Hospital Variation in Time to Endovascular Treatment for Ischemic Stroke: What Is the Optimal Target for Improvement?

Background Time to reperfusion in patients with ischemic stroke is strongly associated with functional outcome and may differ between hospitals and between patients within hospitals. Improvement in time to reperfusion can be guided by between‐hospital and within‐hospital comparisons and requires insight in specific targets for improvement. We aimed to quantify the variation in door‐to‐reperfusion time between and within Dutch intervention hospitals and to assess the contribution of different time intervals to this variation. Methods and Results We used data from the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. The door‐to‐reperfusion time was subdivided into time intervals, separately for direct patients (door‐to‐computed tomography, computed tomography‐to‐computed tomography angiography [CTA], CTA‐to‐groin, and groin‐to‐reperfusion times) and for transferred patients (door‐to‐groin and groin‐to‐reperfusion times). We used linear mixed models to distinguish the variation in door‐to‐reperfusion time between hospitals and between patients. The proportional change in variance was used to estimate the amount of variance explained by each time interval. We included 2855 patients of 17 hospitals providing endovascular treatment. Of these patients, 44% arrived directly at an endovascular treatment hospital. The between‐hospital variation in door‐to‐reperfusion time was 9%, and the within‐hospital variation was 91%. The contribution of case‐mix variables on the variation in door‐to‐reperfusion time was marginal (2%–7%). Of the between‐hospital variation, CTA‐to‐groin time explained 83%, whereas groin‐to‐reperfusion time explained 15%. Within‐hospital variation was mostly explained by CTA‐to‐groin time (33%) and groin‐to‐reperfusion time (42%). Similar results were found for transferred patients. Conclusions Door‐to‐reperfusion time varies between, but even more within, hospitals providing endovascular treatment for ischemic stroke. Quality of stroke care improvements should not only be guided by between‐hospital comparisons, but also aim to reduce variation between patients within a hospital, and should specifically focus on CTA‐to‐groin time and groin‐to‐reperfusion time.

A more comprehensive evaluation of quality of care after total hip and knee arthroplasty: combining 4 indicators in an ordered composite outcome

Background and purpose — Most arthroplasty registers give hospital-specific feedback on revision rates after total hip and knee arthroplasties (THA/TKA). However, due to the low number of events per hospital, multiple years of data are required to reliably detect worsening performance, and any single indicator provides only part of the quality of care delivered. Therefore, we developed an ordered composite outcome including revision, readmission, complications, and long length-of-stay (LOS) for a more comprehensive view on quality of care and assessed the ability to reliably differentiate between hospitals in their performance (rankability)with fewer years of data. Methods — All THA and TKA performed between 2017 and 2019 in 20 Dutch hospitals were included. All combinations of the 4 indicators were ranked from best to worst to create the ordinal composite outcome for THA and TKA separately. Between-hospital variation for the composite outcome was compared with individual indicators standardized for case-mix differences, and we calculated the statistical rankability using fixed and random effects models. Results — 22,908 THA and 20,423 TKA were included. Between-hospital variation for the THA and TKA composite outcomes was larger when compared with revision, readmission, and complications, and similar to long LOS. Rankabilities for the composite outcomes were above 80% even with 1 year of data, meaning that largely true hospital differences were detected rather than random variation. Interpretation — The ordinal composite outcome gives a more comprehensive overview of quality of delivered care and can reliably differentiate between hospitals in their performance using 1 year of data, thereby allowing earlier introduction of quality improvement initiatives.

