Measuring and improving the quality of stroke care

Seminars in Cerebrovascular Diseases and Stroke Vol. 3 No. 2 2003

Measuring and Improving the Quality of Stroke Care JUDITH

A. H I N C H E Y

Boston, M a s s a c h u s e t t s

ABSTRACT

There is ample evidence that we need to improve the quality of care delivered to patients with stroke. There are wide practice variations in the delivery of thrombolytic therapy, in-patient processes to prevent complications and secondary prevention of stroke measures. This article describes the various ways to understand quality of care, including the overuse, underuse and misuse of medical therapies. It also provides examples of how to measure stroke quality of care. It then reviews one project designed to improve the in-hospital delivery of stroke care through the use of quality indicators. Key words: quality of care, quality improvement, quality indicators, performance measures.

What Is Quality Stroke Care?

care services and products, and have reliable and understandable information on the care they receive.

Optimizing the quality of health care is a goal everyone shares. Good quality health care is health care that is accessible, effective, safe, accountable, and fair. A generally agreed-on definition of quality of care is the one proposed by the Institute of Medicine, which states that quality of care is "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. ''1 One can easily and appropriately apply this definition to the provision of~ care to patients with stroke. The general idea of this definition is that the right services (eg, thrombolytics) are given to right stroke patients (without uncontrolled hypertension) at the right time (within 3 hours) in the right place (stroke centers) by the right personnel (a stroke team). Good quality health care also implies that patients can access timely care, have accurate and understandable information about risks and benefits, are protected from unsafe health

Why Measure Quality of Care? There is a need to improve the way medical care is delivered in the United States. Research has shown that there are wide practice variations in the treatment of patients. 2,3 There is evidence that the variation is not solely attributable to patient demographics, disease prevalence, severity of illness, or the presence of other medical problems. In addition, evidence suggests that practice variation is caused by medical uncertainty, local physician practice patterns, patient preferences, and local supply of resources. An example of a procedure with a large amount of variation is carotid endarterectomy (CEA). 2,4 When looking at rates of CEA for the years 1994 to 1995, 56 US regions (56/306, 18%) had rates more than 25% below the national average whereas 60 regions (60/306, 20%) had rates 30% or more above the national average. According to Wennberg and coworkers, only 22% of the variation in rates was caused by prevalence of disease. We also know there is variation in the number of hospitals that use stroke protocols and in how emergency medical services are organized and trained to respond to stroke. 5 Although this variation by itself does not tell us who is doing the right amount, it does suggest there is room for improvement. The cause of the variation and therefore potential quality of care

From the Department of Neurology, St. Elizabeth's Medical Center, Boston, MA.

Address reprint requests to Judith Hinchey, MD, St. Elizabeth's Medical Center, Departmentof Neurology,736 CambridgeSt., Boston, MA 02135. 9 2003 Elsevier Inc. All rights reserved.

1528-9931/03/0302-0004530.00/0 doi: 10.1053/scds.2003.0020

85

86

Seminarsin Cerebrovascular Diseasesand Stroke Vol. 3 No. 2 June 2003

problems fall into one of three areas that can be measured: underuse, overuse, or misuse.

Underuse Underuse problems occur when there is a failure to provide a service when it would have produced a favorable health outcome. 6 Although warfarin has been identified as the best treatment for stroke prevention in patients at risk with atrial fibrillation (AF), Samsa and coworkers found only 34.7% of eligible patients with AF received warfarin7 Brass and coworkers found that in Medicare recipients with AF and stroke, only 53% were prescribed warfarin on discharge from the hospital and of those not receiving warfarin, 58% were also not taking aspirin. 8 Other examples of underuse include the treatment of hypertension, cholesterol management, and thrombolytic use in stroke patients. For example, in a trial of estrogen for secondary prevention of stroke, 1 month after their stroke, only 44% of hypertensive patients had blood pressures within national guidelines. Three years after their stroke, of those who were hypertensive 1 month after stroke, 55% had blood pressures that again remained in excess of the guideline recommendations. 9 Other secondary prevention strategies, including treatment of hypercholesterolemia and smoking cessation counseling, are also underused. 1~

Overuse Overuse occurs when the potential harm from providing a service exceeds the possible benefit. 6 An example of overuse is CEA. Wong and coworkers studied all of the CEAs performed in Edmonton, Alberta, Canada between April 1994 and September 1995.11 They found that 18% were inappropriate, 49% were of uncertain clinical value, and 33% were appropriate. The 18% of inappropriate endarterectomies likely reflects an overuse quality of care problem. Another example of overuse is the treatment of lone atrial fibrillation with warfarin. In a survey conducted by the American Academy of Neurology, 37-70% of respondents would administer warfarin to a patient less than 75 years of age to treat isolated atrial fibrillation, a strategy that has not been shown to be beneficial. [unpublished data, American Academy of Neurology, quintessentials program.]

