Quality-of-care comparison of stroke: The reliability and robustness of ranking by process or outcome measures

Background and aim Discussion on the most rational types of performance measures for care quality comparisons has received increasing attention. The important consideration is to what extent will the measure detect a genuine difference in the underlying quality. In this study, we aimed to compare the ranking of hospitals on the performance of individual indicators, composite scores (CS, that were calculated by the method of opportunity-based score on patient-level), and in-hospital outcome of acute ischemic stroke across hospitals, and determined the reliability and robustness of the three types of ranking. Methods We analyzed data from 15,090 patients diagnosed with acute ischemic stroke who were treated at 184 large tertiary hospitals from January 2014 to May 2017. We ranked the hospital effects of recombinant tissue plasminogen activator (rt-PA) and CS and independence (modified Rankin Scale ≤2) at discharge based on fixed- and random-effects regression models before and after case-mix adjustment. We assessed the time-robustness of the hospital effects and calculated the rankability by relating the uncertainty within the hospital and the total hospital variation “beyond chance.” Results After case-mix and reliability adjustment, we estimated that 84.03% of the variance in CS between hospitals was due to true quality differences. The uncertainty within hospitals caused a poor (49.51%) rankability in rt-PA and moderate rankability (63.34%) in independence at discharge. The hospital rankings of CS were more robust across years compared with rt-PA and independence. Conclusions Our data indicated that CS is the optimal measure to indicate the quality-of-care variation of acute ischemic stroke between hospitals.

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National Surveillance of Stroke Quality of Care and Outcomes by Applying Post-Stratification Survey Weights on the Get With The Guidelines-Stroke Patient Registry

10.21203/rs.3.rs-104624/v1 ◽

2020 ◽

Author(s):

Boback Ziaeian ◽

Haolin Xu ◽

Roland A. Matsouaka ◽

Ying Xian ◽

Yosef Khan ◽

...

Keyword(s):

Ischemic Stroke ◽

Quality Of Care ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Patient Characteristics ◽

Care Quality ◽

Maximum Weight ◽

Get With The Guidelines ◽

Post Stratification

Abstract Background: The U.S. lacks a stroke surveillance system. This study develops a method to transform an existing registry into a nationally representative database to evaluate acute ischemic stroke care quality.Methods: Two statistical approaches were used to develop post-stratification weights for the Get With The Guidelines-Stroke registry by anchoring population estimates to the National Inpatient Sample. Post-stratification survey weights were estimated using a raking procedure and Bayesian interpolation methods. Weighting methods were adjusted to limit the dispersion of weights and make reasonable epidemiologic estimates of patient characteristics, quality of hospital care, and clinical outcomes. Standardized differences in national estimates were reported between the two post-stratification methods for anchored and non-anchored patient characteristics to evaluate estimation quality. Primary measures evaluated were patient and hospital characteristics, stroke severity, vital and laboratory measures, disposition, and clinical outcomes at discharge. Results: A total of 1,388,296 acute ischemic strokes occurred between 2012 and 2014. Raking and Bayesian estimates of clinical data not recorded in administrative databases were estimated within 5% to 10% of the margins of expected values. Median weights for the raking method were 1.386 and the weights at the 99th percentile were 6.881 with a maximum weight of 30.775. Median Bayesian weights were 1.329 and the 99th percentile weights were 11.201 with a maximum weight of 515.689. Conclusions: Leveraging existing databases with patient registries to develop post-stratification weights is a reliable approach to estimate acute ischemic stroke epidemiology and monitoring for stroke quality of care nationally. These methods may be applied to other diseases or settings to better monitor population health.

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Abstract 122: Quality of Care for Patients With Acute Ischemic Stroke as a Function of Hospital Intravenous Thrombolysis With Recombinant Tissue Plasminogen Activator Capability: Insights From China National Stroke Registry II

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/circoutcomes.10.suppl_3.122 ◽

2017 ◽

Vol 10 (suppl_3) ◽

Author(s):

Zhenzhen Rao ◽

Zixiao Li ◽

Hongqiu Gu ◽

Yilong Wang ◽

Yongjun Wang

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Recombinant Tissue Plasminogen Activator ◽

