with individual-level personal autonomy and team-level cohesion. Discussion and conclusion Our findings suggest that interventions to improve team members’ social well-being, communication, and role understanding will improve teams’ performance. To further advance interprofessional team functioning, healthcare organizations should pay attention to developing professionals’ interpersonal skills and interprofessional education.
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Luker JA, Bernhardt J, Grimmer-Somers KA. Age and gender as predictors of allied health quality stroke care. J Multidiscip Healthc 2011; 4:239-45. [PMID: 21847346 PMCID: PMC3155854 DOI: 10.2147/jmdh.s21559] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Indexed: 12/21/2022] Open
Abstract
Background: Improvement in acute stroke care requires the identification of variables which may influence care quality. The nature and impact of demographic and stroke-related variables on care quality provided by allied health (AH) professionals is unknown. Aims: Our research explores the association of age and gender on an index of acute stroke care quality provided by AH professionals. Methods: A retrospective clinical audit of 300 acute stroke patients extracted data on AH care, patients’ age and gender. AH care quality was determined by the summed compliance with 20 predetermined process indicators. Our analysis explored relationships between this index of quality, age, and gender. Age was considered in different ways (as a continuous variable, and in different categories). It was correlated with care quality, using gender-specific linear and logistic regression models. Gender was then considered as a confounder in an overall model. Results: No significant association was found for any treatment of age and the index of AH care quality. There were no differences in gender-specific models, and gender did not significantly adjust the age association with care quality. Conclusion: Age and gender were not predictors of the quality of care provided to acute stroke patients by AH professionals.
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Affiliation(s)
- Julie A Luker
- International Centre for Allied Health Evidence, University of South Australia Adelaide, South Australia, Australia
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Luker JA, Wall K, Bernhardt J, Edwards I, Grimmer-Somers KA. Patients' age as a determinant of care received following acute stroke: a systematic review. BMC Health Serv Res 2011; 11:161. [PMID: 21729329 PMCID: PMC3150246 DOI: 10.1186/1472-6963-11-161] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2011] [Accepted: 07/06/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Evidence-based care should improve acute stroke outcomes with the same magnitude of effect for stroke patients of all ages. However, there is evidence to suggest that, in some instances, older stroke patients may receive poorer quality care than younger patients.Our aim was to systematically review evidence of the quality of care provided to patients with acute stroke related to their age. Quality of care was determined by compliance with recommended care processes. METHODS We systematically searched MEDLINE, CINAHL, ISI Web of Knowledge, Ageline and the Cochrane Library databases to identify publications (1995-2009) that reported data on acute stroke care process indicators by patient age. Data extracted included patient demographics and process indicator compliance. Included publications were critically appraised by two independent reviewers using the Critical Appraisal Skills Programme tool, and a comparison was made of the risk of bias according to studies' findings. The evidence base for reported process indicators was determined, and meta-analysis was undertaken for studies with sufficient similarity. RESULTS Nine from 163 potential studies met the inclusion criteria. Of the 56 process indicators reported, eleven indicators were evidence-based. Seven of these indicators (64%) showed significantly poorer care for older patients compared to younger ones, while younger patients received comparatively inferior care for only antihypertensive therapy at discharge. Our findings are limited by the variable methodological quality of included studies. CONCLUSION Patients' age may be a factor in the care they receive after an acute stroke. However, the possible influence of patients' age on clinicians' decision-making must be considered in terms of the many complex issues that surround the provision of optimal care for older patients with acute stroke.
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Affiliation(s)
- Julie A Luker
- International Centre for Allied Health Evidence, University of South Australia, Adelaide, South Australia.
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van Raak A, Groothuis S, van der Aa R, Limburg M, Vos L. Shifting stroke care from the hospital to the nursing home: explaining the outcomes of a Dutch case. J Eval Clin Pract 2010; 16:1203-8. [PMID: 20695954 DOI: 10.1111/j.1365-2753.2009.01295.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Supply chains can contribute to better care for stroke patients and more efficiency. However, such outcomes are hampered when links in the chain are weak. The article aims to further the knowledge about the causes and possible improvements of weak links thereby using theory about rules for action and routines (action patterns). METHOD We executed a single case study of a chain of service delivery to stroke patients by a university hospital and a nursing home in the city of Maastricht, the Netherlands. Methods included document study, interviews, observations, process mapping, use of data matrices and performance of t-tests. RESULTS In the case, the care delivery process in the chain was redesigned to improve the flow of patients and to reduce the length of hospital stay. Length of stay was reduced. However, transfer of patients from the hospital to the nursing home was hampered. At this weak link in the chain, the redesign clashed with the routines of hospital paramedics who did not want to work according to the redesign. CONCLUSIONS The applied theory is useful to understand why a link in a supply chain is weak. Negotiations can be used to strengthen a link.
