The Right Process Measures Might Reliably Determine the Quality of Stroke Care

A nationwide English study shows that highly organized stroke centers perform better on core process measures and have a correspondingly lower stroke mortality rate.

Healthcare stakeholders increasingly focus on reporting and comparing measures of the quality of care. Ideally, quality measures would involve health outcomes, but these may reflect unmeasured differences in patient characteristics rather than differences in care quality. We can more easily measure compliance with healthcare processes, but this may not always lead to better health outcomes. In particular, the relation between compliance with quality process measures and stroke outcomes is unclear based on existing studies, none of which has been methodologically robust.

To address this uncertainty, investigators prospectively examined compliance with process measures and its association with stroke mortality across centers participating in a nationwide English registry. To reduce confounding by indication, in which patients with a perceived poor prognosis may receive less aggressive care (e.g., a patient on comfort care may not receive a swallowing evaluation), the investigators chose only measures for which 80% of patients were deemed eligible by their providers. A further attempt to reduce confounding involved a statistical method that analyzed hospital-level rather than patient-level quality measures.

The study enrolled approximately 36,000 stroke patients admitted to 106 hospitals. The overall 30-day mortality rate was 11.5%, consistent with recent population-based U.S. data (Stroke 2010; 41:1748). After adjustment for baseline demographic and clinical characteristics, patient-level compliance with at least five of the six chosen process measures (among those eligible for all 6) was associated with significantly lower mortality (odds ratio, 0.74). Similarly, high hospital-level compliance with measures of quality was also associated with lower mortality (OR, 0.62).

CITATION(S):

Bray BD et al. Associations between the organisation of stroke services, process of care, and mortality in England: Prospective cohort study. BMJ 2013 May 10; 346:f2827.