Melanie R. F. Greenway, MD

Haas K, Rücker V, Hermanek P, Misselwitz B, Berger K, Seidel G, Janssen A, Rode S, Burmeister C, Matthis C, et al. Association Between Adherence to Quality Indicators and 7-Day In-Hospital Mortality After Acute Ischemic Stroke. Stroke. 2020;51:3664–3672.

In the age of checklists, quality metrics, and frequent audits, sometimes the importance of these indicators is taken for granted. Instead of serving as a guiding light for quality care, they may be seen as an annoyance, slowing down an already inefficient system. This study reviewing the association between quality indicators (QI) and outcomes is a good reminder of the importance of tending to these quality indicators. 

This study utilized the German Stroke Registers Study Group (Arbeitsgemeinschaft Deutschprachiger Schlaganfall Register), which is a network of nine stroke registers, comprising multiple regions throughout the country. 388,012 patients with acute ischemic stroke admitted to 736 hospitals were reviewed from 2015-2016. Of the hospitals participating, 55.6% of them had stroke unit services. Overall, 7-day in-hospital mortality was 3.4%, and median length of stay was 8 days. 

The quality indicators were based on national recommendations and expert consensus. For this study, they evaluated 11 of the 20 indicators used within the ADSR. These indicators were:

  • Physiotherapy/occupational therapy within 2 days
  • Speech therapy within 2 days
  • Mobilization within 2 days
  • Vascular imaging within 48 hours
  • Brain imaging within 30 minutes
  • Dysphagia screening
  • Screening for atrial fibrillation
  • Antiplatelets within 48 hours
  • Intravenous thrombolysis in eligible patients within 4 hours from onset
  • Door-to-needle time less than 1 hour
  • Treatment on a stroke unit

Overall, more than half of patients fulfilled all quality indicators they were eligible for. The study demonstrated that adhering to these quality indicators was overall associated with lower risk of death within 7-days. The exceptions to this were early brain imaging and door-to-needle time, both of which showed no statistical significance with regards to 7-day mortality. Overall, the authors demonstrated an inverse relationship between number of QI fulfilled and 7-day in-hospital mortality.

Specifically, the mortality rate was 19% when 0-49% of QI were fulfilled and improved steadily to 1.8% if 100% were fulfilled. With univariate analysis, several factors were associated with higher mortality, including decreasing proportion of QI fulfilled, increased age, severity of stroke, female sex, and presence of living will. 

This study builds on prior registry-based studies that compare compliance with quality indicators and outcomes. Hopefully, it can be a source of encouragement for all those who care for patients with acute ischemic stroke that compliance with quality metrics is worth the investment.