Quality Measures in Stroke

Only about 6 pages which our stroke associations should be able to decipher for us survivors so we can make sure our hospitals are following the guidelines. 10 quality measures. I don't think much of them they don't have any hyperacute measures or even mention stopping the neuronal cascade of  death.
http://nho.sagepub.com/content/1/2/71.full?utm_source=neuroscience_A&utm_medium=LandingPage&utm_content=TheNeurohospitalist&utm_campaign=1112050

Abstract

Stroke is a major public health burden, and accounts for many hospitalizations each year. Due to gaps in practice and recommended guidelines, there has been a recent push toward implementing quality measures to be used for improving patient care, comparing institutions, as well as for rewarding or penalizing physicians through pay-for-performance. This article reviews the major organizations involved in implementing quality metrics for stroke, and the 10 major metrics currently being tracked. We also discuss possible future metrics and the implications of public reporting and using metrics for pay-for-performance.

• stroke
• cerebrovascular disorders
• quality < techniques

More than 795 000 strokes occur in the United States annually, and stroke accounts for 889 000 hospitalizations per year.¹ Despite published evidence-based guidelines for stroke care, there remain inconsistencies in how these are applied, leading to a recent push toward measuring and improving the quality of care provided to these patients. Several organizations have created guidelines involving measures of quality, including the Joint Commission (Primary Stroke Center Certification), the American Stroke Association (Get With the Guidelines), the Centers for Disease Control (Paul Coverdell Registry), the National Quality Forum (NQF), and most recently the Centers for Medicare and Medicaid Services (CMS).² These organizations have both independently and collaboratively established quality metrics associated with health care delivery in the inpatient care of patients with stroke, some of which have been distinguished as “performance measures” or metrics that are suitable for public reporting and may be used for comparing institutions and rewarding those who meet specific thresholds (“pay for performance”).³ Quality metrics and performance measures typically focus on processes of care based on specific recommendations in clinical guidelines, and ideally are based on sufficient evidence that failure to provide the recommended care is likely to result in suboptimal clinical outcomes.³ Most stroke registries and quality measurement programs are currently based on voluntary participation, which is in line with the Physician Quality Reporting Initiative, an incentive-based quality reporting system established as part of the 2006 Tax Relief and Health Care Act. In a major shift of perspective from incentive- to disincentive-based systems, however, CMS has recently announced their intention to likely include the NQF-endorsed stroke measures as part of the Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) initiative.⁴ Beginning with inpatient discharges in Fiscal Year 2011, most hospitals will be required to report these measures in order to receive full Medicare payments.

Since many registries and organizations have published guidelines for stroke quality measures, they differ somewhat from one another. Beginning in January 2008, a set of 10 performance measures for inpatient acute stroke care was agreed upon by 3 major stakeholders: the Joint Commission, the American Stroke Association, and the Centers for Disease Control, as part of the Stroke Performance Measure Consensus Group. All 10 measures apply to the care of acute ischemic strokes, and 5 of them also apply to hemorrhagic stroke subtypes. Eight of these measures were endorsed by the NQF, and more recently, CMS has announced that these 8 measures will be included in the RHQDAPU initiative.² The 10 harmonized performance measures (Table 1 ) will be discussed below, along with evidence supporting them.

Possible Future Metrics

Many facets of stroke care which are not currently included in the major performance measures may contribute to better stroke outcomes and could be considered performance measures in the future. While some of the QI organizations apply the existing metrics to TIA, such as AHA and The Joint Commission several do not. In recent years, the high risk of stroke after TIA or minor stroke has been more clearly defined, and perhaps these conditions deserve metrics of their own, emphasizing their urgent diagnostic workup and treatment. Significant evidence now exists for the efficacy of timely carotid endarterectomy (and now some evidence for carotid stenting) in patients with symptomatic severe carotid stenosis.^39–41 Urgent carotid artery evaluation after stroke or TIA suggestive of large vessel etiology, consideration of carotid revascularization in those with symptomatic severe carotid stenosis, and time to carotid revascularization could all be considered as possible future quality metrics. Hypertension is a significant modifiable primary risk factor for stroke, and there is some evidence that antihypertensive treatment also reduces secondary stroke risk.⁴² As inpatient initiation of secondary stroke prevention measures has been associated with high compliance rates 90 days after discharge,⁴³ initiation of antihypertensive treatment after the acute stroke period but prior to discharge could be considered a quality metric. Both fever and hypoxia are frequent complications during hospitalization for stroke and have been found to predict clinical worsening during hospitalization.⁴⁴ Whether treating these complications during hospitalization will improve stroke outcomes remains to be seen, but further research is needed to clarify appropriate measures and to help define what should be tracked for performance.

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Conclusions

Implementation of quality metrics in stroke is inevitable, and CMS will require reporting beginning in 2011. It is important for stroke specialists to be intimately involved in defining what measures are used to evaluate quality care, as these will affect the care our patients receive as well as the compensation given to physicians and institutions. Many metrics applied to other hospitalized patients, such as those tracking hospital-acquired infections (such as ventilator-associated pneumonia and catheter-associated urinary tract infections) have been applied to stroke and other neurology patients by default, when it may be that they are not appropriate in these populations. Moreover, metrics initiated by nonneurologists or nonphysicians could have dangerous consequences for our patients and for neurologists. It is important that we, as neurologists, perform high-quality research to better define what measures are reasonable to track publicly in our patient population, and how the implementation of these metrics affects patient outcomes, and to be strong advocates in setting policies regarding these metrics.

I don't see any evidence of concern or hurry to accommodate the coming 'tsunami' of stroke, I borrowed the term from a Canadian doctor.