There is substantial variation in the benefit of quality measures in acute stroke care

 There should be zero variation. The only quality you measure is 100% recovery!

1. You objectively determine the damage diagnosis.

2. Based upon the EXACT diagnosis, you deliver the EXACT rehab protocols leading to 100% recovery.
   

 

There is substantial variation in the benefit of quality measures in acute stroke care

By Andrew Lee, Kiera Liblik

| Published June 9, 2023

TABLE OF CONTENTS

1. Key takeaways

2. Why this study matters

3. Study design

4. Results and conclusion

5. In-depth

6. Original source

Key Takeaways

• In an acute stroke simulation, early carotid imaging and tissue plasminogen activator were associated with significant cost-effectiveness.

• No significant quantifiable health effects were found for five quality measures endorsed by American Heart Association (AHA)/ American Stroke Association (ASA).

Why this study matters

Stroke is a leading cause of global mortality, with the AHA/ASA providing specific quality measures through guidelines for acute ischemic stroke care. These quality measures have not previously undergone a cost-effectiveness analysis.

Study design

In this stroke simulation model, 15 AHA/ASA quality measures were estimated to improve life expectancy and quality-adjusted life years (QALY).

Results and conclusion

The quality measures were found to be cost-effective based on the a previously published threshold by the AHA of $50,000 per QALY. However, there was significant inconsistency in the value across individual quality measures. Early carotid imaging provided the most significant increase in QALYs and saving of life-years.

Furthermore, tissue plasminogen activator (tPA) produced the second most improvements, including being the only quality measure where quality-of-life adjustment increased incremental QALYs. When the cost-effective threshold was increased, the most costly quality measures accounted for more significant portions of the total value of improvement.

A limitation of this study is that the modeling of the quality measures does not capture the potential confounders of their subsequent interaction with each other and its effect on cost.

In-depth

The present study evaluated the health impact and cost-effectiveness of acute ischemic stroke quality measures based on cost-effectiveness. A computer simulation model was created for patients with incident acute ischemic stroke to project lifetime health and outcomes. Model outputs include incremental life-years, incremental QALYs, incremental cost-effectiveness ratio (ICER), and incremental net health benefit (iNHB).

Model inputs were from the previously published literature describing event rates, interventions’ effect size, utility weights, and costs. The model cohort had a mean age of 71.2 years with a standard deviation of 14.2 years at stroke onset. A total of 53% of the cohort was female and 47% was male.

All quality measures were seen to improve life expectancy and QALYs. On average, the measures were cost-effective based on a threshold of $100,000 per QALY and $50,000 per QALY. This has previously been described by the American College of Cardiology/AHA Task Force on Performance Measures as high-value care. Early carotid imaging led to an increase of 10,814 QALYs and a saving of 34,688 life-years, whereas tPA provided the second-largest improvement in iNHB (6,970 QALYs).

Early carotid imaging and tPA accounted for 72% of the total maximum value of quality improvement measured by iNHB. When the cost-effectiveness threshold increased, the costly quality measures accounted for more significant portions of the total augmentation.

In summary, from a cost perspective, there may be a minimal benefit to some of the quality measures endorsed by the AHA/ASA.

Originally Published By 2 Minute Medicine®. Reused on MDLinx with permission. ©2023 2 Minute Medicine, Inc. All rights reserved. No works may be reproduced without expressed written consent from 2 Minute Medicine, Inc. Inquire about licensing here. No article should be construed as medical advice and is not intended as such by the authors or by 2 Minute Medicine, Inc.

Original Source

AIM.

SNIS establishes partnership to develop quality measures to improve stroke outcomes

One second and I have the answer, 100% recovery for all survivors. Don't you dare let these blithering idiots use the tyranny of low expectations to take over. 
https://www.eurekalert.org/pub_releases/2018-06/sons-sep060118.php

Society of NeuroInterventional Surgery

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Fairfax, Va. - The Society of NeuroInterventional Surgery (SNIS) has assembled a powerful collaboration with key stakeholder groups to develop quality measures for stroke treatment. The collaboration--which includes a mix of industry and nonprofit groups--consists of measures development expertise from Avalere Health and input from the National Association of Emergency Medical Technicians, the National Stroke Association and the American College of Emergency Physicians. Together, these organizations will work to improve outcomes for ischemic stroke patients who have a large vessel occlusion (LVO), or "severe" stroke.

The partners, led by SNIS, have applied for a grant from the Centers for Medicare and Medicaid Services (CMS) to support this evidence-based initiative. This collaborative effort was supported by a grant from Stryker Neurovascular.

