Elsevier

Annals of Emergency Medicine

Volume 64, Issue 3, September 2014, Pages 235-244.e5
Annals of Emergency Medicine

Neurology/systematic review/meta-analysis
A Systematic Review and Critical Appraisal of Quality Measures for the Emergency Care of Acute Ischemic Stroke

https://doi.org/10.1016/j.annemergmed.2014.01.034Get rights and content

Acute stroke is an important focus of quality improvement efforts. There are many organizations involved in quality measurement for acute stroke, and a complex landscape of quality measures exists. Our objective is to describe and evaluate existing US quality measures for the emergency care of acute ischemic stroke patients in the emergency department (ED) setting. We performed a systematic review of the literature to identify the existing quality measures for the emergency care of acute ischemic stroke. We then convened a panel of experts to appraise how well the measures satisfy the American College of Cardiology/American Heart Association (ACC/AHA) criteria for performance measure development (strength of the underlying evidence, clinical importance, magnitude of the relationship between performance and outcome, and cost-effectiveness). We identified 7 quality measures relevant to the emergency care of acute ischemic stroke that fall into 4 main categories: brain imaging, thrombolytic administration, dysphagia screening, and mortality. Three of the 7 measures met all 4 of the ACC/AHA evaluation criteria: brain imaging within 24 hours, thrombolytic therapy within 3 hours of symptom onset, and thrombolytic therapy within 60 minutes of hospital arrival. Measures not satisfying all evaluation criteria were brain imaging report within 45 minutes, consideration for thrombolytic therapy, dysphagia screening, and mortality rate. There remains room for improvement in the development and use of measures that reflect high-quality emergency care of acute ischemic stroke patients in the United States.

Introduction

There is increasing interest in quality, costs, and accountability in our health care systems,1, 2 and quality measurement efforts have developed rapidly during the last decade.3, 4 By measuring and reporting on quality of care and patient outcomes, quality measurement programs aim to improve patient outcomes and increase accountability. Effective quality measurement programs direct a system-based approach for translating effective processes of care to improve quality, enable identification of high and low performers, and allow providers to learn from one another.5 Measures of quality and performance will continue to increase in importance as health care systems transition from the fee-for-service model to models based on pay for performance and value-based purchasing. These measures also are used for quality improvement and public reporting.6

Stroke is the seventh most common reason for emergency department (ED) admissions, and a leading cause of severe disability.7, 8 Effective acute treatment reduces disability and increases the likelihood of favorable clinical outcomes.9, 10, 11, 12, 13, 14, 15 Given the burden of illness caused by stroke and the degree to which emergency care affects patient outcomes, ensuring consistent, high-quality emergency stroke care is important. Performance measurement is being used increasingly to assess the quality of care delivered. Several organizations have developed stroke quality measures for use in both inpatient and outpatient settings.16

It is important that quality measures accurately reflect research evidence and clinical performance because data on quality measures are increasingly used for public reporting, physician accountability, and health care reimbursement. Clinical guidelines are developed with the intention of informing physician judgment, and often include recommendations with various degrees of scientific confidence.5 In contrast, quality measures serve as universally applied standards and are intended to directly assess the quality of care provided.17 Measures should appropriately capture the intended quality construct, should be reliable and valid, and should have minimal unintended consequences for both patients and health care systems. Recognizing this challenge, the joint American College of Cardiology (ACC) and American Heart Association (AHA) Task Force on Performance Measures created criteria for the development of measures in cardiovascular care.5 These criteria have been used to evaluate measures of various emergency conditions (cardiac and noncardiac),18 but have not been applied to the measures for the emergency care of acute ischemic stroke.

Our objective was to identify, summarize, and evaluate existing quality measures for the emergency care of acute ischemic stroke. Our motivation was to translate knowledge about the quality measures in the United States into evidence for clinicians, practicing emergency physicians, policymakers, and the public. We chose to focus on US measures because we seek to inform ongoing US policy and payer discussions on selection of quality measures for emergency care of acute ischemic stroke. We performed a systematic review of the literature and relevant quality programs to identify quality measures for the emergency care of acute ischemic stroke. We then convened an expert panel to evaluate the quality measures. In this article, we describe the current measures, and we appraise how well the measures satisfy the ACC/AHA evaluation criteria.

