Development of Quality Indicators of Stroke Centers and Feasibility of Their Measurement Using a Nationwide Insurance Claims Database in Japan ― J-ASPECT Study ―

Development of a set of quality indicators in paediatric and perinatal care in Japan with a modified Delphi method

BACKGROUNDS

Few paediatric and perinatal quality indicators (QIs) have been developed in the Japanese setting, and the quality of care is not assured or validated. The aim of this study was to develop QIs in paediatric and perinatal care in Japan using an administrative database and confirm the feasibility and applicability of the indicators using a single-site practice test.

METHODS

We used a RAND-modified Delphi method that integrates evidence review with expert consensus development. QI candidates were generated from clinical practice guidelines (CPGs) available in English or Japanese and existing QIs in nine selected paediatric or perinatal conditions. Consensus building was based on independent panel ratings. The performance of QIs was retrospectively assessed using data from an administrative database at the National Children's Hospital. Data between April 2018 and March 2019 were used, while data between April 2019 and March 2021 were also used for selected condition, considering the small number of patients. Each QI was calculated as follows: number of times the indicator was met/number of participants×100.

RESULTS

From the literature review conducted between 2010 and 2020, 124 CPGs and 193 existing indicators were identified to generate QI candidates. Through the consensus-building process, 133 QI candidates were assessed and 79 QIs were accepted. The practice test revealed wide variations in the process-level performance of QIs in four categories: patient safety: median 43.9% (IQR 16.7%-85.6%), general paediatrics: median 98.8% (IQR 84.2%-100%), advanced paediatrics: median 94.4% (IQR 46.0%-100%) and advanced obstetrics: median 80.3% (IQR 59.6%-100%).

CONCLUSIONS

We established 79 QIs for paediatric and perinatal care in Japan using an administrative database that can be applied to hospitals nationwide. The practice test confirmed the measurability of the developed QIs. Benchmarking these QIs will be an attractive approach to improving the quality of care.

Registry Studies of Stroke in Japan

Recently, the Cerebrovascular and Cardiovascular Disease Control Act was enacted, for which it was necessary to establish a comprehensive and accurate nationwide database and promote rational and economical stroke countermeasures in Japan, thus serving the public interest. Among the many studies on stroke registries, the Fukuoka Stroke Registry, a regional cohort, provides highly accurate information, and the Japanese Stroke Data Bank, a nationwide cohort, is highly comprehensive. The findings of these studies have contributed to the construction of evidence and the establishment of guidelines for stroke management. In the Nationwide survey of Acute Stroke care capacity for Proper dEsignation of Comprehensive stroke CenTer in Japan, research on improving the quality of medical care to close the gap between guidelines and clinical practice was performed using electronic medical records. This has enabled the recommendation of medical policies in Japan by visualizing medical care. In the era of healthcare big data and the Internet of Things, plenty of healthcare information is automatically recorded electronically and incorporated into databases. Thus, the establishment of stroke registries with the effective utilization of these electronic records can contribute to the development of stroke care.

Association between population changes and the number of endovascular thrombectomies

Background

Randomized controlled trials have demonstrated the efficacy of mechanical thrombectomy (MT) for acute ischemic stroke. However, few studies indicate an association between the number of mechanical thrombectomies and population changes. We aimed to clarify the association between population changes and the number of mechanical thrombectomies for proper allocation of limited medical resources.

Methods

We retrospectively analyzed data from 162 patients who underwent MT for large vessel occlusion at our hospitals and compared the number of mechanical thrombectomies per 100,000 person/year to population changes in five regions covered by our hospitals within 2015-2016 and 2017-2019. We performed a simple linear regression analysis to determine the association between population changes and the number of mechanical thrombectomies.

Results

Overall, the number of mechanical thrombectomies increased from 15.1 to 19. However, a significant decrease was noted in Toya Lake and Sobetsu/Toyoura. Furthermore, there was a significant negative linear correlation between the overall population reduction rate and the number of mechanical thrombectomies and a positive linear correlation between the increased proportion of the population aged >65 years and the number of mechanical thrombectomies.

Conclusion

The number of mechanical thrombectomies may decrease in areas where the overall population reduction rate exceeds 8% or the increased rate of the population aged >65 years is <4%. However, it is necessary to continue establishing a system for MT in areas that have yet to reach these levels.

National trends in the outcomes of subarachnoid haemorrhage and the prognostic influence of stroke centre capability in Japan: retrospective cohort study

OBJECTIVES

To examine the national, 6-year trends in in-hospital clinical outcomes of patients with subarachnoid haemorrhage (SAH) who underwent clipping or coiling and the prognostic influence of temporal trends in the Comprehensive Stroke Center (CSC) capabilities on patient outcomes in Japan.

DESIGN

Retrospective study.

SETTING

Six hundred and thirty-one primary care institutions in Japan.