Misuse (Avoidable Errors) Misuse occurs when a patient receives an appropriate service but a preventable complication occurs and the patient does not receive the full benefit. 6 The Institute of Medicine focused national attention on this quality of care problem when it published its report on medical errors. 12 They reported that between 44,000 and 98,000

patients die in the hospital each year as the result of medical errors. Examples of misuse include a patient with atrial fibrillation who bleeds because the international normalization ratio (INR) is out of range. Samsa and colleagues have shown that of those treated with warfarin for atrial fibrillation, 50% of the time their INRs were not in the therapeutic range. 7 In addition, patients who do receive thrombolytics are often placed at too great a risk as many are given the therapy despite relative contraindications, t3,14 In a study involving thrombolytic use for ischemic stroke from 16 Connecticut hospitals, patients who had major protocol deviations had a much higher risk of in-hospital mortality (31%) that patients without protocol deviations (13%). 14

Methods to Measure Quality of Care Three types of information exist in which inferences can be made about quality of care: structure, process, and outcome of care. Good structure increases the likelihood of good process, and good process increases the likelihood of a good outcome. 15 Donabedian first proposed this relationship in 1980. Because good outcome is not equivalent to good quality of care and bad outcome is not equivalent to bad quality of care, structural and process measures need to be assessed in addition to outcome measures. For example, a hospital may do everything right and have all the latest technologies, but a patient with a basilar artery occlusion may still die (poor outcome, good structure, and process), yet a patient with a pure sensory lacunar infarction may do well despite poor care (good outcome, poor process, or structure). Therefore, when assessing quality of care, structure, process and outcome measures are complementary and all need to be assessed to get an accurate picture of the quality provided.

Structure Structure applies to the attributes of the setting in which care occurs (staffing, accreditation of a hospital). Physicians do not work in isolation but rather as part of a larger "team" of physicians and nonphysician personnel. There is a growing body of information addressing the necessary infrastructure to provide optimal stroke care. Organized stroke units have been shown to improve patient outcomes compared with traditional medical wards. 16 The brain attack coalition has made recommendations for the development of primary stroke centers that have the ability to rapidly identify and treat stroke patients. 17 The requirements mostly involve structural elements and include an acute stroke team, educated and connected emergency medical services, and neuroimaging capabilities. 17 There are also data to support that

Measuring and Improving the Quality of Stroke Care 9 Hinchey 87 there is a procedure-volume relationship in performing CEAs, suggesting that "high-volume" providers have better patient outcomes than "low-volume" providers. 18

Process Process applies to what is done in giving and receiving care, tests, referrals, procedures, and guideline adherence. 15 These care "processes" are numerous and range from identification and management of risk factors to prevent first-ever or recurrent stroke, to the acute, subacute, and outpatient management of stroke. Specific recommendations for process measure assessment comes from clinical guidelines and have been developed for both the inpatient and rehabilitation setting.19,20 In general, processes that are good measures of quality care should be closely related to an important outcome. For example, controlling hypertension is a good measure of quality because it has been shown to reduce the occurrence of strokes and death. Recommendations that have the strongest process-outcome link include discharging patients with ischemic stroke not due to atrial fibrillation on antiplatelet agents to prevent recurrent stroke and discharging patients with an acute ischemic stroke and atrial fibrillation on anticoagulants unless contraindicated. ~9 However, many things that are done while providing care to patients do not have a solid evidence base (eg, patient education, acute management of blood pressure in ischemic stroke, or timely, accurate communication with patient's primary care physician). Nonetheless, the presence of such events might indicate quality care.