Abstract 9152: Incidence of Cardiac Arrest Among Medicare Beneficiaries

Introduction: Although survival for in-hospital cardiac arrest (IHCA) has improved substantially over the last two decades, survival rates have plateaued in recent years. Our understanding of incidence of IHCA remains limited. We measured incidence of IHCA among Medicare beneficiaries and evaluated hospital variation in incidence of IHCA. Methods: We used an observational cohort study using data from 2014-2017 Get with the Guidelines-Resuscitation (GWTG-R) data linked with Medicare inpatient data summarized by hospital. Hospital incidence of IHCA among Medicare beneficiaries was calculated as the total number of patients 65 years and older with an IHCA divided by the total number of Medicare admissions. Multivariable hierarchical regression models were used to adjust hospital incidence rates for differences in case-mix across study hospitals and evaluate its the association with hospital variables. Results: Among a total of 4.5 million admissions at 170 hospitals, 38,630 patients experienced an IHCA. The median risk-adjusted IHCA incidence was 8.3 per-1000 admissions. Even after adjusting for differences in case-mix index, IHCA incidence varied markedly across hospitals (Figure 1) ranging from 2.1 per-1000 admissions to 24.7 per-1000 admissions (interquartile range: 6.5-11.4; median odds ratio: 1.52; 95% credible interval 1.45-1.59). Among hospital variables, a higher case-mix index, higher nurse staffing and teaching status were associated with a lower hospital incidence of IHCA. Conclusions: Incidence of IHCA varies markedly across hospitals, even after adjustment for differences in patient case-mix. Hospital variables including case-mix severity, nurse staffing and teaching status were significantly associated with incidence rates. Future studies are needed to better understand processes of care at hospitals with exceptionally low IHCA incidence to identify best practices for cardiac arrest prevention.

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.

Hospital Variation in Cancer Treatments and Survival Outcomes of Advanced Melanoma Patients: Nationwide Quality Assurance in The Netherlands

Background: To assure a high quality of care for patients treated in Dutch melanoma centers, hospital variation in treatment patterns and outcomes is evaluated in the Dutch Melanoma Treatment Registry. The aim of this study was to assess center variation in treatments and 2-year survival probabilities of patients diagnosed between 2013 and 2017 in the Netherlands. Methods: We selected patients diagnosed between 2013 and 2017 with unresectable IIIC or stage IV melanoma, registered in the Dutch Melanoma Treatment Registry. Centers’ performance on 2-year survival was evaluated using Empirical Bayes estimates calculated in a random effects model. Treatment patterns of the centers with the lowest and highest estimates for 2-year survival were compared. Results: For patients diagnosed between 2014 and 2015, significant center variation in 2-year survival probabilities was observed even after correcting for case-mix and treatment with new systemic therapies. The different use of new systemic therapies partially explained the observed variation. From 2016 onwards, no significant difference in 2-year survival was observed between centers. Conclusion: Our data suggest that between 2014 and 2015, after correcting for patient case-mix, significant variation in 2-year survival probabilities between Dutch melanoma centers existed. The use of new systemic therapies could partially explain this variation. In 2013 and between 2016 and 2017, no significant variation between centers existed.

Different strategies, equivalent treatment approaches in terms of mortality in four university hospitals: a retrospective multicenter study of gastroschisis in Finland

Purpose Optimal treatment of gastroschisis is not determined. The aim of the present study was to investigate treatment methods of gastroschisis in four university hospitals in Finland. Methods The data of neonates with gastroschisis born between 1993 and 2015 were collected. The primary outcomes were short and long-term mortality and the length of stay (LOS). Statistical analyses consisted of uni- and multivariate models. Results Total of 154 patients were included (range from 31 to 52 in each hospital). There were no statistically significant differences in mortality or LOS between centers. Significant differences were observed between the hospitals in the duration of mechanical ventilation (p = 0.046), time to full enteral nutrition (p = 0.043), delay until full defect closure (p = 0.003), central line sepsis (p = 0.025), abdominal compartment syndrome (p = 0.018), number of abdominal operations during initial hospitalization (p = 0.000) and follow-up (p = 0.000), and ventral hernia at follow-up (p = 0.000). In a Cox multivariate analysis, the treating hospital was not associated with mortality. Conclusion There were no differences in short or long-term mortality between four university hospitals in Finland. However, some inter-hospital variation in postoperative outcomes was present. Level of evidence Level III.