Stroke care: how do we measure quality?

The purpose of this paper is to review the methods used to measure quality of stroke care. Relevant articles were searched for on Medline using the following key words: stroke, quality, outcome of care, process of care, structure of care. Articles that examined how to measure the quality of stroke care and that examined difficulties in the measurement of care outcomes, processes, and structures were selected. Selected articles were reviewed to summarise methods used to measure quality of stroke care and the primary outcome measures of the studies were extracted. Conclusions were drawn about the best ways to measure the quality of stroke care. Practical problems in using outcome measures to monitor quality of care include the consequences of case mix and difficulties in risk adjustment. Clinicians may use process measures to understand differences in outcome. Once a process of care has been linked to an outcome measure, this care process should be measured. The national sentinel audit for stroke is an audit tool used to examine the quality of the processes of stroke care.

Reliability and validity of the Intercollegiate Stroke Audit Package.

The aim of this study was to assure the validity and reliability of the Intercollegiate Stroke Audit Package as used in the National Sentinel Audit of Stroke. The Intercollegiate Working Party for Stroke, which included most stakeholders, including patients, devised the audit standards. These were submitted to a formal consensus (modified Delphi) survey before the audit questions were developed and piloted for validity and reliability. Following the pilot, Help Booklets were developed to promote the involvement of all disciplines as auditors in the national sentinel audit of stroke and ensure inter-rater reliability. During the national audit each Trust was asked to double rate the first five cases with auditors of different disciplines working independently. A total of 886 case notes were double-rated in 184 separate sites (median 5, range 1-5 per site). Trusts used auditors from different disciplines in 77% of cases. After excluding the 'No answer' cases the kappa score for items ranged from 0.49 to 0.87 (median 0.70, IQR 0.63-0.78). Very good agreement was found for seven of the 45 items, good agreement for 30 items, and moderate agreement for eight items. This large study, across a range of hospital sites and involving many disciplines, demonstrates that careful piloting of audit tools, with use of clear instructions to auditors, promotes the reliability of data.