Stroke Care ◽

Care Quality ◽

Composite Score ◽

Stroke Patients ◽

Stroke Registry

Background: Intravenous Thrombolysis with Recombinant Tissue Plasminogen Activator (rt-PA) availability at Chinese hospitals varies and may affect care quality for acute ischemic stroke patients. Limited research has shown whether there were differences in quality of care at China National Stroke Registry (CNSR II) hospitals based on rt-PA capability. Methods: For acute ischemic stroke patients admitted to CNSR II hospitals between 2012 and 2013, care quality at hospitals with or without Intravenous rt-PA capability was examined by evaluating conformity with performance and quality measures. The primary outcome was guideline-concordant care, defined as compliance with 10 predefined individual guideline-recommended performance metrics and composite score. A composite score was defined as the total number of interventions actually performed among eligible patients divided by the total number of recommended interventions among eligible patients. Propensity score matching was used to balance the baseline characteristics. We used cox model with shared frailty model and logistic regression with generalized estimating equation to compare the relationship between hospitals with rt-PA capability and hospitals without rt-PA on quality measures. Results: This study included 19604 acute ischemic stroke patients admitted to 219 CNSR II hospitals. Before matching, there were 7928 patients admitted to 86 (40.4%) hospitals with rt-PA capability and 11676 patients admitted to 133 (59.6%) hospitals without rt-PA capability. After matching, 7606 pairs of patients in rt-PA-capable hospitals and rt-PA-incapable hospitals were analyzed. Before matching, the composite score of guideline-concordant process of care was higher at hospitals with rt-PA capability than hospitals without rt-PA capability (74% versus 73%, P=0.0126). Hospitals with rt-PA capability were more likely to perform deep vein thrombosis prophylaxis within 48 hours of admission, dysphagia screening, assessment or receiving of rehabilitation, discharge antithrombotic, anticoagulation for atrial fibrillation and medications for lowering low-density lipoprotein (LDL) ≥100mg/dL. But hospitals with rt-PA capability were less likely to perform antithrombotic medication within 48 hours of admission and hypoglycemic therapy at discharge for patients with diabetes. After matching, differences of stroke care quality between hospitals with rt-PA capability and without rt-PA capability still exist after adjusting covariates. Conclusions: The CNSR II hospitals were associated with better performance in some of the hospitals but not all of them. The difference in conformity between rt-PA-capable hospitals and rt-PA-incapable hospitals was modest for performance measures of stroke care. However, more room for improvement still exists in key quality performance measures and further studies should be explored.

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National surveillance of stroke quality of care and outcomes by applying post-stratification survey weights on the Get With The Guidelines-Stroke patient registry

BMC Medical Research Methodology ◽

10.1186/s12874-021-01214-z ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Boback Ziaeian ◽

Haolin Xu ◽

Roland A. Matsouaka ◽

Ying Xian ◽

Yosef Khan ◽

...

Keyword(s):

Ischemic Stroke ◽

Quality Of Care ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Patient Characteristics ◽

Care Quality ◽

Maximum Weight ◽

Get With The Guidelines ◽

Post Stratification

Abstract Background The U.S. lacks a stroke surveillance system. This study develops a method to transform an existing registry into a nationally representative database to evaluate acute ischemic stroke care quality. Methods Two statistical approaches are used to develop post-stratification weights for the Get With The Guidelines-Stroke registry by anchoring population estimates to the National Inpatient Sample. Post-stratification survey weights are estimated using a raking procedure and Bayesian interpolation methods. Weighting methods are adjusted to limit the dispersion of weights and make reasonable epidemiologic estimates of patient characteristics, quality of hospital care, and clinical outcomes. Standardized differences in national estimates are reported between the two post-stratification methods for anchored and non-anchored patient characteristics to evaluate estimation quality. Primary measures evaluated are patient and hospital characteristics, stroke severity, vital and laboratory measures, disposition, and clinical outcomes at discharge. Results A total of 1,388,296 acute ischemic strokes occurred between 2012 and 2014. Raking and Bayesian estimates of clinical data not available in administrative data are estimated within 5 to 10% of margin for expected values. Median weight for the raking method is 1.386 and the weights at the 99th percentile is 6.881 with a maximum weight of 30.775. Median Bayesian weight is 1.329 and the 99th percentile weights is 11.201 with a maximum weight of 515.689. Conclusions Leveraging existing databases with patient registries to develop post-stratification weights is a reliable approach to estimate acute ischemic stroke epidemiology and monitoring for stroke quality of care nationally. These methods may be applied to other diseases or settings to better monitor population health.