Outcomes Outcomes denote the effects of care on the health status of patients and populations.15 For an outcome to be a valid measure of quality of care, it must be closely related to processes of care that can be modified to affect the outcome. Outcomes can be measured clinically by morbidity, mortality and functional status. Outcomes may also be patient-based, such as satisfaction or healthrelated quality of life. Finally, outcomes may have an economic perspective with measures, such as length of stay, days missed from work, and costs Of treatment/ tests. Most acute stroke clinical trials collect functional outcomes, including the modified Rankin, Barthel Index of activities of daily living, and National Institute of Health Stroke Scale Scores. Other important outcomes would be complication rates, recurrence rates, healthrelated quality of life, patient satisfaction, and costs of services. The American Heart Association has made some recommendations for outcomes assessment. 21 One disadvantage to collecting outcomes data are that most need to be risk adjusted. If the quality improvement office at a hospital wants to compare the functional status

of their patients at 3 months compared with patients at another hospital, they would need to make sure that the stroke patients at the two hospitals were similar. If one hospital admitted all basilar artery occlusion patients and the other admitted only patients with small vessel strokes and transferred out all their large vessel strokes, than the patients' 3-month functional status or outcome would be very different between these two hospitals. This difference is not attributable to the care the patients received but to the severity of the initial illness. An adjustment would need to be made to control for this to compare the outcomes at the two hospitals. The data required to do adequate adjustments is often not in an administrative database but requires auditors to go through charts and abstract data. Chart abstraction is very expensive and this need makes the measurement of outcomes very expensive and much less attractive for local quality improvement efforts. The Center for Medicare Services (formerly, The Health Care Financing Administration) used to compare hospitals by their 30-day stroke mortality rates; however, they stopped doing this because they realized their risk-adjustment method was not good enough to adequately compare hospitals. 22 More research is needed to develop better risk adjustment methods to assess all outcomes in stroke.

W h a t Do You Collect? A word of caution: quality is in the eyes of the beholder. A patient' s perspective of quality may be related to the quality of hospital food or wait times in an office, which is very different than the neurosonologist's view of technical quality required to perform an adequate transcranial Doppler or a managed care organization's view of length of stay targets. In fact, quality of care goals may compete with one another. Therefore, defining the perspective of the quality of care delivered is critical to proper assessment, measurement, and improvement. In general, patients and payers are interested in outcomes (death rates, complications) whereas physicians and hospitals more easily understand process measures and how to fix them.

H o w to Collect the Data? The data sources that exist to draw conclusions about the provision of stroke care are few and limited. The two most commonly used sources to measure quality of care are the medical record and administrative data. 23 The medical record does not contain many dimensions of quality (eg, the physician may not document that they counseled a patient regarding smoking cessation or performed a screening test for poststroke depression) and is

88

Seminarsin CerebrovascularDiseasesand Stroke Vol. 3 No. 2 June 2003 Table 1. Effective Physician Change Strategies24

Most effective Reminders (at point of need/services) Patient-mediated strategies Outreach visits Opinion leaders Multiple interventions Moderately effective Audit and feedback Educational material Least effective Formal continuing medical education conferences or activities

expensive to abstract. Administrative databases contain even less information about quality, particularly for chronic outpatient stroke care. 23 Improving the underlying information infrastructure, such as with the use o f an electronic medical record, would improve our ability to measure quality. Other methods that are being conducted include patient surveys, clinical case vignettes, standardized patients, and prospective data collection. The pros and cons of some of the methods, which include costs, accuracy, quality and quantity of the data, have been reviewed elsewhere7 3

Improving Quality of Care To improve care, a physician or hospital must change their current behavior. Methods to motivate physicians and other healthcare providers to change their behavior and their relative effectiveness are listed in Table 1. 24 Because health care providers learn in different ways and several factors are involved in changing behavior, the most successful techniques to improve quality and change current behavior include using a combination of the methods mentioned in Table 1.24 One of the most important factors in changing behavior is the recognition that behavior needs to change. This can be done through audits of clinical performance, providing feedback to health care providers on their current practices and how it differs from others, or from a benchmark. Providing benchmarks to physicians has been shown to improve care but only by 10-12%. 25 Below I am going to highlight a project that is designed to improve the quality of acute in-hospital stroke care through the use of feedback, benchmarking, and a multifaceted intervention directed at behavior change.