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Affiliation(s)
- Arno van Raak
- Department of Health Organisation, Policy and Economics (HOPE), School of Public Health and Primary Care: CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.
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Hoeks SE, Scholte Op Reimer WJM, Lingsma HF, van Gestel Y, van Urk H, Bax JJ, Simoons ML, Poldermans D. Process of care partly explains the variation in mortality between hospitals after peripheral vascular surgery. Eur J Vasc Endovasc Surg 2010; 40:147-54. [PMID: 20547077 DOI: 10.1016/j.ejvs.2010.04.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Accepted: 04/21/2010] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The aim of this study is to investigate whether variation in mortality at hospital level reflects differences in quality of care of peripheral vascular surgery patients. DESIGN Observational study. MATERIALS In 11 hospitals in the Netherlands, 711 consecutive vascular surgery patients were enrolled. METHODS Multilevel logistic regression models were used to relate patient characteristics, structure and process of care to mortality at 1 year. The models were constructed by consecutively adding age, sex and Lee index, then remaining risk factors, followed by structural measures for quality of care and finally, selected process of care parameters. RESULTS Total 1-year mortality was 11%, ranging from 6% to 26% in different hospitals. Large differences in patient characteristics and quality indicators were observed between hospitals (e.g., age>70 years: 28-58%; beta-blocker therapy: 39-87%). Adjusted analyses showed that a large part of variation in mortality was explained by age, sex and the Lee index (Akaike's information criterion (AIC)=59, p<0.001). Another substantial part of the variation was explained by process of care (AIC=5, p=0.001). CONCLUSIONS Differences between hospitals exist in patient characteristics, structure of care, process of care and mortality. Even after adjusting for the patient population at risk, a substantial part of the variation in mortality can be explained by differences in process measures of quality of care.
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Affiliation(s)
- S E Hoeks
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
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21
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Scurrah A, Sheppard L, Buttner P. Effects of introducing an allied health assessment pro forma on the management of acute stroke patients. Disabil Rehabil 2009; 31:1293-9. [PMID: 19802929 DOI: 10.1080/09638280802509587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
PURPOSE There is a small body of evidence that supports the use of care pathways and assessment pro formas for the management of acute stroke patients, however, such tools applied specifically to the allied health disciplines are not in widespread use. This study sought to evaluate the effects of introducing an assessment pro forma on the allied health management of acute stroke patients. METHODS The allied health management of 40 consecutive stroke patients admitted after the introduction of the assessment pro forma was compared with that of a historical control group of the same size. The quality of allied health management was assessed by a variety of measures including the quality of documentation, the inclusion of specific recommended assessment components, the use of standardised assessment tools or outcome measures and the use of specific recommended interventions. These outcomes were used to calculate a total score for each of the allied health disciplines and the combined area of upper limb management, which were then used for analysis. RESULTS At baseline, there was no statistically significant difference between the control and intervention groups. After the intervention, total allied health scores increased for all disciplines and for the upper limb management section. These increases were statistically significant for all disciplines (p < 0.001, respectively) except speech therapy (p = 0.139). CONCLUSION This small study demonstrated that the use of an assessment pro forma specifically for the allied health disciplines may improve the management of acute stroke patients in terms of quality of documentation, and the use of specific assessment and treatment processes of care.
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Affiliation(s)
- Alena Scurrah
- Physiotherapy Department, Cairns Base Hospital, Cairns, Queensland, Australia.
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Abstract
Quality indicators are systematically developed statements that can be used to assess the appropriateness of specific healthcare decisions, services and outcomes. In this review, the range and type of indicators that have been developed for children in the UK and USA by prominent governmental agencies and private organisations are highlighted. These indicators are classified in an effort to identify areas of child health that may lack quality measures. The current state of health information technology in both countries is reviewed, since these systems are vital to quality efforts. Finally, several recommendations are proposed to advance the quality indicator development agenda for children. The convergence of quality measurement and indicator development, a growing scientific evidence base and integrated information systems in healthcare may lead to substantial improvements for child health in the 21st century.
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Affiliation(s)
- P L Kavanagh
- Division of General Pediatrics, Boston University School of Medicine/Boston Medical Center, Boston, MA 02118, USA.
