Identifying Performance Outliers for Stroke Care Based on Composite Score of Process Indicators: an Observational Study
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Department of Biostatistics, Public Health College, Harbin Medical University Harbin, China; 2Central Laboratory, Beijing Obstetrics and Gynecology Hospital, Capital Medical University Chaoyang, Beijing, China.
BACKGROUND: Variability in the quality of stroke care is widespread. Identifying performance-based outlier hospitals based on quality indicators (QIs) has become a common practice. OBJECTIVES: To develop a tool for identifying performance-based outlier hospitals based on riskadjusted adherence rates of process indicators. DESIGN: Hospitals were classified into five-level outliers based on the observed-to-expected ratio and P value. The composite quality score was derived by summation of the points for each indicator for each hospital, and associations between outlier status and outcomes were determined. PARTICIPANTS: Patients diagnosed with acute ischemic stroke, January 1, 2011–May 31, 2017. INTERVENTION: N/A MAIN OUTCOME MEASURES: Independence at discharge (the modified Rankin Scale = 0–2). KEY RESULTS: A total of 501,132 patients from 519 hospitals were identified. From 0.39 to 19.65% of hospitals were identified as high outliers according to various QIs. Composite quality scores ranged from − 20 to 16. Providers that were high outliers based on QI2, QI8, QI9, and QI11 had higher independent rates. For composite quality score, each point increase corresponded to an 8% increase in the odds of independent rate. CONCLUSION: Nationwide variation in the quality of acute stroke care exists at the hospital level. Variability in the quality of stroke care can be captured by our proposed quality score. Applying this quality score as a benchmarking tool could provide audit-level feedback to policymakers and hospitals to aid quality improvement. KEY WORDS: stroke; quality of care; composite indicator; performance measures; outliers. J Gen Intern Med DOI: 10.1007/s11606-020-05923-x © Society of General Internal Medicine 2020
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s11606-020-05923-x) contains supplementary material, which is available to authorized users. Received November 9, 2019 Accepted May 11, 2020
BACKGROUND
Stroke is a global health problem, with 10.3 million new cases of stroke accounting for 113 million disability-adjusted life years (DALYs) per year. 1 Although stroke treatment has evolved, the quality of stroke care varies globally, and inequalities exist between medical facilities even within the same country. 2, 3 Comparing health care providers and identifying outlier providers simultaneously based on various indicators of performance, such as the rate of occurrence of particular outcome or process-based measures, has become a common practice. 4–6 Outcomes-based quality indicators are by far the most common measures in quality performance comparisons and identification of hospital outliers. 7, 8 Outlier hospitals can be identified simply according to relative rank based on expected mortality (after risk-adjusted) (e.g., top 10%, bottom 10%) or by
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