and benchmarking alone. The quality indicators assessed were picked by the sites and are listed in Table 2. The specific aims of this project are as follows: 1. To determine achievable benchmarks of care for four quality of care indicators for hospitalized patients with ischemic stroke. 2. To identify physician, nurse, and organizational factors associated with low and high adherence rates 3. To evaluate the effectiveness of a multifaceted intervention designed to remove specific barriers and therefore improve adherence to quality indicators at each of hospitals. The overall design of the study is a group randomized trial nested within a prospective longitudinal study (Fig 1). Study sites have prospectively collected their adherence rates to four quality indicators over a 6-month period. At the end o f this baseline data collection, achievable benchmarks were developed and provided. Benchmarks define the care the top 10% of patients receive and demonstrates what can be a c h i e v e d Y Sites can then compare their adherence rates with the benchmark adherence rate to see where they need to improve (Fig 2). After baseline data collection, sites were then randomized to either receive a multimodal intervention to improve adherence rates or to continue with adherence rate feedback alone. Intervention sites were helped to understand their site-specific barriers to care, including review of all of their current care plans, pathways, order sets, and to develop a quality improvement plan (QIP) to increase their adherence rates. They were also given literature and grand rounds templates to be used at their

Table 2. Quality Indicators Assessed in SPIN 1. t-PA within 1 hour of arrival: = # pts treated with tPA within 1 hour of arrival #pts treated with tPA 2. Screen for dysphagia prior to being given any food or drink = # pts screened for dysphagia before food or drink # pts exluding those kept NPO 3. DVT prophylasis for those who remain non-ambulatory # pts on SQ/IV heparin, Warfarin, compression stockings by end of hospital day 2 # pts who are non-ambulatory except those with terminal illness or comfort care 4. Warfarin in patients with atrial fibrillation

Stroke Practice Improvement Network The Stroke Practice Improvement Network is a prospective ~ongitudinal study to test an intervention with multiple techniques designed to improve adherence to quality indicators compared with receiving audit, feedback

= # of pts with atrial fibrillation discharged on Warfarin # pts with atrial fibrillation and no contraindications to Warfarin # = number; NPO = nothing by mouth; DVT = deep venous thrombosis.

Measuring and Improving the Quality of Stroke Care * Baseline adherence rates of 4 quality indicators

Multifaceted intervention

Benchmark

- ~

Hinchey 89

Post intervention adherence rates to the 4 quality indicators

Adherence rates alone

6 months data collection

6 months data

8 months data collection

Collection

Fig. 1. Timeline for the Stroke Practice Improvement Network.

own sites to motivate change and several focus group sessions so that sites could help each other. The sites now have 6 months to implement their QIP. The QIP will be developed around hospital specific baniers to adherence (knowledge deficits, attitude deficits, organizational deficits, QI infrastructure deficits) identified through surveys. After implementation of the QIP (6 months) all study sites will continue to collect data for another 8 months to assess post implementation adherence rates. Currently, 17 hospitals are prospectively collecting data on nine quality of care indicators (n = 2700). Benchmarks were developed in December 2002 (Fig 2). If successful, this project should provide practical improvement ideas or methods to help neurologists and/or hospitals improve the quality of care they deliver to stroke patients as well as insight into ways to collect and share quality improvement data.

Future Future research is needed to determine what measures are most important in terms of quality and what is the best way to measure quality of care. W e still need to link all process measures with outcomes. Most quality indi-

[

Indicator Adherence Rates

cators or performance measures are generated from clinical practice guidelines that use a combination of evidence and consensus to generate recommendations. The evidence used is mostly generated from randomized controlled trials and is often treatment related. W e need more studies on community usage of medications and other aspects of care, such as diagnostic evaluation, prevention of complications and nontechnical aspects of care. W e also need to make stronger links between the processes that we do and the prevention or improvement in patient outcomes. Lastly, we need a better severity adjustment method in ischemic stroke so that we can measure and compare outcomes. I have tried to show that there is a need to improve the quality of stroke care. One way to do this is to measure stroke quality of care, make an improvement in what we do, and then re-measure to ensure improvement. One project is described that is designed to assess process measures in stroke care. Methods or techniques to improve care generated from these projects should be disseminated to all practicing physicians to globally improve the care we deliver.

Acknowledgement The author would like to thank Robert G. Holloway, MD, for his work on this manuscript.

~low [ ] mean [ ] benchmark

References 94

1O0

l0

6O 40 20

_

74

99

0 ,

,

o>,

.o

L o w = Adherence rate o f t h e lowest adhering site M e a n = mean adherence rate at all 17 sites Benchmark = Adherence o f the top 10% o f patients Dvt = deep venotls thrombosis

Fig. 2. Quality indicator adherence rates.

