TY - JOUR
T1 - Improving quality of stroke care through benchmarking center performance
T2 - why focusing on outcomes is not enough
AU - Amini, Marzyeh
AU - van Leeuwen, Nikki
AU - Eijkenaar, Frank
AU - Mulder, Maxim J.H.L.
AU - Schonewille, Wouter J.
AU - Lycklama à Nijeholt, Geert J.
AU - Hinsenveld, Wouter H.
AU - Goldhoorn, Robert Jan B.
AU - van Doormaal, Pieter Jan
AU - Jenniskens, Sjoerd
AU - Hazelzet, Jan
AU - Dippel, Diederik W.J.
AU - Roozenbeek, Bob
AU - Lingsma, Hester F.
AU - van der Lugt, Aad
AU - Majoie, Charles B.L.M.
AU - Roos, Yvo B.W.E.M.
AU - van Oostenbrugge, Robert J.
AU - van Zwam, Wim H.
AU - Boiten, Jelis
AU - Vos, Jan Albert
AU - Brouwer, Josje
AU - den Hartog, Sanne J.
AU - Kappelhof, Manon
AU - Compagne, Kars C.J.
AU - Jansen, Ivo G.H.
AU - van Es, Adriaan C.G.M.
AU - Emmer, Bart J.
AU - Coutinho, Jonathan M.
AU - Schonewille, Wouter J.
AU - Wermer, Marieke J.H.
AU - van Walderveen, Marianne A.A.
AU - Staals, Julie
AU - Hofmeijer, Jeannette
AU - Martens, Jasper M.
AU - Lycklama à Nijeholt, Geert J.
AU - de Bruijn, Sebastiaan F.
AU - van Dijk, Lukas C.
AU - van der Worp, H. Bart
AU - Lo, Rob H.
AU - van Dijk, Ewoud J.
AU - Boogaarts, Hieronymus D.
AU - de Vries, J.
AU - de Kort, Paul L.M.
AU - van Tuijl, Julia
AU - Peluso, Jo Jo P.
AU - van den Berg, Jan S.P.
AU - Keizer, Koos
AU - Boers, Anna M.M.
AU - Groot, P. F.C.
AU - on behalf of the MR CLEAN Registry Investigators
PY - 2020/10/31
Y1 - 2020/10/31
N2 - Background: Between-center variation in outcome may offer opportunities to identify variation in quality of care. By intervening on these quality differences, patient outcomes may be improved. However, whether observed differences in outcome reflect the true quality improvement potential is not known for many diseases. Therefore, we aimed to analyze the effect of differences in performance on structure and processes of care, and case-mix on between-center differences in outcome after endovascular treatment (EVT) for ischemic stroke.Methods: In this observational cohort study, ischemic stroke patients who received EVT between 2014 and 2017 in all 17 Dutch EVT-centers were included. Primary outcome was the modified Rankin Scale, ranging from 0 (no symptoms) to 6 (death), at 90 days. We used random effect proportional odds regression modelling, to analyze the effect of differences in structure indicators (center volume and year of admission), process indicators (time to treatment and use of general anesthesia) and case-mix, by tracking changes in tau2, which represents the amount of between-center variation in outcome.Results: Three thousand two hundred seventy-nine patients were included. Performance on structure and process indicators varied significantly between EVT-centers (P < 0.001). Predicted probability of good functional outcome (modified Rankin Scale 0–2 at 90 days), which can be interpreted as an overall measure of a center’s case-mix, varied significantly between 17 and 50% across centers. The amount of between-center variation (tau2) was estimated at 0.040 in a model only accounting for random variation. This estimate more than doubled after adding case-mix variables (tau2: 0.086) to the model, while a small amount of between-center variation was explained by variation in performance on structure and process indicators (tau2: 0.081 and 0.089, respectively). This indicates that variation in case-mix affects the differences in outcome to a much larger extent.Conclusions: Between-center variation in outcome of ischemic stroke patients mostly reflects differences in case-mix, rather than differences in structure or process of care. Since the latter two capture the real quality improvement potential, these should be used as indicators for comparing center performance. Especially when a strong association exists between those indicators and outcome, as is the case for time to treatment in ischemic stroke.
AB - Background: Between-center variation in outcome may offer opportunities to identify variation in quality of care. By intervening on these quality differences, patient outcomes may be improved. However, whether observed differences in outcome reflect the true quality improvement potential is not known for many diseases. Therefore, we aimed to analyze the effect of differences in performance on structure and processes of care, and case-mix on between-center differences in outcome after endovascular treatment (EVT) for ischemic stroke.Methods: In this observational cohort study, ischemic stroke patients who received EVT between 2014 and 2017 in all 17 Dutch EVT-centers were included. Primary outcome was the modified Rankin Scale, ranging from 0 (no symptoms) to 6 (death), at 90 days. We used random effect proportional odds regression modelling, to analyze the effect of differences in structure indicators (center volume and year of admission), process indicators (time to treatment and use of general anesthesia) and case-mix, by tracking changes in tau2, which represents the amount of between-center variation in outcome.Results: Three thousand two hundred seventy-nine patients were included. Performance on structure and process indicators varied significantly between EVT-centers (P < 0.001). Predicted probability of good functional outcome (modified Rankin Scale 0–2 at 90 days), which can be interpreted as an overall measure of a center’s case-mix, varied significantly between 17 and 50% across centers. The amount of between-center variation (tau2) was estimated at 0.040 in a model only accounting for random variation. This estimate more than doubled after adding case-mix variables (tau2: 0.086) to the model, while a small amount of between-center variation was explained by variation in performance on structure and process indicators (tau2: 0.081 and 0.089, respectively). This indicates that variation in case-mix affects the differences in outcome to a much larger extent.Conclusions: Between-center variation in outcome of ischemic stroke patients mostly reflects differences in case-mix, rather than differences in structure or process of care. Since the latter two capture the real quality improvement potential, these should be used as indicators for comparing center performance. Especially when a strong association exists between those indicators and outcome, as is the case for time to treatment in ischemic stroke.
KW - Benchmarking
KW - Case-mix
KW - Endovascular treatment
KW - Outcome differences
KW - Process of care
KW - Quality of care
KW - Stroke
UR - http://www.scopus.com/inward/record.url?scp=85095405236&partnerID=8YFLogxK
U2 - 10.1186/s12913-020-05841-y
DO - 10.1186/s12913-020-05841-y
M3 - Article
C2 - 33129362
AN - SCOPUS:85095405236
SN - 1472-6963
VL - 20
JO - BMC health services research
JF - BMC health services research
IS - 1
M1 - 998
ER -