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Abilleira S, Gallofré M, Ribera A, Sánchez E, Tresserras R. Quality of In-Hospital Stroke Care According to Evidence-Based Performance Measures. Stroke 2009; 40:1433-8. [DOI: 10.1161/strokeaha.108.530014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Evidence-based standards are used worldwide to determine quality of care. We assessed quality of in-hospital stroke care in all acute-care hospitals in Catalonia by determining adherence to 13 evidence-based performance measures (PMs) of process of care.
Methods—
Data on PMs were collected by retrospective review of medical records of consecutive stroke admissions (January to June, 2005). Compliance with PMs was calculated according to 3 hospital levels determined by their annual stroke case-load (level 1, <150 admissions/yr; level 2, 150 to 350; and level 3, >350). We defined sampling weights that represented each patient’s inverse probability of inclusion in the study sample. Sampling weights were applied to produce estimates of compliance. Factors that predicted good/bad compliance were determined by multivariate weighted logistic regression models. An external monitoring of 10% of cases recruited at each hospital was undertaken, after random selection, to assess quality of data.
Results—
We analyzed data from 1791 stroke cases (17% of all stroke admissions). Global interobserver agreement was 0.7. Eight PMs achieved compliances ≥75%, 4 of which were more than 90%, and the remaining showed adherences ≤62%. Analysis of compliance across hospital levels displayed some significant differences that persisted after multivariate analysis. We observed lower adherences to “early mobilization,” “assessment of rehabilitation needs,” and “prescription of anticoagulants for atrial fibrillation” in females and in the elderly.
Conclusions—
In 2005, in-hospital stroke care in Catalonia was heterogeneous across hospital levels. Rehabilitation-related measures showed poor compliances compared to acute care-related ones, which achieved more satisfactory adherences.
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Affiliation(s)
- Sònia Abilleira
- From the Stroke Programme, General Directorate for Planning and Evaluation, Ministry of Health of the Autonomous Government of Catalonia (S.A., R.T., M.G.); the Catalan Agency for Health Technology Assessment and Research (CAHTA) (S.A., E.S.); the Cardiovascular Epidemiology Unit (A.R.), Hospital Vall d’Hebron, Barcelona; and CIBER Epidemiología y Salud Pública (CIBERESP) (A.R., E.S.), Spain; Facultat de Medicina, Universitat Autonoma de Barcelona (M.G.)
| | - Miquel Gallofré
- From the Stroke Programme, General Directorate for Planning and Evaluation, Ministry of Health of the Autonomous Government of Catalonia (S.A., R.T., M.G.); the Catalan Agency for Health Technology Assessment and Research (CAHTA) (S.A., E.S.); the Cardiovascular Epidemiology Unit (A.R.), Hospital Vall d’Hebron, Barcelona; and CIBER Epidemiología y Salud Pública (CIBERESP) (A.R., E.S.), Spain; Facultat de Medicina, Universitat Autonoma de Barcelona (M.G.)
| | - Aida Ribera
- From the Stroke Programme, General Directorate for Planning and Evaluation, Ministry of Health of the Autonomous Government of Catalonia (S.A., R.T., M.G.); the Catalan Agency for Health Technology Assessment and Research (CAHTA) (S.A., E.S.); the Cardiovascular Epidemiology Unit (A.R.), Hospital Vall d’Hebron, Barcelona; and CIBER Epidemiología y Salud Pública (CIBERESP) (A.R., E.S.), Spain; Facultat de Medicina, Universitat Autonoma de Barcelona (M.G.)
| | - Emília Sánchez
- From the Stroke Programme, General Directorate for Planning and Evaluation, Ministry of Health of the Autonomous Government of Catalonia (S.A., R.T., M.G.); the Catalan Agency for Health Technology Assessment and Research (CAHTA) (S.A., E.S.); the Cardiovascular Epidemiology Unit (A.R.), Hospital Vall d’Hebron, Barcelona; and CIBER Epidemiología y Salud Pública (CIBERESP) (A.R., E.S.), Spain; Facultat de Medicina, Universitat Autonoma de Barcelona (M.G.)
| | - Ricard Tresserras
- From the Stroke Programme, General Directorate for Planning and Evaluation, Ministry of Health of the Autonomous Government of Catalonia (S.A., R.T., M.G.); the Catalan Agency for Health Technology Assessment and Research (CAHTA) (S.A., E.S.); the Cardiovascular Epidemiology Unit (A.R.), Hospital Vall d’Hebron, Barcelona; and CIBER Epidemiología y Salud Pública (CIBERESP) (A.R., E.S.), Spain; Facultat de Medicina, Universitat Autonoma de Barcelona (M.G.)
