title: Structure, process, and outcomes in stroke rehabilitation.
abstract: BACKGROUND
  The health services research framework of structure, process, and outcome is used commonly to examine quality of care, and it indicates that structure influences process, which in turn influences outcomes. However, little empirical work has been done to test this hypothesis, particularly for medical rehabilitation.
  
  
  OBJECTIVE
  To determine if, among stroke patients, (1) structure of care was associated with process of care, and (2) structure of care was associated with outcomes after adjusting for process.
  
  
  METHODS
  Two-year, prospective study of 288 acute stroke patients in 11 VA medical centers, of whom 128 were included in the current analysis.
  
  
  METHODS
  Structure of care: systemic organization, staffing expertise, and technological sophistication. Process of care: compliance with the AHCPR poststroke rehabilitation guidelines.
  
  
  METHODS
  baseline prior walking ability and Functional Independence Measure (FIM) motor subscale.
  
  
  RESULTS
  the FIM motor subscale 6-months poststroke.
  
  
  RESULTS
  The combination of systemic organization and staffing expertise, along with technological sophistication, were independent predictors of process of care (beta coefficients 0.21, P<0.05 and 0.37, P<0.001, respectively). When controlling simultaneously for patient characteristics, structure and process of care, structure of care did not have and process of care did have a statistically significant association (beta coefficient 0.18, P<0.01) with functional outcomes.
  
  
  CONCLUSIONS
  Better process of care was associated with better 6-month functional outcomes, therefore improving process of care probably would improve stroke outcomes. However, our results indicate that improving key structure of care elements might facilitate improving process of care for stroke patients.
authors.affiliation: Durham VA Medical Center and Department of Medicine, Duke University Medical Center, Durham, North Carolina 27705, USA. helen.hoenig@duke.edu
authors.forename: Helen
authors.initials: H
authors.lastname: Hoenig
authors.forename: Pamela W
authors.initials: PW
authors.lastname: Duncan
authors.forename: Ronnie D
authors.initials: RD
authors.lastname: Horner
authors.forename: Dean M
authors.initials: DM
authors.lastname: Reker
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Samsa
authors.forename: Tara K
authors.initials: TK
authors.lastname: Dudley
authors.forename: Byron B
authors.initials: BB
authors.lastname: Hamilton
mesh_terms: D000203:Activities of Daily Living; D000368:Aged; D005260:Female; D006302:Health Services Research; D006801:Humans; D008297:Male; D015999:Multivariate Analysis; D010043:Outcome and Process Assessment, Health Care; D011446:Prospective Studies; D020127:Recovery of Function; D000071939:Stroke Rehabilitation