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Abstract W P287: Does Comprehensive Stroke Certification Demonstrate a Significant Effect on Volume and Quality of Care?

Stroke ◽

10.1161/str.45.suppl_1.wp287 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Laurie Paletz ◽

Shlee Song ◽

Nili Steiner ◽

Betty Robertson ◽

Nicole Wolber ◽

...

Keyword(s):

Ischemic Stroke ◽

Quality Of Care ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Turnaround Time ◽

Joint Commission ◽

Stroke Patients ◽

Number Of Patients ◽

The Impact

Introduction/Background information: At the onset of acute stroke symptoms, speed, capability, safety and skill are essential-lost minutes can be the difference between full recoveries, poor outcome, or even death. The Joint Commission's Certificate of Distinction for Comprehensive Stroke Centers recognizes centers that make exceptional efforts to foster better outcomes for stroke care. While many hospitals have been surveyed, Cedars Sinai was the 5 th hospital in the nation to receive this certification. Researchable question: Does Comprehensive stroke certification (CSC) demonstrate a significant effect on volume and quality of care? Methods: We assembled a cross-functional, multidisciplinary expert team representing all departments and skill sets involved in treating stroke patients. We carefully screened eligible patients with acute ischemic stroke We assessed the number of patients treated at Cedars-Sinai with IV-T-pa t 6 months before and then 6 months after CSC and the quality of their care including medical treatment and door to needle time. Results: In the 6 months prior to Joint Commissions Stroke Certification we treated 20 of 395acute stroke patients with t-PA with an average CT turnaround time of 31±19minutes and an average Door to needle time (DTNT) of 68±32minutes. In the 6 months since Joint Commission Stroke Certification we have increased the number of acute stroke patients treated by almost double. There were 37 out of 489(P=0.02, Chi Square) patients treated with IV t-PA with an average CT turnaround time of 22±7minutes (p=0.08, t-test, compared to pre-CSC) and an average DTNT of 61± 23minutes (not different than pre-CSC). Conclusion: We conclude that Joint Commission Certification for stroke was associated with an increased rate of treatment with IV rt-PA in acute ischemic stroke patients. We were not able to document an effect on quality of care. Further studies of the impact of CSC certification are warranted.

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Correction to: The Need for Speed: Accelerating Quality of Care in Acute Ischemic Stroke

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.0000000000000052 ◽

2019 ◽

Vol 12 (2) ◽

Keyword(s):

Ischemic Stroke ◽

Quality Of Care ◽

Acute Ischemic Stroke

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Al Ain Hospital in UAE maintains excellent standard of quality of care for acute ischemic stroke

Journal of the Neurological Sciences ◽

10.1016/j.jns.2019.10.546 ◽

2019 ◽

Vol 405 ◽

pp. 64-65

Author(s):

R. Renganathan ◽

M. Sunil ◽

A. Jose ◽

L. Joseph ◽

A. Sabbah ◽

...

Keyword(s):

Ischemic Stroke ◽

Quality Of Care ◽

Acute Ischemic Stroke ◽

Al Ain

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Abstract WMP92: Quality of Care and Outcomes for Acute Ischemic Stroke Patients Admitted During the International Stroke Conference

Stroke ◽

10.1161/str.48.suppl_1.wmp92 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Steven R Messe ◽

Michael T Mullen ◽

Marguerrite Cox ◽

Gregg Fonarow ◽

Eric E Smith ◽

...

Keyword(s):

Ischemic Stroke ◽

Quality Of Care ◽

Acute Ischemic Stroke ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Multivariable Analysis ◽