PARTICIPANTS

Forty-five thousand and eleven patients with SAH who were urgently hospitalised, identified using the J-ASPECT Diagnosis Procedure Combination database.

PRIMARY AND SECONDARY OUTCOME MEASURES

Annual number of patients with SAH who remained untreated, or who received clipping or coiling, in-hospital mortality and poor functional outcomes (modified Rankin Scale: 3-6) at discharge. Each CSC was assessed using a validated scoring system (CSC score: 1-25 points).

RESULTS

In the overall cohort, in-hospital mortality decreased (year for trend, OR (95% CI): 0.97 (0.96 to 0.99)), while the proportion of poor functional outcomes remained unchanged (1.00 (0.98 to 1.02)). The proportion of patients who underwent clipping gradually decreased from 46.6% to 38.5%, while that of those who received coiling and those left untreated gradually increased from 16.9% to 22.6% and 35.4% to 38%, respectively. In-hospital mortality of coiled (0.94 (0.89 to 0.98)) and untreated (0.93 (0.90 to 0.96)) patients decreased, whereas that of clipped patients remained stable. CSC score improvement was associated with increased use of coiling (per 1-point increase, 1.14 (1.08 to 1.20)) but not with short-term patient outcomes regardless of treatment modality.

CONCLUSIONS

The 6-year trends indicated lower in-hospital mortality for patients with SAH (attributable to better outcomes), increased use of coiling and multidisciplinary care for untreated patients. Further increasing CSC capabilities may improve overall outcomes, mainly by increasing the use of coiling. Additional studies are necessary to determine the effect of confounders such as aneurysm complexity on outcomes of clipped patients in the modern endovascular era.

Guideline adherence in speech and language therapy in stroke aftercare. A health insurance claims data analysis

Background

Impairments to comprehension and production of speech (aphasia, dysarthria) and swallowing disorders (dysphagia) are common sequelae of stroke, reducing patients’ quality of life and social participation. Treatment oriented on evidence-based guidelines seems likely to improve outcomes. Currently, little is known about guideline adherence in stroke aftercare for the above-mentioned sequelae. This study aims to analyse guideline adherence in the treatment of aphasia, dysarthria and dysphagia after stroke, based on suitable test parameters, and to determine factors that influence the implementation of recommended therapies.

Methods

Six test parameters were defined, based on systematic study of guidelines for the treatment of speech impairments and swallowing disorders (e.g. comprehensive diagnostics, early initiation and continuity). Guideline adherence in treatment was tested using claims data from four statutory health insurance companies. Multivariate logistic and linear regression analyses were performed in order to test the outcomes.

Results

4,486 stroke patients who were diagnosed with specific disorders or received speech therapy were included in the study. The median age was 78 years; the proportion of women was 55.9%. Within the first year after the stroke, 90.3% of patients were diagnosed with speech impairments and swallowing disorders. Overall, 44.1% of patients received outpatient speech and language therapy aftercare. Women were less frequently diagnosed with specific disorders (OR 0.70 [95%CI:0.55/0.88], p = 0.003) and less frequently received longer therapy sessions (OR 0.64 [95%CI:0.43/0.94], p = 0.022). Older age and longer hospitalization duration increased the likelihood of guideline recommendations being implemented and of earlier initiation of stroke aftercare measures.

Conclusions

Our observations indicate deficits in the implementation of guideline recommendations in stroke aftercare. At the same time, they underscore the need for regular monitoring of implementation measures in stroke aftercare to address group-based disparities in care.

Influence of hospital capabilities and prehospital time on outcomes of thrombectomy for stroke in Japan from 2013 to 2016

To determine whether increasing thrombectomy-capable hospitals with moderate comprehensive stroke center (CSC) capabilities is a valid alternative to centralization of those with high CSC capabilities. This retrospective, nationwide, observational study used data from the J-ASPECT database linked to national emergency medical service (EMS) records, captured during 2013–2016. We compared the influence of mechanical thrombectomy (MT) use, the CSC score, and the total EMS response time on the modified Rankin Scale score at discharge among patients with acute ischemic stroke transported by ambulance, in phases I (2013–2014, 1461 patients) and II (2015–2016, 3259 patients). We used ordinal logistic regression analyses to analyze outcomes. From phase I to II, MTs increased from 2.7 to 5.5%, and full-time endovascular physicians per hospital decreased. The CSC score and EMS response time remained unchanged. In phase I, higher CSC scores were associated with better outcomes (1-point increase, odds ratio [95% confidence interval]: 0.951 [0.915–0.989]) and longer EMS response time was associated with worse outcomes (1-min increase, 1.007 [1.001–1.013]). In phase II, neither influenced the outcomes. During the transitional shortage of thrombectomy-capable hospitals, increasing hospitals with moderate CSC scores may increase nationwide access to MT, improving outcomes.

