Quality of Acute Care and Long-Term Quality of Life and Survival

Abstract

Stroke is a leading cause of death and adult disability, worldwide. Variability in the care provided to patients admitted to hospital with acute stroke can affect their recovery and is inefficient.1,2 Most studies of the outcomes after hospital care have focused on survival, discharge destination, or disability in the short term. Research on the quality of hospital Background and Purpose-Uncertainty exists over whether quality improvement strategies translate into better healthrelated quality of life (HRQoL) and survival after acute stroke. We aimed to determine the association of best practice recommended interventions and outcomes after stroke. Methods-Data are from the Australian Stroke Clinical Registry during 2010 to 2014. Multivariable regression was used to determine associations between 3 interventions: received acute stroke unit (ASU) care and in various combinations with prescribed antihypertensive medication at discharge, provision of a discharge care plan, and outcomes of survival and HRQoL (EuroQoL 5-dimensional questionnaire visual analogue scale) at 180 days, by stroke type. An assessment was also made of outcomes related to the number of processes patients received. Results-There were 17 585 stroke admissions (median age 77 years, 47% female; 81% managed in ASUs; 80% ischemic stroke) from 42 hospitals (77% metropolitan) assessed. Cumulative benefits on outcomes related to the number of care processes received by patients. ASU care was associated with a reduced likelihood of death (hazard ratio, 0.49; 95% confidence interval, 0.43-0.56) and better HRQoL (coefficient, 21.34; 95% confidence interval, 15.50-27.18) within 180 days. For those discharged from hospital, receiving ASU+antihypertensive medication provided greater 180-day survival (hazard ratio, 0.45; 95% confidence interval, 0.38-0.52) compared with ASU care alone (hazard ratio, 0.64; 95% confidence interval, 0.54-0.76). HRQoL gains were greatest for patients with intracerebral hemorrhage who received care bundles involving discharge processes (range of increase, 11%-19%). We aimed to determine the relationship between receiving combinations of 3 recommended processes of acute care in hospital (referred herein as quality indicators) and patient outcomes ≤180 days after the onset of stroke, assessing the differences by stroke type. Conclusions-Patients MethodsThe data were from 42 hospitals participating in the Australian Stroke Clinical Registry (AuSCR) between 2010 and 2014. Staff from participating hospitals enter the data prospectively using the online system. Information includes patient characteristics, quality indicators, and health outcome measures.9,10 Longer-term patient outcomes are obtained centrally by AuSCR staff using survey methods (eg, for HRQoL) or annual data linkage to national death registrations.Eligible patients were aged ≥18 years with a diagnosis of ischemic stroke, intracerebral hemorrhage (ICH), or stroke of undetermined cause recorded by clinicians in the AuSCR database. For this study, the preference was to use ...

Factors Associated with Stroke Misdiagnosis in the Emergency Department: A Retrospective Case-Control Study

“…Even if our misdiagnosed patients did not qualify for acute intervention, unwarranted variations in clinical care [22], for example, admission to a non-neurological ward rather than the stroke unit and delayed commencement of secondary stroke prevention therapies may have contributed to the worse outcome seen in patients admitted under non-neurology services [6].…”

“…Misdiagnosis of acute stroke may result in worse patient functional outcomes due to failure to implement acute stroke interventions as well as standard processes of care [6]. Studies have reported that 2-26% of acute stroke presentations are misdiagnosed in the emergency department (ED) [5,[7][8][9][10].…”

Improving the quality of care for people who had a stroke in a low‐/middle‐income country: A qualitative analysis of health‐care professionals’ perspectives

“…Internationally, experts, consensus statements and stroke care literature have consistently emphasized the need to have a multidisciplinary approach to standardize health care . Participants in the present study also expressed similar need.…”

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

“…Seven studies (17,24,25,32,34,36,38) had consistent findings whereby adherence to a combination of several KPIs ("bundle") was associated with a greater decrease in stroke mortality. A lower risk for poor outcome was also reported when full stroke care bundle was achieved (25,36).…”

“…Second, the increased risk of early case fatality (17) and medical complications (21) that were reported after early CT/MRI brain imaging in two Danish studies, was most likely due to reverse causality; patients who deteriorated during the first hours after hospitalization were more 38 likely to receive an early CT/MRI brain imaging, and also had a greater risk of death or medical complications (21). Third, some of the analyses of data may have been hampered by small sample sizes, and lack of statistical power to show the differential benefit.…”