Variations in Acute Hospital Stroke Care and Factors Influencing Adherence to Quality Indicators in 6 European Audits
Background and Purpose—We compared compliance with standards of acute stroke care between 6 European audits and identified factors associated with delivery of appropriate care.
Methods—Data were derived from stroke audits in Germany, Poland, Scotland, Catalonia, Sweden, and England/Wales/Northern-Ireland participating within the European Implementation Score (EIS) collaboration. Associations between demographic and clinical characteristics with adherence to predefined quality indicators were investigated by hierarchical logistic regression analyses.
Results—In 2007/2008 data from 329 122 patients with stroke were documented. Substantial variations in adherence to quality indicators were found; older age was associated with a lower probability of receiving thrombolytic therapy, anticoagulant therapy, or stroke unit treatment and a higher probability of being tested for dysphagia. Women were less likely to receive anticoagulant or antiplatelet therapy or stroke unit treatment. No major weekend effect was found.
Conclusions—Detected variations in performance of acute stroke services were found. Differences in adherence to quality indicators might indicate population subgroups with specific needs for improving care delivery.
Monitoring quality of care between healthcare providers might reveal current service needs and identify gaps in delivery of appropriate care. Valid comparisons between regions and healthcare systems might clarify factors driving implementation of research evidence into practice. We analyzed data from European acute stroke care audits to compare quality of care by predefined quality indicators (QIs) and to identify patient and clinical characteristics being associated with appropriate care delivery.
Data from national (German Stroke Register Study Group [ADSR], Germany; the Scottish Stroke Care Audit [SSCA], Scotland; the National Stroke Register in Sweden [Riks-Stroke], Sweden; the National Sentinel Audit of Stroke [NSSA], England/Wales/Northern-Ireland; and the Hospital Stroke Registry of National Program for Prevention and Treatment of Cardiovascular Diseases [POLKARD], Poland) and regional (Catalan Stroke Audit [CSA], Catalonia, Spain) audits cooperating within an EU FP7 project (European Implementation Score [EIS] Collaboration) were included with details described previously (Table I in the online-only Data Supplement).1
Variables that were documented in a comparable way in ≥5 of the 6 audits were used for the analyses (definitions in Appendix in the online-only Data Supplement). QIs of acute hospital stroke care were defined a priori by a European consensus group within the European Implementation Score project. Compliance with QIs (definitions in Appendix in the online-only Data Supplement) was estimated for measures that could be calculated in ≥5 of the 6 audits including: stroke unit treatment; thrombolysis; dysphagia screening; antiplatelet therapy; and anticoagulation in atrial fibrillation.
The effect of factors associated with delivery of appropriate care was estimated by hierarchical logistic regression analyses. For estimating odds ratios and resulting 95% confidence intervals, distinct multilevel models were built, taking into account clustering of patients within regions/countries. Cross-level interactions between first- level (patients) and second-level (country/region) variables were assessed. For estimating variations of adherence by center, standardized ratios were calculated by comparing the observed proportion of an indicator within a center with the proportion expected when factor-specific event rates in the respective audit derived from multiple logistic regression models were applied to the center-specific population.
Audit and patient’s characteristics are presented in Table I in the online-only Data Supplement; data collection details are presented in Table II in the online-only Data Supplement. Adherence to QIs varied substantially across audits (Table 1). Figure I in the online-only Data Supplement shows the observed adherence to QIs by the expected adherence based on the center-specific case-mix. Patient characteristics influenced delivery of appropriate care in univariable (Table III in the online-only Data Supplement) and multivariable analyses (Table 2). No significant cross-level interactions were found for QIs between patient characteristics and region/country, including missing variables did not change associations substantially (data not shown).
Substantial variations in adherence to QIs were identified between 6 audits in Europe, especially for thrombolysis, dysphagia screening, and anticoagulant therapy. Patient characteristics, such as age, sex, or stroke subtype, were identified that were associated with delivery of appropriate care.
A consistent proportion of 3 quarters or more of patients were treated on a stroke unit, a higher proportion compared with reports from Canada.2 Different stroke unit definitions between healthcare systems might limit comparability of findings. Substantial variations in tissue-type plasminogen activator -rates were found between audits ranging from 1.3% to 9.1%. The higher proportion of tissue-type plasminogen activator in previous studies might be because of differences in study populations (eg, considering exclusion criteria for tissue-type plasminogen activator).3 The proportions of patients with ischemic stroke with atrial fibrillation and anticoagulant therapy at discharge ranged between 23.7% and 57.3% in our study. Substantial higher rates were observed in previous studies from the United States.4 However, in contrast to our data, in the later study patients were excluded if a contraindication was documented.4
Homogeneous patterns between proportions of appropriate healthcare delivery observed and proportions expected within centers were documented for antiplatelet and anticoagulant therapy, indicating that these measures might have already been translated successfully into clinical practice.
Similar to our data, previous studies have shown that older patients receive less often anticoagulation if they experience atrial fibrillation 5,6 and more often a swallow screening.7 This might be because of the fact that older age is associated with more severe strokes being associated with higher risk of complications. In accordance with our findings, other studies have found sex differences in diagnosis and treatment.8
The study was designed retrospectively; therefore, no common definitions and methods were used for data collection. Potential selection biases might have contributed to our findings as in some audits participation was voluntary. No uniform criteria were applied for ensuring completeness of case ascertainment. We cannot exclude that some of our findings were caused by potential confounders. No outcome data, such as in-hospital mortality, could be calculated because of limited data availability. Data were derived from 2007 to 2008, and current treatment patterns within regions/audits might be substantially different.
Differences in adherence to QI might indicate population subgroups with specific needs for improving care delivery.
German Stroke Register Study Group (Misselwitz, Seidel, Bruder, Berger, Hoffmann, Matthis, Janssen, and Burmeister); Hospital Stroke Registry of National Program for Prevention and Treatment of Cardiovascular Diseases (Członkowska, Ryglewicz, Sarzyńska-Długosz, and Skowrońska), Scottish Stroke Care Audit (Murphy, Dodds, McLeod, Langhorne, and Barber); Catalan Stroke Audit (Gallofré); Riks-Stroke (Jonsson); National Sentinel Audit of Stroke (Hoffmann); and Quality Register of Flemish Hospital Network of the KU Leuven, Flanders (Thijs).
Sources of Funding
This study was supported by EU FP7 (European Implementation Score Collaboration [EIS]; No 223153).
Dr Heuschmann received research support from the European Union (EIS; No 223153). The other authors report no conflicts.
Guest Editor for this article was Eric E. Smith, MD, MPH.
The online-only Data Supplement is available with this article at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.114.007504/-/DC1.
- Received September 19, 2014.
- Revision received November 12, 2014.
- Accepted November 18, 2014.
- © 2014 American Heart Association, Inc.
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