Neurology -- Correspondence for Gropen et al., 67 (1) 88-93

Correspondence published:

Quality improvement in acute stroke: The New York State Stroke Center Designation Project: Sharon Downie (5 October 2006)

Reply from the Authors: Toby I. Gropen, Patricia J. Gagliano, Cathy A. Blake, Ralph L. Sacco, Thomas Kwiatkowski, Neal J. Richmond, Dana Leifer, Richard Libman, Salman Azhar, and Maryanne B. Daley (5 October 2006)

Quality improvement in acute stroke: The New York State Stroke Center Designation Project 5 October 2006

Sharon Downie,
Monash Medical Centre (Stroke Unit)
OT Department, Monash Medical Centre, Locked Bag 29, Clayton 3169, Victoria, Australia
Send Correspondence to journal:
Re: Quality improvement in acute stroke: The New York State Stroke Center Designation Project

sharon.downie{at}southernhealth.org.au Sharon Downie

I read with interest Gropen et al’s conclusion that "stroke center designation and selective triage of acute stroke patients improved the quality of care." [1] I commend the authors for their obvious commitment to improving acute stroke management yet their study was effectively restricted to review of the delivery but due to study design, fails to address quality of care in its totality.
Definitions of quality of care are inherently difficult given the multi-dimensional and subjective nature of quality but are ultimately integral to its measurement. [2] The domain of ‘access to care’ forms the primary focus of Gropen et al’s suite of quality indicators, and undoubtedly has the potential to impact upon stroke outcomes. However, access alone fails to capture quality as the sum of the patient’s health experiences, [3] as advocated by the seminal "Quality Chasm" report, [4] and thus leads one to question the authors’ broad assertion that "stroke center designation and selective triage ... were associated with improved quality of care for patients." [1]
Gropen et al's study methodology is consequently reliant on process indicators related to access rather than global patient outcomes. The authors state that enhanced quality of care was partly "related to more timely assessment, diagnosis and treatment of stroke patients" [1] with the underlying assumption being that process achievement must be indicative of improved outcomes. This is contrary to opinion within the literature which cautions against assuming causal attribution owing to the likely effect of extraneous variables upon healthcare outcomes. [3,5] Outcome measures included within this study, specifically rates of post t-PA hemorrhage, peri-stroke complications and home discharge, did not reach statistical significance at remeasurement, and also failed to support the authors' contention that good processes translate to good patient outcomes.
The study by Gropen et al fails to provide a patient-focused definition of quality to guide accurate data measurement. [2,4] To this end, the authors’ use of process indicators as pseudo-measures of patient outcome limits prospective investigation of the longer term patient impacts of care processes, [5] and ulimately fails to validate the guidelines for stroke center designation. [3] The only definitive conclusion that should be drawn from this research is that stroke center designation criteria and selective triage resulted in improved access and timeliness of specific processes of care. Ultimately, further studies will be required to address patient quality of care issues.
References
1. Gropen TL, Gagliano PJ, Blake CA, et al. Quality improvement in acute stroke: the New York State Stroke Center Designation Project. Neurology 2006;67: 88-93.
2. DeGeyndt W. Definitions, objectives and rationale: managing the quality of health care in developing countries. World Bank Technical Paper 1995;258: 2-6.
3. Bernstein SJ, Hillbourne LH. Clinical indicators: the road to quality of care? Joint Commission Journal on Quality Improvement 1993;19: 501-509.
4. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Washington: National Academy Press, 2001.
5. Donabedian A. The quality of care: how can it be assessed? JAMA 1988;260: 1743-1748.
Disclosure: The authors report no conflicts of interest.

Reply from the Authors 5 October 2006

Toby I. Gropen,
Long Island College Hospital
339 Hicks Street, Brooklyn, NY, 11201,
Patricia J. Gagliano, Cathy A. Blake, Ralph L. Sacco, Thomas Kwiatkowski, Neal J. Richmond, Dana Leifer, Richard Libman, Salman Azhar, and Maryanne B. Daley
Send Correspondence to journal:
Re: Reply from the Authors

tgropen{at}chpnet.org Toby I. Gropen, et al.

We appreciate the interest of Ms. Downie in our article. She takes issue with reliance of our study on process measures rather than outcome data which we acknowledged as a limitation. However, it has been observed that process data are usually more sensitive measures of quality than outcome data because a poor outcome does not occur every time there is an error in the process of care. [6]
The issue is that we must have sound scientific evidence or a formal consensus of experts that the process of care, when applied, leads to an improvement in health. [6] Fortunately, as we pointed out, [1] the benefits of timely and appropriately administered t- PA and Stroke Unit care have already been established in randomized clinical trials.
We have a different perspective on what constitutes quality of care. One definition encompassed by our study is technical quality of care [7] consisting of the appropriateness of the services provided (i.e., t-PA and Stroke Unit Care for patients with stroke) and the skill with which appropriate care is performed (timely administration of t-PA without increased protocol violations or complications). [1]
Another relevant perspective on quality is that related to how well an integrated acute stroke system of care functions. This was shown in our study by improved access to t-PA and Stroke Unit care for patients in Brooklyn and Queens. [1]
As Ms. Downie points out, definitions of quality of care are inherently difficult. It has been observed that several formulations are both possible and legitimate; [5] it follows that different perspectives on and definitions of quality of care will call for different approaches to measurement and management. [7] Accordingly, we suspect that no study design would address quality of care in its totality.
References

6. Brook RH, McGlynn EA, Cleary PD. Quality of health care. Part 2: measuring quality of care. NEJM 1996;335:966-970.
7. Blumenthal D. Quality of health care. Part 1: quality of care – what is it? NEJM 1996;335:891-893.
Disclosure: The authors report no conflicts of interest.