http://stroke.ahajournals.org/content/early/2014/01/23/01.str.0000441948.35804.77.abstract
A Statement for Healthcare Professionals From the American Heart Association/American Stroke Association
- Irene L. Katzan, MD, MS, FAHA, Chair,
- John Spertus, MD, FAHA, Co-Chair,
- Janet Prvu Bettger, ScD, FAHA*,
- Dawn M. Bravata, MD*,
- Mathew J. Reeves, PhD, DVM, FAHA*,
- Eric E. Smith, MD, MPH, FAHA*,
- Cheryl Bushnell, MD, MHS, FAHA,
- Randall T. Higashida, MD, FAHA,
- Judith A. Hinchey, MD, FAHA,
- Robert G. Holloway, MD, MPH,
- George Howard, DrPH,
- Rosemarie B. King, PhD, RN, FAHA,
- Harlan M. Krumholz, MD, FAHA,
- Barbara J. Lutz, PhD, RN, CRRN, FAHA,
- Robert W. Yeh, MD, MSc, FAHA and
- on behalf of the American Heart Association Stroke Council, Council on Quality of Care and Outcomes Research, Council on Cardiovascular and Stroke Nursing, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular Surgery and Anesthesia, and Council on Clinical Cardiology
Abstract
Background and Purpose—Stroke
is the fourth-leading cause of death and a leading cause of long-term
major disability in the United States. Measuring
outcomes after stroke has important policy
implications. The primary goals of this consensus statement are to (1)
review statistical
considerations when evaluating models that
define hospital performance in providing stroke care; (2) discuss the
benefits,
limitations, and potential unintended
consequences of using various outcome measures when evaluating the
quality of ischemic
stroke care at the hospital level; (3)
summarize the evidence on the role of specific clinical and
administrative variables,
including patient preferences, in
risk-adjusted models of ischemic stroke outcomes; (4) provide
recommendations on the minimum
list of variables that should be included in
risk adjustment of ischemic stroke outcomes for comparisons of quality
at the
hospital level; and (5) provide
recommendations for further research.
Methods and Results—This
statement gives an overview of statistical considerations for the
evaluation of hospital-level outcomes after stroke
and provides a systematic review of the
literature for the following outcome measures for ischemic stroke at 30
days: functional
outcomes, mortality, and readmissions. Data
on outcomes after stroke have primarily involved studies conducted at an
individual
patient level rather than a hospital level.
On the basis of the available information, the following factors should
be included
in all hospital-level risk-adjustment models:
age, sex, stroke severity, comorbid conditions, and vascular risk
factors. Because
stroke severity is the most important
prognostic factor for individual patients and appears to be a
significant predictor
of hospital-level performance for 30-day
mortality, inclusion of a stroke severity measure in risk-adjustment
models for 30-day
outcome measures is recommended.
Risk-adjustment models that do not include stroke severity or other
recommended variables
must provide comparable classification of
hospital performance as models that include these variables. Stroke
severity and
other variables that are included in
risk-adjustment models should be standardized across sites, so that
their reliability
and accuracy are equivalent. There is a
pressing need for research in multiple areas to better identify methods
and metrics
to evaluate outcomes of stroke care.
Conclusions—There
are a number of important methodological challenges in undertaking
risk-adjusted outcome comparisons to assess the quality
of stroke care in different hospitals. It is
important for stakeholders to recognize these challenges and for there
to be
a concerted approach to improving the methods
for quality assessment and improvement.
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