Measuring Quality of Public Hospitals in Croatia Using a Multi-Criteria Approach

Quality of public hospital services presents one of the most important aspects of public health in general. A significant number of health services are delivered due to public hospitals. Under the World Bank program "Improving Quality and Efficiency of Health Services: Program for Results", the competent bodies in Croatia aimed to identify the top 40% best-performing public acute hospitals in Croatia, based on a clinical audit in the preceding 12 months. This paper presents how this goal was achieved, using a multi-criteria decision-making (MCDM) approach. A MCDM approach was selected due to the multidimensionality and complexity of healthcare performance and service quality. We aimed to develop a methodology for ranking top-performing hospitals at the national level. We chose the composite indicator methodology, combined with the analytic hierarchy process (AHP) as a tool for determining weights for aggregation of individual indicators. The study looked at three clinical entities: acute myocardial infarction, cerebrovascular insult, and antimicrobial prophylaxis in colorectal surgery. Indicators for each entity were evidence-based, following the national guidelines, but limited by availability of data. The clinical audit and databases of competent administrative bodies were used as sources of data. The problem investigated in this paper has a significant impact at the strategic (national) level. Even though the AHP has already been applied in the public health domain, to the best of our knowledge, this is the first application of the AHP in combination with composite indicators for hospital ranking at a national level. The AHP enabled participation of experts from the audited hospitals in the assessment of indicator weights. Results show that composite indicators can be successfully implemented for acute hospital evaluation using the AHP methodology: (1) the AHP supported a flexible structuring of the problem; (2) the resulting complexity of pairwise comparisons was appropriate for the experts (consistency ratios were under 0.1); (3) using the AHP approach enabled a successful aggregation of different opinions into group priorities; (4) the developed methodology was robust and enabled identifying the top 40% ranking best-performing public acute hospitals in Croatia combining 20 criteria within three entities, based on input from 36 clinical experts. The proposed methodology can be useful to other researchers for assessment of healthcare quality at the strategic level.

Quality Improvement in Otolaryngology-Head and Neck Surgery: Developing Registry-Enabled Quality Measures From Guidelines for Cerumen Impaction and Allergic Rhinitis Through a Transparent and Systematic Process

BACKGROUND AND SIGNIFICANCE

Quality measurement can drive improvement in clinical care and allow for easy reporting of quality care by clinicians, but creating quality measures is a time-consuming and costly process. ECRI (formerly Emergency Care Research Institute) has pioneered a process to support systematic translation of clinical practice guidelines into electronic quality measures using a transparent and reproducible pathway. This process could be used to augment or support the development of electronic quality measures of the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) and others as the Centers for Medicare and Medicaid Services transitions from the Merit-Based Incentive Payment System (MIPS) to the MIPS Value Pathways for quality reporting.

METHODS

We used a transparent and reproducible process to create electronic quality measures based on recommendations from 2 AAO-HNSF clinical practice guidelines (cerumen impaction and allergic rhinitis). Steps of this process include source material review, electronic content extraction, logic development, implementation barrier analysis, content encoding and structuring, and measure formalization. Proposed measures then go through the standard publication process for AAO-HNSF measures.

RESULTS

The 2 guidelines contained 29 recommendation statements, of which 7 were translated into electronic quality measures and published. Intermediate products of the guideline conversion process facilitated development and were retained to support review, updating, and transparency. Of the 7 initially published quality measures, 6 were approved as 2018 MIPS measures, and 2 continued to demonstrate a gap in care after a year of data collection.

CONCLUSION

Developing high-quality, registry-enabled measures from guidelines via a rigorous reproducible process is feasible. The streamlined process was effective in producing quality measures for publication in a timely fashion. Efforts to better identify gaps in care and more quickly recognize recommendations that would not translate well into quality measures could further streamline this process.

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

BACKGROUND

In Japan there is no consensus on how to efficiently measure quality indicators (QIs), defined as a standard of care, for acute ischemic stroke (AIS). Using information from a health insurance claims database and electronic medical records, we evaluated the feasibility and validity of measuring QIs for AIS patients who received intravenous recombinant tissue plasminogen activator (IV rt-PA) or endovascular therapy (EVT).

METHODS AND RESULTS

AIS patients receiving rt-PA or EVT between 2013 and 2015 were identified. We selected 17 AIS QI measures for primary stroke centers (PSCs) and 8 for comprehensive stroke centers (CSCs). Defined QIs were calculated for each hospital and then averaged. In total, the data of 8,206 patients (rt-PA 83.7%, EVT 34.9%) from 172 hospitals were obtained. Median National Institute of Health Stroke Scale score at admission was 14, and 37.7% of the patients were functionally independent at discharge. All target QIs were successfully measured with fewer missing values, and the accuracy of preset data was about 90%. Adherence rates were low (<50%) in 5 QI measures among PSCs, including door-to-needle time ≤1 h, and in 1 QI measure among CSCs (door-to-brain and vascular imaging time ≤30 min).

CONCLUSIONS

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