Towards a National System for Monitoring the Quality of Hospital-Based Stroke Services

Abstract

, MB ChB, MRCP(UK); Martin S. Dennis, MB ChB, FRCP; on behalf of the Scottish Stroke Outcomes Study Group Background and Purpose-We sought to evaluate a system for monitoring the quality of hospital-based stroke services that uses routinely collected case fatality data, adjusted for case mix, as well as simple measures of the process of stroke care. Methods-We compared the process of care and case fatality after stroke between 5 Scottish hospitals (A through E) during 1995-1997. We retrospectively identified 2724 patients with acute stroke using routine discharge data and obtained case mix and process of care data from the medical record. We ascertained case fatality by record linkage and adjusted for case mix using a simple, externally validated regression model. Results-Crude case fatality varied by 21 deaths per 100 admissions between the 5 hospitals. After adjustment, case fatality still differed significantly (Pϭ0.047), with 5 to 7 more deaths per 100 admissions at Hospital A than at Hospitals B through E. There were major shortcomings in the specialization and organization of care, the use of CT scanning, and the completeness of documentation at Hospital A compared with the other hospitals. There were smaller, but clinically important, differences in care between Hospitals B through E but no significant differences in adjusted case fatality. Conclusions-Once adjusted for important prognostic variables, routinely collected case fatality data might identify hospitals with major shortcomings in the processes of stroke care. More moderate, but still clinically important, variations in stroke care can only be identified by monitoring the process of care directly.

Stroke Monitoring on a National Level

“…First, the most important predictor of outcome for benchmarking purposes, severity of stroke at onset, 28,29 was not recorded. Training all national physicians to use stroke severity scales, such as the National Institutes of Health Stroke Scale, would be a huge effort and could easily fail.…”

Incidence, comorbidity, case fatality and readmission of hospitalized stroke patients in Canada

“…to enhancing our understanding of the epidemiology of stroke, monitoring and surveillance are crucial for health care planning, audit and resource management (7,8). A substantial proportion of the total resource expenditure on stroke is incurred during the initial period of hospitalization.…”

What is the best imaging strategy for acute stroke?

“…For example, there was a larger proportion of milder strokes in the LSR than in some of the other Scottish hospitals for which comparable data were available 337 although, unfortunately, not in the detail that was required for the present study. There has been a major interest in stroke in the Western General Hospital (where the LSR is based) since the late 1980s, whereas other hospitals in the UK may not have had such highly developed stroke services during that time.…”

“…66,67,336 There was a clear need for the strategies not only to reflect these differences in availability, but also to take account of the wide variety of problems posed by acute stroke patients, and the different case mix in different hospitals serving different populations. 337 However, there was also a need to keep the list of strategies fairly simple. A final problem was to ensure that sufficient data were available to evaluate the expected costs and outcomes associated with each strategy.…”