Risk adjustment of ischemic stroke outcomes for comparing hospital performance: a statement for healthcare professionals from the American Heart Association/American Stroke Association.
OBJECTIVE
Stroke is the fourth-leading cause of death and a leading cause of long-term major disability in the United States. Measuring outcomes after stroke has important policy implications. The primary goals of this consensus statement are to (1) review statistical considerations when evaluating models that define hospital performance in providing stroke care; (2) discuss the benefits, limitations, and potential unintended consequences of using various outcome measures when evaluating the quality of ischemic stroke care at the hospital level; (3) summarize the evidence on the role of specific clinical and administrative variables, including patient preferences, in risk-adjusted models of ischemic stroke outcomes; (4) provide recommendations on the minimum list of variables that should be included in risk adjustment of ischemic stroke outcomes for comparisons of quality at the hospital level; and (5) provide recommendations for further research.


RESULTS
This statement gives an overview of statistical considerations for the evaluation of hospital-level outcomes after stroke and provides a systematic review of the literature for the following outcome measures for ischemic stroke at 30 days: functional outcomes, mortality, and readmissions. Data on outcomes after stroke have primarily involved studies conducted at an individual patient level rather than a hospital level. On the basis of the available information, the following factors should be included in all hospital-level risk-adjustment models: age, sex, stroke severity, comorbid conditions, and vascular risk factors. Because stroke severity is the most important prognostic factor for individual patients and appears to be a significant predictor of hospital-level performance for 30-day mortality, inclusion of a stroke severity measure in risk-adjustment models for 30-day outcome measures is recommended. Risk-adjustment models that do not include stroke severity or other recommended variables must provide comparable classification of hospital performance as models that include these variables. Stroke severity and other variables that are included in risk-adjustment models should be standardized across sites, so that their reliability and accuracy are equivalent. There is a pressing need for research in multiple areas to better identify methods and metrics to evaluate outcomes of stroke care.


CONCLUSIONS
There are a number of important methodological challenges in undertaking risk-adjusted outcome comparisons to assess the quality of stroke care in different hospitals. It is important for stakeholders to recognize these challenges and for there to be a concerted approach to improving the methods for quality assessment and improvement.
Irene L
IL
Katzan
John
J
Spertus
Janet Prvu
JP
Bettger
Dawn M
DM
Bravata
Mathew J
MJ
Reeves
Eric E
EE
Smith
Cheryl
C
Bushnell
Randall T
RT
Higashida
Judith A
JA
Hinchey
Robert G
RG
Holloway
George
G
Howard
Rosemarie B
RB
King
Harlan M
HM
Krumholz
Barbara J
BJ
Lutz
Robert W
RW
Yeh
D000572:American Heart Association; D002545:Brain Ischemia / Q000401:mortality / Q000628:therapy*; D006761:Hospitals / Q000592:standards*; D006801:Humans; D017146:Models, Organizational; D017063:Outcome Assessment, Health Care / Q000379:methods; D010359:Patient Readmission / Q000706:statistics & numerical data; D011237:Predictive Value of Tests; D011379:Prognosis; D011787:Quality of Health Care; D020127:Recovery of Function; D015203:Reproducibility of Results; D020379:Risk Adjustment / Q000592:standards*; D018401:Sample Size; D020521:Stroke / Q000401:mortality / Q000628:therapy*; D016896:Treatment Outcome; D014481:United States
AHA Scientific Statements; health policy; outcomes; stroke