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Abstract
In the era of evidence-based medicine, clinical practice guidelines (CPGs) have become an integral part of many aspects of medical practice. Because practicing neurosurgeons rarely have the time or, in some cases, the methodological expertise, to assess and assimilate the totality of primary research, CPGs can in theory provide a vehicle through which neurosurgeons could more efficiently integrate the most current evidence into patient management. Clinical practice guidelines have been met with some skepticism, however, particularly within the neurosurgical community. Some have expressed concerns that the promise of CPGs has not been matched by the reality. Others who oppose CPGs fear that they hinder the art of medicine, and limit physician and patient autonomy. The purpose of this paper is to provide the practicing neurosurgeon with an up-to-date review of CPGs. The authors discuss some of the complexities and recent advancements in CPG development, appraisal, and publication. An overview of the various systems for grading medical evidence and issuing CPG recommendations, each of which has its advantages and disadvantages, is included, and the current knowledge on the impact of CPGs in 2 important realms, patient care and medicolegal issues, is discussed. The purpose of this review is to provide a balanced, current synopsis of what CPGs are, how they are developed, and what they can and cannot do. The authors hope that this will allow neurosurgeons to make more informed decisions about the many CPGs that will inevitably become an essential component of medical practice in the years to come.
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Affiliation(s)
- Shobhan Vachhrajani
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
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Hankey GJ. Costs and health care system issues. HANDBOOK OF CLINICAL NEUROLOGY 2009; 92:373-388. [PMID: 18790285 DOI: 10.1016/s0072-9752(08)01919-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Graeme J Hankey
- Stroke Unit, Department of Neurology, Royal Perth Hospital and School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.
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Observation of Meaningful Activities: A Case Study of a Personalized Intervention on Poststroke Functional State. J Neurol Phys Ther 2008; 32:97-102. [DOI: 10.1097/npt.0b013e31817323dc] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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What is the empirical evidence that hospitals with higher-risk adjusted mortality rates provide poorer quality care? A systematic review of the literature. BMC Health Serv Res 2007; 7:91. [PMID: 17584919 PMCID: PMC1924858 DOI: 10.1186/1472-6963-7-91] [Citation(s) in RCA: 90] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2006] [Accepted: 06/20/2007] [Indexed: 11/24/2022] Open
Abstract
Background Despite increasing interest and publication of risk-adjusted hospital mortality rates, the relationship with underlying quality of care remains unclear. We undertook a systematic review to ascertain the extent to which variations in risk-adjusted mortality rates were associated with differences in quality of care. Methods We identified studies in which risk-adjusted mortality and quality of care had been reported in more than one hospital. We adopted an iterative search strategy using three databases – Medline, HealthSTAR and CINAHL from 1966, 1975 and 1982 respectively. We identified potentially relevant studies on the basis of the title or abstract. We obtained these papers and included those which met our inclusion criteria. Results From an initial yield of 6,456 papers, 36 studies met the inclusion criteria. Several of these studies considered more than one process-versus-risk-adjusted mortality relationship. In total we found 51 such relationships in a widen range of clinical conditions using a variety of methods. A positive correlation between better quality of care and risk-adjusted mortality was found in under half the relationships (26/51 51%) but the remainder showed no correlation (16/51 31%) or a paradoxical correlation (9/51 18%). Conclusion The general notion that hospitals with higher risk-adjusted mortality have poorer quality of care is neither consistent nor reliable.
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Abstract
BACKGROUND Our previous work identified deficiencies in stroke care practices at regional hospitals in comparison to standards suggested by published stroke care guidelines. These deficiencies might be improved by the implementation of clinical pathways. The aim of this study was to assess changes in acute stroke care practices following the implementation of stroke care pathways at four regional Queensland hospitals. METHODS The medical records of two cohorts of 120 patients with a discharge diagnosis of stroke or transient ischaemic attack were retrospectively audited before and after implementation of stroke care pathways to identify differences in the use of acute interventions, investigations and secondary prevention strategies. RESULTS Following pathway implementation there were clinically important, but not statistically significant, increases in the rates of swallow assessment, allied health assessment (significant for occupational therapy, P = 0.04) and use of deep vein thrombosis prevention strategies (also significant, P = 0.006). Fewer patients were discharged on no anti-thrombotic therapy (statistically significant in the subgroup of patients with atrial fibrillation, P = 0.02). Only 37% of the patients audited were actually enrolled on the pathway. Among this subgroup there were significant increases in the rates of swallow assessment (first 24 h, P = 0.01; any time during admission, P = 0.0001), allied health assessments (all P < 0.05), estimation of blood glucose level (P = 0.0015) and the use of deep vein thrombosis prevention strategies (P = 0.0003). CONCLUSION Stroke care pathways appear to improve the process of care. Whether this influences outcomes such as mortality, functional and neurological recovery, the incidence of complications, length of stay or the cost of care was beyond the scope of this study and will require further examination.