"Clear quality measures in cases of stroke can help doctors and first responders make quick decisions to help their patients survive," said Dr. Blaise Baxter, a neurointerventionalist at Erlanger Hospital in Chattanooga, Tennessee, and the President of SNIS. "Our partners bring expertise in emergency room protocols, data collection, inter-hospital transfers and the patient perspective, and will help us get a clear picture of the new measures that need to be developed and adopted to help stroke patients."

This partnership is bringing together diverse stakeholders who will identify gaps in quality of care and ensure that patients who require mechanical thrombectomy to remove a blood clot receive treatment quickly. Currently, no standard set of measures encompassing triage and treatment exist in the stroke care landscape, resulting in less than 10 percent of severe stroke patients receiving this life-saving stroke surgery.

"Stryker is pleased to support this important initiative. Development of clear quality measures will enable more stroke patients to receive treatment quickly," said Mark Paul, President of Stryker Neurovascular.

CMS is expected to provide notification of the SNIS grant application by late summer. SNIS will begin measure development immediately thereafter.

###

About the Society of NeuroInterventional Surgery

The Society of NeuroInterventional Surgery (SNIS) is a scientific and educational association dedicated to advancing the specialty of neurointerventional surgery through research, standard-setting and education and advocacy in order to provide the highest quality of patient care in diagnosing and treating diseases of the brain, spine, head and neck. http://www.snisonline.org. Follow us on Twitter @SNISinfo and on Facebook @SNISOnline.

How do patients define quality medical care?

One view here from a doctor.
How do patients define quality medical care?
At the risk of hubris, I will offer some thoughts:

Deans' thoughts in red

1. Patients want a physician to listen carefully, look them in the eye, and address their concerns.
2. Patients want correct diagnoses. This one fails a fair number of times in young person strokes. It fails all the time in an objective damage diagnosis. With no damage diagnosis you can never correlate interventions to results with any accuracy.
3. Patients want to understand "the plan" - what is the diagnosis, what is the proposed treatment, what diagnostic tests are ordered and why.  There is no plan in stroke rehabilitation, it is all winging it. Why do you think you are told; 'All strokes are different, all stroke recoveries are different?'
4. Patients want access to their physician - timely appointments, email, text, phone calls - and do not want unnecessary visits scheduled
5. Patients want to avoid medication side effects. Statins, warfarin and blood pressure meds.
6. Patients want cost considered when at all possible. Really!

Cross-National Key Performance Measures of the Quality of Acute Stroke Care in Western Europe

How long before this is measured in the United States? I bet at least 50 years since our stroke associations will not be tackling this project until management is replaced by stroke survivors who will work on solving all the problems in stroke, rather than sitting on their asses, JUST WAITING FOR SOMEONE ELSE TO SOLVE THE PROBLEM! The former president of the WSO (Bo Norrving, MD, PhD,) seems to be doing more after his term than when he was president.
http://stroke.ahajournals.org/content/early/2015/08/11/STROKEAHA.115.008811.abstract?sid=be9cbfe0-ac87-4d08-899e-ede87e9d54aa

1. Bo Norrving, MD, PhD,
2. Benjamin D. Bray, MD,
3. Kjell Asplund, MD,
4. Peter Heuschmann, MD, MPH,
5. Peter Langhorne, PhD,
6. Anthony G. Rudd, MD,
7. Markus Wagner, PhD,
8. Silke Wiedmann, PhD,
9. Charles D.A. Wolfe, MD,
10. for the European Implementation Score Collaboration

+ Author Affiliations

1. From the Department of Clinical Sciences, Section of Neurology, Lund University, Lund, Sweden (B.N.); Division for Health and Social Care Research, King’s College London, London, United Kingdom (B.D.B., A.G.R., C.D.A.W.); Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden (K.A.); Institute of Clinical Epidemiology and Biometry, Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany (P.H., S.W.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (P.L.); National Institute for Health Research Biomedical Research, Centre Guy’s & St Thomas’ NHS Foundation Trust, London, United Kingdom (A.G.R., C.D.A.W.); and Department of Integrated Care, German Stroke Foundation, Gütersloh, Germany (M.W.).

1. Correspondence to Benjamin D. Bray, MD, PhD, Division of Health and Social Care Research, Capital House, 42 Weston St, London SE1 3QD, United Kingdom. E-mail benjamin.bray@kcl.ac.uk

Abstract

Background and Purpose—There are no agreed measures of stroke care quality that enable the standardized comparison of stroke care between countries. We aimed to develop a set of measures of quality of acute stroke care involving stroke quality registers in Western Europe.

