Estimating and Reporting on the Quality of Inpatient Stroke Care by Veterans Health Administration Medical Centers

Abstract

Background Reporting of quality indicators (QIs) in Veterans Health Administration Medical Centers is complicated by estimation error due to small numbers of eligible patients per facility. We applied multilevel modeling and empirical Bayes (EB) estimation in addressing this issue in performance reporting of stroke care quality in the Medical Centers. Methods and Results We studied a retrospective cohort of 3812 veterans admitted to 106 Medical Centers with ischemic stroke during fiscal year 2007. The median number of study patients per facility was 34 (range: 12-105). Inpatient stroke care quality was measured with thirteen evidence-based QIs. Eligible patients could either pass or fail each indicator. Multilevel modeling of a patient’s pass/fail on individual QIs was used to produce facility-level EB estimated QI pass rates and confidence intervals. The EB estimation reduced inter-facility variation in QI rates. Small facilities and those with exceptionally high or low rates were most affected. We recommended 8 of the 13 QIs for performance reporting: dysphagia screening, NIH Stroke Scale documentation, early ambulation, fall risk assessment, pressure ulcer risk assessment, Functional Independence Measure documentation, lipid management, and deep vein thrombosis prophylaxis. These QIs displayed sufficient variation across facilities, had room for improvement, and identified sites with performance that was significantly above or below the population average. The remaining 5 QIs were not recommended because of too few eligible patients or high pass rates with little variation. Conclusions Considerations of statistical uncertainty should inform the choice of QIs and their application to performance reporting.

Care Trajectories of Veterans in the 12 Months After Hospitalization for Acute Ischemic Stroke

“…By understanding the dynamics of health and functional change, care utilization and costs, and the patterns of these outcomes over time, we can identify points of intervention and system changes that can lead potentially to more effective care delivery. In earlier studies of this stroke cohort, we found opportunities for improved care processes during the inpatient stay 9,21 and risk management during the postdischarge period. 22,23 One key intervention point seems to be hospital discharge when the decisions are made about the care setting and access to rehabilitation services.…”

“…Ninety-five percent were living at home before the stroke. Exactly half of the sample had mild strokes (NIHSS, 0-2), 40% moderate strokes (NIHSS, [3][4][5][6][7][8][9], and 10% severe strokes (NIHSS ≥10). Among the 2851 patients with FIM scores, 37% had complete independence (FIM, 6-7), 45% modified dependence (FIM, [3][4][5], and 18% complete dependence (FIM, 0-2) on the Total FIM.…”

“…9 For this analysis, we excluded patients with in-hospital death, or discharge against medical advice, to another inpatient facility, or with comfort care only or hospice. The resulting analytic sample was 3811 patients discharged from 129 VA medical centers.…”

Validation of Stroke Meaningful Use Measures in a National Electronic Health Record System

“…Accurate quality measurement is critical for improving stroke care and outcomes. Stroke care in the VHA is not ideal, 19 and measurement is the first step toward identifying deficiencies and addressing them; however, manual chart measurement can be onerous and time-consuming, leading to delays in recognition of suboptimal care. Accurate, automated eCQMs such as those developed in this study will not only meet Meaningful Use measure requirements, but hopefully will provide early feedback to frontline providers and administrators for institution of quality improvement in stroke.…”

Most Important Outcomes Research Papers on Stroke and Transient Ischemic Attack

“…The following summaries review systems of care for stroke, including quality measurement, 84,85 cost-effectiveness of telestroke centers, 86 and rapid access to endovascular therapy. Conclusion: Despite the positive association between EMS use and reduced time to hospital presentation and rapid evaluation and treatment of stroke, over one-third of stroke patients did not use EMSs.…”