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Affiliation(s)
- S J Read
- Department of Neurology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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Taylor WJ, Wong A, Siegert RJ, McNaughton HK. Effectiveness of a clinical pathway for acute stroke care in a district general hospital: an audit. BMC Health Serv Res 2006; 6:16. [PMID: 16504101 PMCID: PMC1403773 DOI: 10.1186/1472-6963-6-16] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2005] [Accepted: 02/23/2006] [Indexed: 11/24/2022] Open
Abstract
Background Organised stroke care saves lives and reduces disability. A clinical pathway might be a form of organised stroke care, but the evidence for the effectiveness of this model of care is limited. Methods This study was a retrospective audit study of consecutive stroke admissions in the setting of an acute general medical unit in a district general hospital. The case-notes of patients admitted with stroke for a 6-month period before and after introduction of the pathway, were reviewed to determine data on length of stay, outcome, functional status, (Barthel Index, BI and Modified Rankin Scale, MRS), Oxfordshire Community Stroke Project (OCSP) sub-type, use of investigations, specific management issues and secondary prevention strategies. Logistic regression was used to adjust for differences in case-mix. Results N = 77 (prior to the pathway) and 76 (following the pathway). The median (interquartile range, IQR) age was 78 years (67.75–84.25), 88% were European NZ and 37% were male. The median (IQR) BI at admission for the pre-pathway group was less than the post-pathway group: 6 (0–13.5) vs. 10 (4–15.5), p = 0.018 but other baseline variables were statistically similar. There were no significant differences between any of the outcome or process of care variables, except that echocardiograms were done less frequently after the pathway was introduced. A good outcome (MRS<4) was obtained in 66.2% prior to the pathway and 67.1% after the pathway. In-hospital mortality was 20.8% and 23.1%. However, using logistic regression to adjust for the differences in admission BI, it appeared that admission after the pathway was introduced had a significant negative effect on the probability of good outcome (OR 0.29, 95%CI 0.09-0.99). Conclusion A clinical pathway for acute stroke management appeared to have no benefit for the outcome or processes of care and may even have been associated with worse outcomes. These data support the conclusions of a recent Cochrane review.
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Affiliation(s)
- William J Taylor
- Rehabilitation Teaching & Research Unit, Wellington School of Medicine & Health Sciences, University of Otago, PO Box 7343, Wellington, New Zealand
| | - Annie Wong
- Rehabilitation Teaching & Research Unit, Wellington School of Medicine & Health Sciences, University of Otago, PO Box 7343, Wellington, New Zealand
| | - Richard J Siegert
- Rehabilitation Teaching & Research Unit, Wellington School of Medicine & Health Sciences, University of Otago, PO Box 7343, Wellington, New Zealand
| | - Harry K McNaughton
- Medical Research Institute of New Zealand, PO Box 10055, Wellington, New Zealand
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McNaughton H, DeJong G, Smout RJ, Melvin JL, Brandstater M. A Comparison of Stroke Rehabilitation Practice and Outcomes Between New Zealand and United States Facilities. Arch Phys Med Rehabil 2005; 86:S115-S120. [PMID: 16373146 DOI: 10.1016/j.apmr.2005.08.115] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2005] [Revised: 07/11/2005] [Accepted: 08/02/2005] [Indexed: 11/26/2022]
Abstract
UNLABELLED McNaughton H, DeJong G, Smout RJ, Melvin JL, Brandstater M. A comparison of stroke rehabilitation practice and outcomes between New Zealand and United States facilities. OBJECTIVE To compare stroke rehabilitation practice and outcomes between New Zealand (NZ) and the United States. DESIGN Prospective observational cohort study. SETTING Seven inpatient rehabilitation facilities (IRFs) in the United States and NZ. PARTICIPANTS Consecutive convenience sample of 1161 patients in 6 U.S. IRFs and 130 in 1 NZ IRF (age, >18 y) after acute stroke. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Change in FIM score and discharge destination. RESULTS NZ participants were older than U.S. participants (mean: 74.1 y vs 66.0 y, respectively; P<.001). Measures of initial stroke severity were higher for U.S. participants. Mean rehabilitation length of stay (LOS) was shorter for U.S. participants (18.6d vs 30.0 d, P<.001), but physical and occupational therapy time per patient was considerably higher despite the shorter LOS. U.S. therapists were involved in more active therapies for more of the time. Outcomes were better for U.S. participants, with fewer discharged to institutional care (13.2% vs 21.5%, P=.006) and larger changes in FIM scores. CONCLUSIONS U.S. participants with acute stroke who were selected for rehabilitation had better outcomes than NZ participants, despite shorter stays in the rehabilitation facility. U.S. participants had more intensive input from physiotherapists and occupational therapists, which may explain some of the larger increases in FIM scores. This suggests that further studies with tighter controls on case mix may add additional information on the effects of therapy intensity on patients with stroke.
