Quality improvement in acute stroke: The New York State Stroke Center Designation Project
SharonDownie, Monash Medical Centre (Stroke Unit), OT Department, Monash Medical Centre, Locked Bag 29, Clayton 3169, Victoria, Australiasharon.downie@southernhealth.org.au
Submitted October 05, 2006
I read with interest Gropen et
al’s conclusion that "stroke center designation and selective triage of
acute stroke patients improved the quality of care." [1] I commend the authors for their obvious commitment to improving acute stroke
management yet their study was effectively restricted to review of the delivery but due to study design, fails to address quality of care in its totality.
Definitions of quality of care are inherently difficult given the
multi-dimensional and subjective nature of quality but are
ultimately integral to its measurement. [2] The domain of ‘access to care’
forms the primary focus of Gropen et al’s suite of quality indicators,
and undoubtedly has the potential to impact upon stroke outcomes.
However, access alone fails to capture quality as the sum of the patient’s
health experiences, [3] as advocated by the seminal "Quality Chasm" report, [4]
and thus leads one to question the authors’ broad assertion that "stroke
center designation and selective triage ... were associated with improved
quality of care for patients." [1]
Gropen et al's study methodology is consequently reliant on process
indicators related to access rather than global patient outcomes. The
authors state that enhanced quality of care was partly "related to more
timely assessment, diagnosis and treatment of stroke patients" [1] with the underlying assumption being that process achievement must be
indicative of improved outcomes. This is contrary to opinion within the literature which cautions against assuming causal attribution
owing to the likely effect of extraneous variables upon healthcare
outcomes. [3,5] Outcome measures included within this study, specifically
rates of post t-PA hemorrhage, peri-stroke complications and home
discharge, did not reach statistical significance at remeasurement, and
also failed to support the authors' contention that good processes
translate to good patient outcomes.
The study by Gropen et al fails to provide a patient-focused definition of quality to guide accurate
data measurement. [2,4] To this end, the authors’ use of process indicators
as pseudo-measures of patient outcome limits prospective investigation of
the longer term patient impacts of care processes, [5] and ulimately fails
to validate the guidelines for stroke center designation. [3] The only
definitive conclusion that should be drawn from this research is that
stroke center designation criteria and selective triage resulted in
improved access and timeliness of specific processes of care. Ultimately,
further studies will be required to address patient quality of care
issues.
References
1. Gropen TL, Gagliano PJ, Blake CA, et al. Quality improvement in
acute stroke: the New York State Stroke Center Designation Project.
Neurology 2006;67: 88-93.
2. DeGeyndt W. Definitions, objectives and rationale: managing the
quality of health care in developing countries. World Bank Technical
Paper 1995;258: 2-6.
3. Bernstein SJ, Hillbourne LH. Clinical indicators: the road to
quality of care? Joint Commission Journal on Quality Improvement
1993;19: 501-509.
4. Institute of Medicine. Crossing the quality chasm: a new health
system for the 21st century. Washington: National Academy Press, 2001.
5. Donabedian A. The quality of care: how can it be assessed? JAMA
1988;260: 1743-1748.
Disclosure: The authors report no conflicts of interest.
I read with interest Gropen et al’s conclusion that "stroke center designation and selective triage of acute stroke patients improved the quality of care." [1] I commend the authors for their obvious commitment to improving acute stroke management yet their study was effectively restricted to review of the delivery but due to study design, fails to address quality of care in its totality.
Definitions of quality of care are inherently difficult given the multi-dimensional and subjective nature of quality but are ultimately integral to its measurement. [2] The domain of ‘access to care’ forms the primary focus of Gropen et al’s suite of quality indicators, and undoubtedly has the potential to impact upon stroke outcomes. However, access alone fails to capture quality as the sum of the patient’s health experiences, [3] as advocated by the seminal "Quality Chasm" report, [4] and thus leads one to question the authors’ broad assertion that "stroke center designation and selective triage ... were associated with improved quality of care for patients." [1]
Gropen et al's study methodology is consequently reliant on process indicators related to access rather than global patient outcomes. The authors state that enhanced quality of care was partly "related to more timely assessment, diagnosis and treatment of stroke patients" [1] with the underlying assumption being that process achievement must be indicative of improved outcomes. This is contrary to opinion within the literature which cautions against assuming causal attribution owing to the likely effect of extraneous variables upon healthcare outcomes. [3,5] Outcome measures included within this study, specifically rates of post t-PA hemorrhage, peri-stroke complications and home discharge, did not reach statistical significance at remeasurement, and also failed to support the authors' contention that good processes translate to good patient outcomes.
The study by Gropen et al fails to provide a patient-focused definition of quality to guide accurate data measurement. [2,4] To this end, the authors’ use of process indicators as pseudo-measures of patient outcome limits prospective investigation of the longer term patient impacts of care processes, [5] and ulimately fails to validate the guidelines for stroke center designation. [3] The only definitive conclusion that should be drawn from this research is that stroke center designation criteria and selective triage resulted in improved access and timeliness of specific processes of care. Ultimately, further studies will be required to address patient quality of care issues.
References
1. Gropen TL, Gagliano PJ, Blake CA, et al. Quality improvement in acute stroke: the New York State Stroke Center Designation Project. Neurology 2006;67: 88-93.
2. DeGeyndt W. Definitions, objectives and rationale: managing the quality of health care in developing countries. World Bank Technical Paper 1995;258: 2-6.
3. Bernstein SJ, Hillbourne LH. Clinical indicators: the road to quality of care? Joint Commission Journal on Quality Improvement 1993;19: 501-509.
4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press, 2001.
5. Donabedian A. The quality of care: how can it be assessed? JAMA 1988;260: 1743-1748.
Disclosure: The authors report no conflicts of interest.