Evaluating the quality of in-hospital stroke care, using an opportunity-based composite measure: a multilevel approach

Abstract

Evaluating the quality of in-hospital stroke care, using an opportunity-based composite measure: a multilevel approach Aida Ribera,1–3 Sònia Abilleira,1,3 Gaietà Permanyer-Miralda,2,3 Ricard Tresserras,4 Joan MV Pons,1,3 Miquel Gallofré3,4 1Stroke Program, Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain; 2Cardiovascular Epidemiology Unit, Hospital Vall d'Hebron, Barcelona, Spain; 3CIBER Epidemiología y Salud Pública, Madrid, Spain; 4Stroke Program, Department of Health, Autonomous Government of Catalonia, Barcelona, Spain Background: Development of process-based quality measures has been of increasing interest. We aimed to construct a composite quality measure for acute stroke care and to evaluate its performance at the hospital level. Methods: We used data from the Stroke Audit 2007, based on retrospective review of medical charts linked to the Mortality Register 2007–2008 (Catalonia, Spain). Eight quality measures were selected on the basis of clinical relevance, scientific evidence, and relationship to mortality: screening of dysphagia, initiation of antiplatelets at less than 48 hours (if ischemic stroke), early mobilization, assessment of rehabilitation, management of hypertension, management of dyslipidemia, anticoagulation in case of atrial fibrillation (if ischemic stroke), and antithrombotics on discharge (ischemic strokes only). We constructed an opportunity-based composite quality measure of eight individual measures and correlated noncompliance with the individual and composite quality measures with risk-standardized 30-day mortality at the hospital level. Noncompliance with the opportunity-based composite measure was calculated as the sum of the total instances that a required individual measure was not performed or not documented. Multilevel linear regression analyses were conducted to assess the variability of noncompliance at the hospital level and to what extent variability could be explained by differences in hospital characteristics. Results: We analyzed data from 1,686 patients (representing 9,334 opportunities for compliance with the composite quality measure) admitted to 47 acute hospitals. Noncompliance with the composite was 32.7% (95% confidence interval [CI], 31.5%–33.9%), and the correlation with hospital risk-adjusted 30-day mortality was 0.24 (P=0.1). Using multilevel logistic modeling, hospitals with an intermediate number of annual stroke admissions (150–350 versus <150) and hospitals with an ongoing stroke registry showed better compliances (odds ratio for noncompliance, 0.59 [95% CI, 0.4–0.87] and 0.5 [95% CI, 0.35–0.73], respectively). Individual factors explained 3.9% of hospital variability, whereas structural variables explained 49.4% of hospital variability. Conclusion: An opportunity-based composite may be useful to globally assess quality of stroke care across providers, even though correlations with mortality are weak. In addition, it offers new insights about the relationship between hospitals' structural resources and quality. Keywords: acute stroke care, composite quality measure, multilevel analysis