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Affiliation(s)
- Harry McNaughton
- Stroke/Rehabilitation Research, Medical Research Institute of New Zealand, Wellington, New Zealand.
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Mohammed MA, Mant J, Bentham L, Stevens A, Hussain S. Process of care and mortality of stroke patients with and without a do not resuscitate order in the West Midlands, UK. Int J Qual Health Care 2005; 18:102-6. [PMID: 16214881 DOI: 10.1093/intqhc/mzi081] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE . To compare the process of care of stroke patients with and without a do not resuscitate (DNR) order. DESIGN Retrospective case note review with prospective follow up of mortality. SETTING Seven acute hospitals, with stroke units, in the West Midlands, UK. PARTICIPANTS A random sample of patients (n = 702) admitted to hospital with acute stroke over a twelve month period. MAIN OUTCOME MEASURES Case mix and process of care measures derived from the intercollegiate stroke audit package. Thirty day and one year mortality. RESULTS About one-third (34%, 238/702) of stroke patients had DNR orders. The thirty-day mortality for DNR patients was 67% (160/238) versus 10% (46/449) for patients without DNR orders. DNR patients had significantly worse case-mix profile than non-DNR patients - median age 81 y vs 75y; fully conscious 36% vs 79%, able to walk 1% vs 21% and no loss of power in either arm 5% vs 24% (all p < 0.0001). DNR patients were more likely to be assessed early by a speech and language therapist (77% vs 59%, p < 0.001), but less likely to receive the majority of their care in a stroke/rehabilitation unit (20% vs 57%, p < 0.0001), or be cared for on a stroke unit or by a stroke team (42% vs 70%, p <0.0001), or had a description of the site of the cerebral lesion (31% vs 38%, p = 0.05) or be given aspirin (30% vs 42%, p = 0.007). CONCLUSIONS Stroke patients with a DNR order are not receiving optimum care in that they are not being cared for on stroke units or by specialist teams. This may reflect the inadequate provision of specialist stroke services in the UK.
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Hasegawa Y, Yoneda Y, Okuda S, Hamada R, Toyota A, Gotoh J, Watanabe M, Okada Y, Ikeda K, Ibayashi S. The effect of weekends and holidays on stroke outcome in acute stroke units. Cerebrovasc Dis 2005; 20:325-31. [PMID: 16131801 DOI: 10.1159/000087932] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2004] [Accepted: 06/20/2005] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND AND PURPOSE In almost all acute stroke units in Japan, staffing level is lower on weekends and holidays and rehabilitative services are provided only on weekdays. We sought to investigate the effects of low-volume care early after stroke resulting from weekends and holidays on the outcome of stroke. METHODS Patients with completed stroke within 72 h of onset were prospectively registered by 10 acute stroke units in Japan. Main outcome measures were favorable outcomes as indicated by a score of 0-1 on the modified Rankin scale (mRS01) on their 21st hospital day and at discharge and case fatality during the hospital stay. Cox proportional hazardsmodels were used to identify the effects of weekday admission and a weekday ratio (a number of weekdays / total length of hospital stay, or 21 days if hospitalization was longer than 21 days) on the main outcome measures. RESULTS In a total of 1,134 patients, Cox proportional hazards regression analyses demonstrated that the weekday admission was significantly associated with mRS01 at discharge (hazard ratio, HR: 1.385, 95% CI: 1.087-1.764) and case fatality (HR: 0.477, 95% CI: 0.285-0.798). In 858 patients with rehabilitative therapy, the weekday ratio was significantly associated with mRS01 at discharge (p = 0.014). Compared with the lowest tertile of weekday ratio (<66.6%), the highest tertile (>71.4%) was significantly positively associated with mRS01 at discharge (HR: 1.524, 95% CI: 1.053-2.206; p < 0.026). CONCLUSIONS Weekday admission was an independent negative predictor of case fatality and a positive predictor of favorable outcome (mRS01) at discharge from acute stroke units. In patients with rehabilitative therapy, a reduction in the weekday ratio was also associated with unfavorable outcome, probably due to a reduction in multidisciplinary care.