Section snippets

Materials and Methods

We use the American Stroke Association definition of ischemic stroke as an episode of neurologic dysfunction caused by focal cerebral, spinal, or retinal infarction.19 Our prespecified search protocol was developed in collaboration with a medical research librarian. We first searched the medical literature, using PubMed for relevant articles published after 2000, given the launch of the Centers for Medicare & Medicaid Services quality initiatives in 2001.4 Appendix E1 (available online at //www.annemergmed.com

Results

The PubMed search yielded 976 potentially eligible articles for title and abstract review. Additional steps (screening references, related citations in PubMed and SCOPUS) identified no further articles for inclusion. After full-text review, the 2 authors agreed on 3 articles for inclusion and met to discuss disagreement over 6 additional articles, only 1 of which was eventually included, resulting in 4 articles being included in this study (Table E1, available online at //www.annemergmed.com

Limitations

We were obliged to make tradeoffs to sufficiently cover the details of existing quality measures relevant to all US acute care hospitals. Because we aimed to inform ongoing US policy discussions related to quality measure selection, we focused only on US quality measures. We did not include measurement programs that exist internationally or regionally, and thus excluded important systems such as the Centers for Disease Control and Prevention's Paul Coverdell National Acute Stroke Registry and

Discussion

In our review of quality measures relevant to the emergency care of acute ischemic stroke, we identified 7 measures that can be classified into 4 categories: brain imaging, thrombolytic administration, dysphagia screening, and mortality. In our evaluation, we found that only 3 of the existing measures met all 4 of the ACC/AHA measure evaluation criteria: brain imaging within 24 hours, tPA administered within 3 hours of symptom onset, and delivery of tPA within 60 minutes from hospital arrival.

References (65)

  • J.A. Spertus et al.

    American College of Cardiology and American Heart Association methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care

    Circulation

    (2005)
  • Chapter 6: Report on Comparing Quality Among Medicare Advantage Plans and Between Medicare Advantage and Fee-for-Service Medicare

    medpac

    (2010)
  • A.O.P. Elixhauser

    Reasons for Being Admitted to the Hospital Through the Emergency Department 2003

    Agency for Healthcare Research and Quality

    (2006)
  • Prevalence of stroke—United States, 2006-2010

    MMWR Morb Mortal Wkly Rep

    (2012)
  • Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group

    N Engl J Med

    (1995)
  • W. Hacke et al.

    Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials

    Lancet

    (2004)
  • W. Hacke et al.

    Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke

    N Engl J Med

    (2008)
  • J.R. Marler et al.

    Early stroke treatment associated with better outcome: the NINDS rt-PA stroke study

    Neurology

    (2000)
  • J.L. Saver

    Time is brain—quantified

    Stroke

    (2006)
  • J.L. Saver et al.

    The “golden hour” and acute brain ischemia: presenting features and lytic therapy in >30,000 patients arriving within 60 minutes of stroke onset

    Stroke

    (2010)
  • M.J. Reeves et al.

    Development of stroke performance measures: definitions, methods, and current measures

    Stroke

    (2010)
  • R.L. Sacco et al.

    An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association

    Stroke

    (2013)
  • B.B. Brown

    Delphi Process: A Methodology Used for the Elicitation of Opinions of Experts

    (1968)
  • E.C. Jauch et al.

    Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

    Stroke

    (2013)
  • Cost-Effectiveness Analysis Registry. Available at: https://research.tufts-nemc.org/cear4/. Accessed March...
  • National Quality Forum: who we are. Available at: http://www.qualityforum.org/Home_New/Who_we_are.aspx. Accessed...
  • A.R. Abdullah et al.

    Advance hospital notification by EMS in acute stroke is associated with shorter door-to-computed tomography time and increased likelihood of administration of tissue-plasminogen activator

    Prehosp Emerg Care

    (2008)
  • A.G. Kelly et al.

    Predictors of rapid brain imaging in acute stroke: analysis of the Get With the Guidelines–Stroke program

    Stroke

    (2012)
  • J.L. Saver et al.

    Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke

    JAMA

    (2013)
  • J.M. Wardlaw et al.

    Immediate computed tomography scanning of acute stroke is cost-effective and improves quality of life

    Stroke

    (2004)
  • L.B. Goldstein et al.

    Is this patient having a stroke?

    JAMA

    (2005)
  • L.B. Morgenstern et al.

    Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association

    Stroke

    (2010)
  • Cited by (0)

    Supervising editor: Donald M. Yealy, MD

    Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist and provided the following details: Dr. Levine is funded by National Institutes of Health (NIH) grant K23 AG040278 and received research support from NIH grant P30DK092926. Dr. Burke is funded by NIH grant K08 NS082597.

    A podcast for this article is available at www.annemergmed.com.

    View full text