title: Associations between the organisation of stroke services, process of care, and mortality in England: prospective cohort study.
abstract: OBJECTIVE
  To estimate the relations between the organisation of stroke services, process measures of care quality, and 30 day mortality in patients admitted with acute ischaemic stroke.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Hospitals (n=106) admitting patients with acute stroke in England and participating in the Stroke Improvement National Audit Programme and 2010 Sentinel Stroke Audit.
  
  
  METHODS
  36,197 adults admitted with acute ischaemic stroke to a participating hospital from 1 April 2010 to 30 November 2011.
  
  
  METHODS
  Associations between process of care (the assessments, interventions, and treatments that patients receive) and 30 day all cause mortality, adjusting for patient level characteristics. Process of care was measured using six individual measures of stroke care and summarised into an overall quality score.
  
  
  RESULTS
  Of 36,197 patients admitted with acute ischaemic stroke, 25,904 (71.6%) were eligible to receive all six care processes. Patients admitted to stroke services with high organisational scores were more likely to receive most (5 or 6) of the six care processes. Three of the individual processes were associated with reduced mortality, including two care bundles: review by a stroke consultant within 24 hours of admission (adjusted odds ratio 0.86, 95%confidence interval 0.78 to 0.96), nutrition screening and formal swallow assessment within 72 hours (0.83, 0.72 to 0.96), and antiplatelet therapy and adequate fluid and nutrition for first the 72 hours (0.55, 0.49 to 0.61). Receipt of five or six care processes was associated with lower mortality compared with receipt of 0-4 in both multilevel (0.74, 0.66 to 0.83) and instrumental variable analyses (0.62, 0.46 to 0.83).
  
  
  CONCLUSIONS
  Patients admitted to stroke services with higher levels of organisation are more likely to receive high quality care as measured by audited process measures of acute stroke care. Those patients receiving high quality care have a reduced risk of death in the 30 days after stroke, adjusting for patient characteristics and controlling for selection bias.
authors.affiliation: King's College London, Division of Health and Social Care Research, London SE13QD, UK. benjamin.bray@kcl.ac.uk
authors.forename: Benjamin D
authors.initials: BD
authors.lastname: Bray
authors.forename: Salma
authors.initials: S
authors.lastname: Ayis
authors.forename: James
authors.initials: J
authors.lastname: Campbell
authors.forename: Alex
authors.initials: A
authors.lastname: Hoffman
authors.forename: Michael
authors.initials: M
authors.lastname: Roughton
authors.forename: Pippa J
authors.initials: PJ
authors.lastname: Tyrrell
authors.forename: Charles D A
authors.initials: CD
authors.lastname: Wolfe
authors.forename: Anthony G
authors.initials: AG
authors.lastname: Rudd
mesh_terms: D000328:Adult; D002545:Brain Ischemia / Q000150:complications*; D015331:Cohort Studies; D003133:Commission on Professional and Hospital Activities; D003695:Delivery of Health Care / Q000379:methods / Q000592:standards / Q000706:statistics & numerical data; D019468:Disease Management; D004739:England / Q000453:epidemiology; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D058996:Quality Improvement / Q000458:organization & administration*; D059039:Standard of Care; D020521:Stroke / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy; D016019:Survival Analysis