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Affiliation(s)
- Yasuhiro Hasegawa
- Cerebrovascular Division, Department of Medicine, National Cardiovascular Center, Osaka, Japan.
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Abstract
BACKGROUND Stroke care pathways have the potential to promote organised and efficient patient care that is based on best evidence and guidelines, but evidence to support their use is unclear. OBJECTIVES We aimed to assess the effects of care pathways, compared with standard medical care, among patients with acute stroke who had been admitted to hospital. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched in June 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (1975 to June 2003), EMBASE (1980 to June 2003), CINAHL (1982 to June 2003), ISI Proceedings: Science & Technology (1990 to November 2003), and HealthSTAR (1994 to May 2001). We also handsearched the Journal of Integrated Care Pathways (2001 to 2003), formerly Journal of Managed Care (1997 to 1998) and Journal of Integrated Care (1998 to 2001). Reference lists of articles were searched. SELECTION CRITERIA We considered randomised controlled trials and non-randomised studies that compared care pathway care with standard medical care. DATA COLLECTION AND ANALYSIS One reviewer selected studies for inclusion and the other independently checked the decisions. Two reviewers independently assessed the methodological quality of the studies. One reviewer extracted the data and the other checked the extracted data. MAIN RESULTS Three randomised controlled trials (340 patients) and 12 non-randomised studies (4081 patients) were included. There was significant statistical heterogeneity in the analysis of many of the outcomes. We found no significant difference between care pathway and control groups in terms of death or discharge destination. Patients managed with a care pathway were: (a) more dependent at discharge (P = 0.04); (b) less likely to suffer a urinary tract infection (Odds Ratio (OR) 0.51, 95% Confidence Interval (CI) 0.34 to 0.79); (c) less likely to be readmitted (OR 0.11, 95% CI 0.03 to 0.39); and (d) more likely to have neuroimaging (OR 2.42, 95% CI 1.12 to 5.25). Evidence from randomised trials suggested that patient satisfaction and quality of life were significantly lower in the care pathway group (P = 0.02 and P < 0.005 respectively). REVIEWERS' CONCLUSIONS Use of stroke care pathways may be associated with positive and negative effects. Since most of the results have been derived from non-randomised studies, they are likely to be influenced by potential biases and confounding factors. There is currently insufficient supporting evidence to justify the routine implementation of care pathways for acute stroke management or stroke rehabilitation.
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Affiliation(s)
- J Kwan
- University Department of Geriatric Medicine, University of Southampton, Level E (807), Southampton General Hospital, Tremona Road, Southampton, HANTS, UK, SO16 6YD.
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Abstract
BACKGROUND Stroke care pathways have the potential to promote organised and efficient patient care that is based on best evidence and guidelines, but evidence to support their use is unclear. OBJECTIVES We aimed to assess the effects of care pathways, compared with standard medical care, among patients with acute stroke who had been admitted to hospital. SEARCH STRATEGY We searched the Cochrane Stroke Group Trials Register (last searched in June 2003), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 2, 2003), MEDLINE (1975 to June 2003), EMBASE (1980 to June 2003), CINAHL (1982 to June 2003), ISI Proceedings: Science & Technology (1990 to November 2003), and HealthSTAR (1994 to May 2001). We also handsearched the Journal of Integrated Care Pathways (2001 to 2003), formerly Journal of Managed Care (1997 to 1998) and Journal of Integrated Care (1998 to 2001). Reference lists of articles were searched. SELECTION CRITERIA We considered randomised controlled trials and non-randomised studies that compared care pathway care with standard medical care. DATA COLLECTION AND ANALYSIS One reviewer selected studies for inclusion and the other independently checked the decisions. Two reviewers independently assessed the methodological quality of the studies. One reviewer extracted the data and the other checked the extracted data. MAIN RESULTS Three randomised controlled trials (340 patients) and 12 non-randomised studies (4081 patients) were included. There was significant statistical heterogeneity in the analysis of many of the outcomes. We found no significant difference between care pathway and control groups in terms of death or discharge destination. Patients managed with a care pathway were: (a) more dependent at discharge (P = 0.04); (b) less likely to suffer a urinary tract infection (Odds Ratio (OR) 0.51, 95% Confidence Interval (CI) 0.34 to 0.79); (c) less likely to be readmitted (OR 0.11, 95% CI 0.03 to 0.39); and (d) more likely to have neuroimaging (OR 2.42, 95% CI 1.12 to 5.25). Evidence from randomised trials suggested that patient satisfaction and quality of life were significantly lower in the care pathway group (P = 0.02 and P < 0.005 respectively). REVIEWERS' CONCLUSIONS Use of stroke care pathways may be associated with positive and negative effects. Since most of the results have been derived from non-randomised studies, they are likely to be influenced by potential biases and confounding factors. There is currently insufficient supporting evidence to justify the routine implementation of care pathways for acute stroke management or stroke rehabilitation.