Methods—A multinational working group identified 6 regional or national stroke quality registers in Europe and reviewed their data sets, performance measures, and the method by which these had been developed. Measures used in the registers were presented for discussion to a consensus group of representatives from the quality registers identified, as well as other stroke experts, and the final set of common performance measures was agreed through majority consensus.

Results—Thirty final performance measures were agreed by the European consensus group, encompassing the domains of coordination of care (stroke unit–based care), diagnosis (brain imaging, vascular imaging, cardiac arrhythmia detection, and therapy assessment), preservation of neural tissue (thrombolytic therapy and door-to-needle time), prevention of complications (dysphagia screening), initiation of secondary prevention (antiplatelet, anticoagulation, lipid lowering, blood pressure lowering, carotid surgery, time from vascular imaging to carotid surgery, and smoking cessation), survival (90-day poststroke mortality), and functional outcomes (90-day modified Rankin Scale).

Conclusions—On the basis of experience of quality registers in Europe, we have proposed a common set of performance measures that will facilitate the international comparison of acute stroke care quality.

Evaluating the Quality of Medical Care

Whom is doing this for stroke? Because if we don't know about the problems in stroke and the current disastrous results we will never be able to make them better.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690293/
A medical blogger arguing against using this for pay for performance.

The problem with “measuring quality” – as Donabedian told us

I forcibly disagree, we have to start evaluating stroke results or we will never fix the problems. Once again proving that our stroke doctors have their heads so far up their asses they will never see any helpful research.

Use patients, families as experts to improve quality

This won't occur with stroke survivors because hospitals don't want to know how badly they are failing their patients.
http://www.fiercehealthcare.com/story/use-patients-families-experts-improve-quality/2014-10-30?
Hospitals could improve quality and safety if they engaged patients and their families in improvement initiatives, experts say.
Patients and family members "possess intricate knowledge and vastly different perspectives on care processes, communication and coordination systems," H&HN Daily reported, citing discussion from the Quality & Patient Safety Roadmap hosted by the American Hospital Association's Symposium for Leaders in Healthcare Quality.
But most hospitals haven't been able to leverage that "huge untapped potential" for improvement initiatives because they haven't effectively engaged patients and families, according to the roadmap.
One hospital system that has had success is Vidant Health in Greenville, N.C., which involves patient and family advisers "from the bedside to the boardroom," Vidant adviser Dorothea Handron says in the H&HN article. They participate on quality teams, review patient materials, join safety rounds, help with facility design and development of the electronic health record patient portal, and formally advise the board. As a result, Vidant reports it has reduced serious safety events by 83 percent and hospital-acquired infections by 62 percent.
Roadmap discussion also focused on "hardwiring processes" such as checklists into the organizational culture to build high-reliability organizations, H&HN reported.
High-reliability organizations "employ human factors integration; they make it obvious to do the right thing and impossible to do the wrong thing," according to the article. "As a result, processes are immune to inevitable human errors."
Other medical groups also are studying how to build high-reliability organizations. American Anesthesiology focused its efforts on the operating room (OR), where it recommended empowering patient-safety champions who train the rest of the OR team to develop a safety-first culture.
In Connecticut, hospitals are taking a page from the aviation and nuclear-power sectors to develop systemic routines that reduce medical errors and improve safety and patient experience.

Quality measurement – a delusion

A doctor discussing how to measure a doctors quality. How would you measure your doctors quality?
Mine would have gone into negatives if that is possible or maybe an irrational number.
Quality measurement – a delusion

Minnesota Stroke System is set to launch in 2014

Contact them and  demand to know what acute therapies are being provided in the first week other than the failure of tPA. 10% full recovery is a complete failure. What are their plans to get to 100% recovery? Its only possible if you try, but I bet they won't even try. Lazy bastards.
Existing standards for care are a failure, they need to know that. So tell them.

Minnesota Stroke System 

The Minnesota Stroke System is set to launch in 2014. The first phase of the system is for the MDH to designate hospitals and emergency centers according to their level of acute stroke care. Participation in the system is voluntary. We intend for every acute care hospital and emergency center in the state to participate in order to ensure high quality stroke care for all Minnesotans. All acute care hospitals and emergency centers are eligible to apply for designation. 

