Structure, process, and outcomes in stroke rehabilitation.
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.
Hoenig
Helen
H
Durham VA Medical Center and Department of Medicine, Duke University Medical Center, Durham, North Carolina 27705, USA. helen.hoenig@duke.edu
Duncan
Pamela W
PW
Horner
Ronnie D
RD
Reker
Dean M
DM
Samsa
Gregory P
GP
Dudley
Tara K
TK
Hamilton
Byron B
BB
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