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Affiliation(s)
- J Kwan
- University Department of Geriatric Medicine, University of Southampton, Level E (807), Southampton General Hospital, Tremona Road, Southampton, HANTS, UK, SO16 6YD.
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Kapral MK, Laupacis A, Phillips SJ, Silver FL, Hill MD, Fang J, Richards J, Tu JV. Stroke Care Delivery in Institutions Participating in the Registry of the Canadian Stroke Network. Stroke 2004; 35:1756-62. [PMID: 15143293 DOI: 10.1161/01.str.0000130423.50191.9f] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Guidelines and performance indicators have been established for acute stroke care. However, little is known about the process of stroke care delivery in Canada.
Methods—
The Registry of the Canadian Stroke Network (RCSN) captured detailed clinical data on patients with stroke and transient ischemic attack seen at 21 acute care institutions across Canada. Data from phase 1 of the RCSN (June 2001 to February 2002) were used to determine the use of evidence-based acute stroke care interventions in participating institutions.
Results—
Overall, 4439 patients were seen during the study time frame and 1701 (38%) consented to full data collection. Thirty-one percent received care on a stroke unit or from a mobile stroke team. Among patients with ischemic stroke, 7% received thrombolysis, 80% underwent carotid imaging, 89% received antithrombotic agents, and 54% of those with atrial fibrillation received warfarin. There were significant intersite variations in the delivery of all of these interventions except for the use of antithrombotic agents, and these persisted after adjustment for age, sex, stroke type, and other comorbid conditions.
Conclusions—
Patients in institutions participating in the RCSN received high-quality stroke care based on a number of performance measures. However, gaps exist in the provision of other elements of stroke care, particularly organized inpatient stroke care and warfarin for atrial fibrillation. Future research should explore explanations for these findings and focus on solutions to deficiencies in care.
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Affiliation(s)
- Moira K Kapral
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Lilford R, Mohammed MA, Spiegelhalter D, Thomson R. Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma. Lancet 2004; 363:1147-54. [PMID: 15064036 DOI: 10.1016/s0140-6736(04)15901-1] [Citation(s) in RCA: 279] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The history of monitoring the outcomes of health care by external agencies can be traced to ancient times. However, the danger, now as then, is that in the search for improvement, comparative measures of mortality and morbidity are often overinterpreted, resulting in judgments about the underlying quality of care. Such judgments can translate into performance management strategies in the form of capricious sanctions (such as star ratings) and unjustified rewards (such as special freedoms or financial allocations). The resulting risk of stigmatising an entire institution injects huge tensions into health-care organisations and can divert attention from genuine improvement towards superficial improvement or even gaming behaviour (ie, manipulating the system). These dangers apply particularly to measures of outcome and throughput. We argue that comparative outcome data (league tables) should not be used by external agents to make judgments about quality of hospital care. Although they might provide a reasonable measure of quality in some high-risk surgical situations, they have little validity in acute medical settings. Their use to support a system of reward and punishment is unfair and, unsurprisingly, often resisted by clinicians and managers. We argue further that although outcome data are useful for research and monitoring trends within an organisation, those who wish to improve care for patients and not penalise doctors and managers, should concentrate on direct measurement of adherence to clinical and managerial standards.
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Affiliation(s)
- Richard Lilford
- Department of Public Health and Epidemiology, University of Birmingham, UK.
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Affiliation(s)
- Anthony G Rudd
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, UK
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Likosky DS, Likosky WH, Cress TL. Re: Relationship between process and outcome in stroke care. Stroke 2003; 34:e158. [PMID: 12920265 DOI: 10.1161/01.str.0000089492.22879.8e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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