Neurology -- Correspondence for California Acute Stroke Pilot Registry (CASPR) Investigators, 65 (3) 360-365

Correspondence published:

The impact of standardized stroke orders on adherence to best practices: Joseph Kwan (19 October 2005)

Reply to Kwan: S. Claiborne Johnston, CASPR Investigators (19 October 2005)

The impact of standardized stroke orders on adherence to best practices 19 October 2005

Joseph Kwan,
University of Southampton
Level E (807), Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
Send Correspondence to journal:
Re: The impact of standardized stroke orders on adherence to best practices

jk{at}1to1.org Joseph Kwan

I read with great interest the article by the Californian Acute Stroke Pilot Registry (CASPR) Investigators. [1] The investigators should be commended for performing such a well-designed, large-scaled multi-center before-and-after study to test the effectiveness of standardized orders for admission and discharge of stroke patients. Physicians often struggle to find practical ways of improving quality of stroke care, and the implementation of standardized orders seems to be a logical step toward bringing evidence-based stroke treatments closer to the bedside. However, there are several methodological issues about this study that deserve clarification.
Firstly, one of the major confounding factors in this study is the retrospective nature of data collection through case notes examination. Year 2 data were presumably retrieved through examination of the standardized orders in the case notes, and the quality of documentation was presumably extremely high. However, since the standardized orders did not exist in Year 1, data retrieval was presumably achieved through examination of the conventional case notes. It is possible that the observed differences in outcome merely reflected poor documentation in the Year 1 case notes (since if an intervention was not documented, it was presumed not to have occurred), rather than a real change in practice.
Secondly, since the authors used an intention-to-treat method of data analysis, it would be helpful if the authors reported the data for compliance with the standardized orders, (i.e., what proportion of patients was managed using the standardized orders, were there differences between the six hospitals, when the standardized orders were used, and how completely were they filled in) Moreover, it would be interesting to explore the correlation between compliance and outcome.
Standardized orders used in this study are similar to care pathways in terms of their intention and format, especially when documented �variances� (i.e. acceptable reasons for not undertaking an intervention or achieving a goal) were analyzed. In theory, care pathways involve standardized orders that are designed around a pre-defined timeline and should involve multiple disciplines. However, in practice, care pathways vary and many would resemble the standardized orders used in this study.
In the Cochrane review on the use of �in-hospital care pathways for stroke� [2], we included three randomized and 12 non-randomized studies (4421 patients). The Cochrane review did not find any significant differences between care pathway and control groups in terms of death or discharge destination. However, care pathway management was associated with fewer urinary tract infections, fewer readmissions, and more patients receiving a computed tomography scan. Interestingly, the Cochrane review also found evidence that patients managed with a care pathway were more dependent at discharge, had lower patient satisfaction and lower quality of life, although the reasons for these findings are unclear.
Although interventions involving standardized orders (such as care pathways) may improve certain processes of stroke care and quality of documentation, evidence for improved functional outcome is unclear.
References:
1. Californian Acute Stroke Pilot Registry (CASPR) Investigators. The impact of standardized stroke orders on adherence to best practices. Neurology 2005;65:360-365.
2. Kwan J, Sandercock P. In-hospital care pathways for stroke. The Cochrane Database of Systematic Reviews 2004, Issue 4.
Disclosure: The authors report no conflicts of interest.

Reply to Kwan 19 October 2005

S. Claiborne Johnston,
University of California, San Francisco
505 Parnassus Ave; M-798, San Francisco, CA 94143-0114,
CASPR Investigators
Send Correspondence to journal:
Re: Reply to Kwan

clay.johnston{at}ucsfmedctr.org S. Claiborne Johnston, et al.

We thank Dr. Kwan for his comments and are glad he has drawn attention to his excellent meta-analysis on care pathways. He raises an important point about the possibility that standardized stroke orders could have made documentation of medication usage more complete. We did demonstrate that documentation of contraindications to therapy had improved. However, we also demonstrated that for most of the interventions we were tracking, actual usage also increased after institution of standardized orders. We do not believe that the order templates simply improved documentation of receipt of these interventions; we required that a specific physician order was present and these were carefully and completely documented at all our hospitals both before and after institution of the standardized orders.
Dr. Kwan also raises an interesting point about correlating extent of order usage with improvements. We recognized at the initiation of the intervention that implementing the orders would have collateral benefits at the hospitals by educating physicians about standards of care and would likely improve care even when they were not used. Therefore, we did not gather these data. Even so, utilization might have been a surrogate measure of enthusiasm for the intervention and it would certainly be interesting to produce the analysis suggested.
In the Quality Improvement in Stroke Prevention (QUISP) trial, we have randomized seven hospitals to receive an intervention based upon standardized discharge orders and seven to continue usual care. The primary outcome is utilization of optimal medications for secondary prevention 6 months after discharge. Actual use of the orders is tracked as part of the trial. The primary analysis will be intention to treat, but we will certainly evaluate the correlation between usage and outcomes.
When those results are available, we will be able to respond to Dr. Kwan�s second point, and we will also have much more solid data about the impact of standardized orders which are only one component of care pathways.