We are committed to supporting hospitals to become designated. We are hosting workshops, created a toolkit and a how-to guide for applying, and we will be hosting a webinar in February to talk about the designation process. We also created a newsletter, which is attached. To find out more, please contact health.stroke@state.mn.us or visit our website. Please watch for more announcements through this newsletter and other communications.

Statewide Quality Reporting  

 All acute care hospitals in Minnesota are required to submit data on health care measures as part of the Health Reform Act of 2008. This year, for stroke, the "Door to imaging performed" measure will continue to be reported, and a new measure, "Time to IV Thrombolytic Therapy" will also be required. These data must be submitted on all eligible patient cases starting July 1, 2013. Please visit the MDH health reform website to get more information about or to report your data. There will be a webinar on Jan 8 at 2 pm hosted by Stratis Health to review general reporting requirements with a special section on stroke measures. See info below in the Webinars section.

MSS Newsletter 2013 Dec.pdf

Quality of life after TIA and stroke

Less than 5 years after stroke is way too early to evaluate how you feel about your quality of life. You probably haven't made it to acceptance yet.
http://www.neurology.org/content/early/2013/10/09/WNL.0b013e3182a9f45f

1. Ramon Luengo-Fernandez, DPhil,
2. Alastair M. Gray, PhD,
3. Linda Bull, RGN,
4. Sarah Welch, RGN,
5. Fiona Cuthbertson, MCSP,
6. Peter M. Rothwell, FMedSci;
7. For the Oxford Vascular Study

+Show Affiliations

| + Show Full Disclosures

1. Correspondence to Prof. Rothwell: peter.rothwell@ndcn.ox.ac.uk

1. Published online before print October 9, 2013, doi: 10.1212/WNL.0b013e3182a9f45f Neurology 10.1212/WNL.0b013e3182a9f45f

• Abstract
• Full Text (PDF)

1. Also available:
2. Data Supplement

Abstract

Objective: To evaluate the 5-year impact of stroke and TIA on utility and quality-adjusted survival.

Methods: TIA and stroke patients from a UK population-based study (Oxford Vascular Study) were recruited from 2002 to 2007, and followed up until 2012. Quality of life was assessed over 5 years using the EQ-5D (EuroQol-5 Dimensions), with responses converted into utilities ranging from −0.59 (worse than death) to 1 (perfect health), using UK population valuations. Utilities for stroke and TIA patients were compared with those in matched controls obtained from the 2006 Health Survey for England. Five-year quality-adjusted life years were estimated by combining utility and survival information.

Results: Four hundred forty TIA and 748 stroke patients were ascertained and included. Utility remained constant at approximately 0.78 over the 5 years after TIA. Utility improved from 0.64 one month after stroke to 0.70 at 6 months (p = 0.006), remaining at approximately 0.70 thereafter. Matched controls had considerably higher utility levels than stroke/TIA patients (0.85, p < 0.001). Event severity and recurrent stroke were significant predictors of decreased long-term utility. Five-year quality-adjusted life expectancy was 3.32 (95% confidence interval: 3.22–3.48) quality-adjusted life years after TIA and 2.21 (2.15–2.37) after stroke, varying considerably by severity (minor: 2.94; moderate: 1.65; and severe: 0.70).

Conclusion: Quality-adjusted survival is low over the 5 years after stroke and TIA, with severity and recurrent stroke being major predictors. There remains considerable scope for improvements in acute treatment and secondary prevention to improve the quality of life after TIA and stroke.

Function and quality of life following stroke rehabilitation: have our stroke patients gained optimum recovery?

The answer is NO. Who is going to fix that?
http://www.biomedcentral.com/1471-2458/12/S2/A7

Background

There is limited research data on post-rehabilitation function and quality of life despite the increasing role of rehabilitation in the care of stroke patients in Malaysia. Outcome data is important in evaluating the effectiveness of stroke rehabilitation services in the country.

Aims

The aim of this study was to assess function and quality of life in stroke patients following intensive rehabilitation at a tertiary hospital.

Materials and methods

This was a cross-sectional study of 91 stroke patients; mean age 58.9±10.6 years, 79% male, median stroke duration 13 months who have completed intensive individual rehabilitation at the Universiti Kebangsaan Malaysia Medical Centre in the years 2010 and 2011. Rehabilitation outcome was measured with the use of standardised tools; Rivermead Mobility Scale (RMI), Berg’s Balance Scale (BBS), Sit to Stand Test (STS) for lower limb strength and Timed 10 metre walk test for walking speed. Post-rehabilitation disability level and quality of life were also assessed on a Modified Rankin Scale (mRS) and Euro-Qol 5 Dimensions-Visual analogue Scale (EQ5D-VAS), respectively. All data were analysed descriptively using SPSS version 18.