1. Lohr KN (ed): Medicare: A Strategy for Quality Assurance, vol I and II. Washington, DC, National Academy of Sciences Press, 1990 2. Wennberg JE, Cooper MM (eds): The Dartmouth Atlas of Health Care in the United States. Chicago, American Hospital Publishing, Inc., 1998 31 Jencks SF, Cuerdon T, Burwen DR, et al: Quality of medical care delivered to Medicare beneficiaries. A profile at state and national levels. JAMA 284:1670-1676, 2000 4. Kresowik TF, Bratzler D, Karp HR, et al: Multistate utilization, processes, and outcomes of carotid endarterectomy. J Vasc Surg 33:227-235, 2001 5. Goldstein LB, Hey LA, Laney R: North Carolina stroke

90

Seminarsin Cerebrovascular Diseasesand Stroke Vol. 3 No. 2 June 2003

prevention and treatment facilities survey. Statewide availability of programs and services. Stroke 31:66-70, 2000 6. Chassin MR, Galvin RW, and the National Roundtable on Health Care Quality. The urgent need to improve health care quality. Institute of medicine national roundtable on health care quality. JAMA 280:1000-1005, 1998 7. Samsa GP, Matchar DB, Goldstein LB, et al: Quality of anitcoagulation management among patients with atrial fibrillation: results of a review of medical records from 2 communities. Arch Intern Med 160:967-973, 2000 8. Brass LM, Krumholz HM, Scinto JM, et al: Warfarin use following stroke among Medicare patients with atrial fibrillation. Arch Intern Med 158:2093-2100, 1998 9. Kernan WN, Viscoli CM, Brass LM, et al: Blood pressure exceeding national guidelines among Women after stroke. Stroke 31:415-419, 2000 10. Holloway RG, Benesch C, Rush SR: Stroke prevention. Narrowing the evidence-practice gap. Neurology 54:18991906, 2000 11. Wong JH, Findlay JM, Suarez-Almazor ME: Regional performance of carotid endarterectomy. Appropriateness, outcomes, and risk factors for complications. Stroke 28:891-898, 1997 12. Kohn L, Corrigans J (eds): To Err Is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of medicine. Washington DC, National Academy of Sciences Press, 1999. 13. Katzan IL, Furlan AJ, Way LE, et al: Use of tissue-type plasminogen activator for acute ischemic stroke: the Cleveland area experience. JAMA 283:1151-1158, 2000 14. Bravata DM, Kim N, Concato J, et al: Thrombolysis for acute stroke in routine clinical practice. Arch Int Med 162: 1994-2001, 2002

15. Donabedian A: The Quality of care. How can it be assessed? JAMA 260:1743-1748, 1988 16. Stroke Unit Trialiats' Collaboration. Collaborative systematic review of the randomized trials of organized inpatient (stroke unit) care after stroke. BMJ 314:1151-1159, 1997 17. Alberts MJ, Hademenos G, Latchaw RE, et al: Recommendations for the establishment of primary stroke centers Brain Attack Coalition JAMA 283:3102-3109, 2000 18. Hannen EL, Popp AJ, Tranmer B, et al: Relationship between provider volume and mortality for carotid enarterectomies in New York State. Stroke 29:2292-2297, 1998 19. Holloway RG, Vickrey BG, Benesch C, et al, and National Expert Stroke Panel: Development of performance measures for acute ischemic stroke. Stroke 32:2058-2074, 2001 20. LaClair BJ, Reker DM, Duncan PW, et al: Stroke care: a method for measuring compliance with AHCPR guidelines. Am J Phys Med Rehab 80:235-42, 2001 21. Quality of Care & Outcomes Research in CVD & Stroke Working Groups. Measuring and improving quality of care. Circulation 101;1483-1493, 2000 22. Blumenthal D: Part 1: quality of care--what is it? N Engl J Med 335:891-894, 1996 23. Lanska DJ, Hartz AJ: Measurement of quality in health care. Neurology 50:584-587, 1998 24. Davis DA, Thomson MA, Oxman AD, et al: Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 274:700-705, 1995 25. Kiefe CI, Allison JJ, Williams OD, et al: Improving quality improvement using achievable benchmarks for physician feedback: a randomized controlled trial. JAMA 285:2871-2879, 2001