Towards a national system for monitoring the quality of hospital-based stroke services.
OBJECTIVE
We sought to evaluate a system for monitoring the quality of hospital-based stroke services that uses routinely collected case fatality data, adjusted for case mix, as well as simple measures of the process of stroke care.


METHODS
We compared the process of care and case fatality after stroke between 5 Scottish hospitals (A through E) during 1995-1997. We retrospectively identified 2724 patients with acute stroke using routine discharge data and obtained case mix and process of care data from the medical record. We ascertained case fatality by record linkage and adjusted for case mix using a simple, externally validated regression model.


RESULTS
Crude case fatality varied by 21 deaths per 100 admissions between the 5 hospitals. After adjustment, case fatality still differed significantly (P=0.047), with 5 to 7 more deaths per 100 admissions at Hospital A than at Hospitals B through E. There were major shortcomings in the specialization and organization of care, the use of CT scanning, and the completeness of documentation at Hospital A compared with the other hospitals. There were smaller, but clinically important, differences in care between Hospitals B through E but no significant differences in adjusted case fatality.


CONCLUSIONS
Once adjusted for important prognostic variables, routinely collected case fatality data might identify hospitals with major shortcomings in the processes of stroke care. More moderate, but still clinically important, variations in stroke care can only be identified by monitoring the process of care directly.
Weir
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Department of Clinical Neurosciences, Western General Hospital, Crewe Rd, Edinburgh EH4 2XU, Scotland.
Dennis
M S
MS
D000368:Aged; D000369:Aged, 80 and over; D019468:Disease Management; D005260:Female; D006748:Hospital Departments / Q000458:organization & administration / Q000592:standards* / Q000706:statistics & numerical data; D006769:Hospitals, General / Q000706:statistics & numerical data; D006784:Hospitals, Teaching / Q000706:statistics & numerical data; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000379:methods*; D011237:Predictive Value of Tests; D011379:Prognosis; D011785:Quality Assurance, Health Care / Q000592:standards*; D012372:ROC Curve; D012189:Retrospective Studies; D020379:Risk Adjustment; D012606:Scotland / Q000453:epidemiology; D012720:Severity of Illness Index; D012923:Social Class; D020521:Stroke / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D015996:Survival Rate