Results

The median duration of rehabilitation was 10.5 months (range 5-25) in the study patients and post-rehabilitation mean mRS was 2.3±0.7. The median RMI was 13 (range 6-15), median BBS 51 (range 20-56) and median STS 15.5 secs (range 7.9-83.9 secs). The EQ5D-VAS mean score was 71.5±17 and mean walking speed at the completion of intensive rehabilitation was 49.4±28.3 m/min; less 22 m/min when compared with the optimum walking speed required for safe road crossing.

Conclusion

Although our stroke patients gained satisfactory levels of mobility, balance and strength following intensive rehabilitation, they have not achieved optimum speed of walking to enable effective community ambulation. Prolongation of rehabilitation programme may assist in further functional and quality of life gain among the post-stroke patients.

email from Minnesota Stroke Digest - November 2012

You need to ask for the bolded information from your hospital wherever it is. See how pathetic it is and then ask what they are doing to replace it with. I list 11 options here;

You are subscribed to Minnesota Stroke Partnership Announcements for Minnesota Department of Health. This information has recently been updated, and is now available.

Dear Minnesota Stroke Partners,

This month's  Minnesota Stroke Digest features an important announcement on hospital quality measure reporting on stroke from the Minnesota Department of Health.  The 2012 amendments to Minnesota Rules, Chapter 4654, Permanent Rules Relating to Health Care Quality Measures, were approved by the Office of Administrative Hearings on October 16, 2012, and were published in the November 13, 2012, edition of the State Register. The adopted rule and appendices are available at http://www.health.state.mn.us/healthreform/measurement/adoptedrule/index.html.

For the “Emergency Department Stroke Registry” indicators, there is a change in this year’s rule: the “NIHSS Performed in Initial Evaluation” indicator was removed. This indicator will no longer required to be reported for patients discharged on and after July 1, 2012.

The stroke data reporting tool, Minnesota Stroke Registry Tool (MSRT), will be modified as soon as possible to accommodate this change. This element (“NIHSS”) will remain visible as an “optional” data element – since it is still required on eligible patient cases discharged between July 1, 2011 (Q1 2011) and June 30, 2012 (Q2 2012), and some hospitals have not completed reporting through this date yet. (Incidentally, the deadline for Q2 2012 reporting is in two days - Thursday, November 15.) Hospitals may continue to collect and report on this indicator for patients discharged on and after July 1, 2012, but it will not be required for SQRMS reporting.

Two final notes:

• Reporting on “Door-to-Imaging Performed Time” will continue to be required of all hospitals.
• Hospitals participating in the Minnesota Stroke Registry Program will continue to collect data on both indicators. 

If you have any questions, please contact our team at health.stroke@state.mn.us.

Also, please keep watching the Minnesota Stroke Partnership website for updates on activities of the Steering Committee and our partners.  The Minnesota Stroke Partnership Steering Committee will lead the implementation of tactics and strategies specific to stroke in the Minnesota Heart Disease and Stroke Prevention Plan: 2011-2020.  Periodic updates on the steering committee's work will be added to the MSP website, and shared with all of you via these periodic emails.  The Resources page includes many useful items for stroke care professionals, including the following:

• Stroke Guidelines and Best Practices Resource Guide - Comprehensive online bibliography on prevention, emergency care, clinical treatment, medical management, and rehabilitation medicine for stroke.  This online tool is continually reviewed and updated (last updated in October 2012) by a team of stroke care experts in Minnesota.
• Minnesota Public Service Announcement - Stroke Signs & Symptoms - A 30-second YouTube clip utilizing rural Minnesota EMS professionals to spread the word on Signs & Symptoms of Stroke.  Find a way to use this clip in your organization or community! 
• Minnesota EMS and ED Stroke Consensus Statement - A short document outlining best practice standards and guidelines for the emergency transport and care of stroke partients.  Includes resources to help hospitals and EMS agencies meet high standards of care (last updated in May 2012).
  As always, please send any questions or comments to health.stroke@state.mn.us .
  Sincerely,
  Jim
  James Peacock, PhD, MPH
  Epidemiologist Senior
  Heart Disease & Stroke Prevention Unit
  Minnesota Department of Health
  PO Box 64882
  St. Paul, MN 55164-0882
  (651) 201-5405
  james.peacock@state.mn.us