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doi: 10.1097/01.NT.0000407221.36890.1b
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Joint Commission: How Do Hospitals Measure Up in Stroke Care?

Samson, Kurt

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ARTICLE IN BRIEF

A Joint Commission report on compliance with stroke measures showed a 92.8 percent national composite score among 3,000 member hospitals.

In its annual review of hospital performance, the Joint Commission (JC) has for the first time incorporated data on compliance with stroke treatment recommendations. The results are encouraging, with a 92.8 percent national composite score among 3,000 member hospitals. But some scores also pointed to areas in need of improvement — for example, in providing warfarin instructions at discharge and prophylaxis for stroke.

DR. GUSTAVO SAPOSNIK...
DR. GUSTAVO SAPOSNIK...
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The independent, not-for-profit Joint Commission accredits and certifies more than 19,000 health care organizations and programs in the United States. Its new report, based on 2010 data, recognized 450 for having superior care, including success in following stroke guidelines developed by the American Heart/Stroke Association, the Brain Attack Coalition — of which the AAN is a member — and the Centers for Medicare and Medicaid Services (CMS).

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ACCOUNTABILITY MOTIVATES

Gustavo Saposnik, MD, associate professor of neurology at the University of Toronto and director of the Stroke Outcomes Research Unit at St. Michael's Hospital, served as chair of a working group at the American Heart Association's Stroke Council, which earlier this year published an overview of the current evidence about the evaluation and treatment of adults with acute ischemic stroke.

He told Neurology Today in a telephone interview that he was not surprised that the compliance rate was high in the new report.

“An important yet under-recognized lesson from this report is the importance of public reporting,” he explained, noting that research indicates that such reporting can result in better clinical outcomes and fewer deaths from stroke.

Dr. Saposnik said his main concern is how the ratings will be used. There is always the risk of having money allocated to programs cut if there is any decline in performance rather than continued improvement, he noted. The problem, though, is that when ratings are as high as they are in the top ranked hospitals, the focus of the JC's report, it is very difficult to continue improving.

“If a hospital has a 2 percent drop after a really good rating, it can be misinterpreted as indicating systemic problems rather than resulting from variables that cannot be controlled for, such as changes in patient population characteristics at any given time,” he said. “Therefore the opportunity for improvement is more limited at institutions with already outstanding benchmarks.”

DR. LARRY B. GOLDSTE...
DR. LARRY B. GOLDSTE...
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COMPLIANCE ATTAINABLE

Larry B. Goldstein, MD, director of the Duke University Stroke Center in Durham, NC, told Neurology Today that the high composite rate for compliance at the top-rated hospitals in the new JC report should encourage all hospitals to beef up their programs.

“The point is that this [report] shows us that excellent compliance is achievable, but that it requires dedication,” he said in a telephone interview. “Even at moderate-volume stroke centers, though, this generally requires at least one full-time person working on stroke-related quality improvement projects and monitoring, collecting, and recording performance data.”

Duke's stroke center has two staff devoted to stroke improvement projects, he said — one who retrieves and enters compliance data and another working on the hospital wards, who monitors and makes sure quality standards are being followed and, hopefully, met. Most performance measures are based on the American Heart/Stroke Association's “Get with the Guidelines-Stroke” program, which was introduced in 2003, he noted.

“A large number of hospitals have voted with their feet, voluntarily participating in these programs, reflecting their commitment to provide the highest quality stroke care.” he said. “And, generally, whenever guideline quality standards monitoring and data collection are actively incorporated into a hospital's stroke program, there is improvement in compliance.”

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STROKE MEASURES: AREAS IN NEED OF IMPROVEMENT

Among hospitals that had an overall 90 percent or greater performance score on stroke measures:

* 48.1 percent provided stroke education;

* 74 percent discharged patients with statins;

* 18.8 percent offered thrombotic therapy;

* 45.3 percent provided venous thromboembolism prophylaxis for stroke.

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AAN INVOLVEMENT IN STROKE MEASURES

“The AAN is one of multiple groups involved in developing performance measures for treating stroke,” said Irene Katzan, MD, director of the Neurological Institute Center for Outcomes Research & Evaluation at the Cleveland Clinic in Ohio. Dr. Katzan, a member of the AAN Stroke Systems Work Group, was one of the authors of a September 2011 guideline for health professionals for preventing stroke in patients with ischemic stroke or transient ischemic attack, as well as a 2008 update to the AHA/ASA recommendations.

She told Neurology Today in a telephone interview that the three stroke performance measures with the lowest adherence rate in the recent JC report — offering warfarin instructions at discharge, thrombotic therapy, and venous thromboembolism (VTE) prophylaxis for stroke — were the most complicated measures and that documentation issues may be part of the reasons for their lower performance. [See “Stroke Measures: Areas in Need of Improvement.”] In addition, she noted that the regulations and definitions for quality reporting “seem to grow more complicated as time goes on.”

“Currently, the Joint Commission uses the CMS definitions for VTE prophylaxis and stroke education performance measures, which are not quite the same as the “Get with the Guidelines' definitions,” she explained.

Yet Dr. Katzan remains very optimistic that over time, these performance measures will become unified. Those involved are “working hard” toward that goal, she said.

Sarah Tonn, MPH, AAN associate director of clinical quality and performance evaluation, told Neurology Today in a telephone interview that the Academy has, and continues to have, a great deal of influence through their involvement in developing and helping to implement performance measures for stroke treatment. The Academy supports measuring all aspects of quality including clinical outcomes, patient health status, and patient experience, she noted, and the AAN Quality Measurement and Reporting Subcommittee continues to prepare the field of neurology for the forthcoming challenges.

“Performance measurement enables alignment and action in times of scarce resources by focusing on improving care while reducing costs,” she said. “The field of performance measures is still in its infancy, but the bottom line is that the issue is not going to go away. Application of these measures requires partnership, so we have to be transparent and work together. If we are not active now, someone is going to do it for us.”

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REFERENCES:

Improving America's Hospitals: The Joint Commission's annual report on quality and safety 2011. Sept. 14, 2011. www.jointcommission.org

Sacco RL, Adams R, Katzan I, et al. Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: A statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and Intervention. Stroke 2006;37:577-617.

Adams RJ, Albers G, Alberts MJ, et al. Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack. Stroke 2008;39(5).

Hart RG, Hinchey JA, Howard VJ, et al. Guidelines for the Primary Prevention of Stroke : A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2011, 42:517-584.

Saposnik G, Barinagarrementeria F, Brown RD Jr, et al. Diagnosis and management of cerebral venous thrombosis: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2011;42:1158-1192.

Lichtman, JH. Jones SB, Goldstein LB, et al. Outcomes after ischemic stroke for hospitals with and without Joint Commission–certified primary stroke centers. Neurology 2011;76:1976-1982.

©2011 American Academy of Neurology

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