Stroke Patients ◽

Time Periods ◽

Iv Tpa

Introduction: Patients who present to the hospital during off-hours receive sub-optimal care and experience worse outcomes, often attributed to reduced staffing. It is unknown whether stroke patients receive less guideline-adherent care and experience worse outcomes when medical providers attend scientific meetings. The AHA International Stroke Conference (ISC) is the premier US conference for cerebrovascular disease and is well attended by stroke clinicians. Methods: The national Get With The Guidelines - Stroke (GWTG-Stroke) dataset was analyzed from 2009-2015 to identify acute ischemic stroke (AIS) patients admitted during: 1) the week of ISC, and 2) the 2 weeks before and 2 weeks after ISC. We compared adherence to GWTG-Stroke quality measures and outcomes for AIS patients admitted during these two time periods using univariable and multivariable analysis, including both patient and hospital level variables. Results: Overall, 69,738 AIS patients were included, mean age 72, 52% female, and 29% non-white. There was no difference between the average weekly number of AIS cases admitted during ISC weeks versus non-ISC weeks (1,984 vs 1,997, p= 0.95). Patient and hospital characteristics were also similar between ISC vs. non-ISC time periods. No significant differences were noted in 14 quality of care metrics and 5 clinical outcomes between AIS patients treated during ISC vs. non-ISC weeks (Table). After adjusting for potential confounders, among patients who presented within 2 hours of onset there was no difference in the likelihood of receiving IV tPA within 3 hours (adjusted odds ratio 0.89, 95% confidence interval [CI] 0.77 - 1.03, p=0.13), nor in the likelihood of receiving IV tPA within 60 minutes of arrival (adjusted odds ratio 0.92, 95% CI 0.83 - 1.02, p=0.13). Conclusions: The treatment and outcome of patients who present with AIS to a GWTG-Stroke participating hospital are not degraded during the week of the International Stroke Conference.

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Differences in Acute Ischemic Stroke Quality of Care and Outcomes by Primary Stroke Center Certification Organization

Stroke ◽

10.1161/strokeaha.116.014426 ◽

2017 ◽

Vol 48 (2) ◽

pp. 412-419 ◽

Cited By ~ 25

Author(s):

Shumei Man ◽

Margueritte Cox ◽

Puja Patel ◽

Eric E. Smith ◽

Mathew J. Reeves ◽

...

Keyword(s):

Ischemic Stroke ◽

Quality Of Care ◽

Acute Ischemic Stroke ◽

Primary Stroke Center ◽

Stroke Center

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Abstract 12: National Surveillance of Stroke Quality of Care and Outcomes Using Post-stratification Survey Weights on the Get With the Guidelines-stroke Patient Registry

Circulation Cardiovascular Quality and Outcomes ◽

10.1161/hcq.13.suppl_1.12 ◽

2020 ◽

Vol 13 (Suppl_1) ◽

Author(s):

Boback Ziaeian ◽

Haolin Xu ◽

Roland Matsouaka ◽

Ying Xian ◽

Yosef Khan ◽

...

Keyword(s):

Ischemic Stroke ◽

Quality Of Care ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Stroke Patient ◽

Population Estimates ◽

Maximum Weight ◽

Get With The Guidelines ◽

Post Stratification

Background: The U.S. lacks an appropriate stroke surveillance system. This study developed and validated post-stratification weights for an existing stroke patient registry to represent the entire U.S. population across the nine U.S. Census divisions. Methods: Two statistical approaches were used to develop post-stratification weights for the Get With The Guidelines-Stroke registry by anchoring population estimates to the National Inpatient Sample to model the burden of acute ischemic stroke. Post-stratification survey weights were estimated using a raking procedure and Bayesian interpolation methods. Both strategies for developing weights were compared. Weighting methods were adjusted to limit dispersion of weights and make reasonable national estimates of patient characteristics, quality of hospital care, and clinical outcomes. Standardized differences in national population estimates were reported between the two post-stratification methods. Color treemaps were used to visualize the distribution of post-stratification weights across relevant sub-populations. Primary measures evaluated were patient and hospital characteristics, stroke severity, vital and laboratory measures, disposition, and clinical outcomes at discharge. Results: There were a total of 1,388,296 acute ischemic strokes between 2012 and 2014. Raking and Bayesian estimates of clinical data not recorded in administrative databases were estimated within 5 to 10% of the margins of reference values. Median weights for the raking method were 1.366 and the weights at the 99 th percentile were 6.881 with a maximum weight of 30.775. Median Bayesian weights were 1.329 and the 99 th percentile weights were 11.201 with a maximum weight of 515.689. Conclusions: Leveraging existing databases with patient registries to develop post-stratification weights is a reliable approach to estimate acute ischemic stroke epidemiology and monitoring for stroke quality of care nationally. Post-stratification weighting may be used as a basis for more advanced modeling relevant to understanding the burden of acute ischemic stroke and the quality of care delivered in U.S. hospitals. These methods may be applied to other diseases or settings to better monitor population health.

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