Validity of Early Outcomes as Indicators for Comparing Hospitals on Quality of Stroke Care

• Published in: Journal of the American Heart Association Vol. 12; no. 8; p. e027647
• Main Authors: Amini, Marzyeh, Eijkenaar, Frank, Lingsma, Hester F, den Hartog, Sanne J, Olthuis, Susanne G H, Martens, Jasper, van der Worp, Bart, van Zwam, Wim, van der Hoorn, Anouk, Roosendaal, Stefan D, Roozenbeek, Bob, Dippel, Diederik, van Leeuwen, Nikki
• Format: Journal Article
• Language: English
• Published: England John Wiley and Sons Inc 18.04.2023; Wiley
• Subjects: acute ischemic stroke; Brain Ischemia - therapy; case‐mix; Cerebral Infarction - etiology; early outcome; Endovascular Procedures - adverse effects; expanded thrombolysis in cerebral infarction; hospitals' patient volume; Humans; Ischemic Stroke - etiology; National Institutes of Health Stroke Scale; Original Research; Prospective Studies; Stroke - diagnosis; Stroke - etiology; Stroke - therapy; Thrombectomy - adverse effects; Treatment Outcome; acute ischemic stroke; National Institutes of Health Stroke Scale; early outcome; hospitals' patient volume; expanded thrombolysis in cerebral infarction; quality of care; case‐mix
• ISSN: 2047-9980; 2047-9980
• DOI: 10.1161/JAHA.122.027647

Background Insight into outcome variation between hospitals could help to improve quality of care. We aimed to assess the validity of early outcomes as quality indicators for acute ischemic stroke care for patients treated with endovascular therapy (EVT). Methods and Results We used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry, a large multicenter prospective cohort study including 3279 patients with acute ischemic stroke undergoing EVT. Random effect linear and proportional odds regression were used to analyze the effect of case mix on between-hospital differences in 2 early outcomes: the National Institutes of Health Stroke Scale (NIHSS) score at 24 to 48 hours and the expanded thrombolysis in cerebral infarction score. Between-hospital variation in outcomes was assessed using the variance of random hospital effects (tau ). In addition, we estimated the correlation between hospitals' EVT-patient volume and (case-mix-adjusted) outcomes. Both early outcomes and case-mix characteristics varied significantly across hospitals. Between-hospital variation in the expanded thrombolysis in cerebral infarction score was not influenced by case-mix adjustment (tau =0.17 in both models). In contrast, for the NIHSS score at 24 to 48 hours, case-mix adjustment led to a decrease in variation between hospitals (tau decreases from 0.19 to 0.17). Hospitals' EVT-patient volume was strongly correlated with higher expanded thrombolysis in cerebral infarction scores ( =0.48) and weakly with lower NIHSS score at 24 to 48 hours ( =0.15). Conclusions Between-hospital variation in NIHSS score at 24 to 48 hours is significantly influenced by case-mix but not by patient volume. In contrast, between-hospital variation in expanded thrombolysis in cerebral infarction score is strongly influenced by EVT-patient volume but not by case-mix. Both outcomes may be suitable for comparing hospitals on quality of care, provided that adequate adjustment for case-mix is applied for NIHSS score.