[Evaluation of the public-health intervention "Healthy Lower Rhine...against Stroke" by means of clinic data in the district of Wesel, Germany. Comparative study with clinic data samples in 2003 and in 2005]. / Evaluation des Public-Health-Programms "Gesunder Niederrhein ... gegen den Schlaganfall" durch Primärdaten aus Kliniken im Kreis Wesel: Vergleichende Studie von Stichprobendaten aus den Jahren 2003 und 2005.

BACKGROUND AND PURPOSE: The initiative "Healthy Lower Rhine ... against Stroke" aims at improving stroke knowledge in the community, i.e., knowledge of stroke symptoms and proper action when stroke signs occur (call emergency number 112) in order to reduce prehospital times/delay. An expert group in the district of Wesel decided to raise an inventory of stroke-care quality in the whole district. Samples of patient data were drawn in all hospitals in the district of Wesel, in order to gain a database for evaluation of possible effects on prehospital time due to the intervention. MATERIAL AND METHODS: All hospitals in the Wesel district collected data from patients presenting with stroke signs. Data collection was performed for a time span of 3 months before (T0 in 2003) and during (T1 in 2005) the public-health intervention. Standardized data collection was performed with a short version of the questionnaire issued by the German Stroke Registers Study Group (ADSR). Influential factors on prehospital time and means of transportation were analyzed by multivariate logistic regression. RESULTS: The portion of patients hospitalized within a <3-h window after onset of stroke symptoms did no vary between 2003 and 2005 (27.3% vs. 27.5%). In 2005, acute care of stroke patients was performed more frequently in the emergency department (33% in 2003 vs. 84% in 2005). Before the start of the stroke intervention, seven clinics collected data on 326 patients, and in 2005, 375 patients were registered by all eight hospitals in the district of Wesel. Mean age of patients rose from 72 to 74 years. The portion of men dropped from 50% to 43%. CONCLUSION AND PERSPECTIVE: Obviously, prehospital delay was not reduced after a 2-year run of a stroke campaign. It is recommended to carry out a second survey into community stroke knowledge in the district of Wesel. If a significant trend of improved knowledge should be detected, a new evaluation through clinic data sampling would make sense.

Development and implementation of evidence-based indicators for measuring quality of acute stroke care: the Quality Indicator Board of the German Stroke Registers Study Group (ADSR).

BACKGROUND AND PURPOSE: There is no consensus about indicators for measuring quality of acute stroke care in Germany. Therefore, a standardized process was initiated recently to develop and implement evidence-based indicators for the measurement of quality of acute hospital stroke care. METHODS: Quality indicators were developed by a multidisciplinary board between November 2003 and December 2005. The process was initiated by the German Stroke Registers Study Group in cooperation with the German Stroke Society, the German Society of Neurology, the German Stroke Foundation, Regional Offices for Quality Assurance and other experts proven in the field. National and international recommendations were considered during the development process. The process was based on a systematic literature review, an independent external evaluation of the process and its results, and a prospective pilot study to evaluate the defined indicators in clinical practice. RESULTS: Overall a set of 24 indicators was developed to measure performance of acute care hospitals in the 3 health care dimensions structure, process and outcome as well as in 3 treatment phases prehospital, in-hospital/acute and postacute. Practicability of the derived indicators was tested in a prospective pilot study. During a 2-month period, 1006 patients in 13 hospitals were documented. Application of the new indicator set was found to be feasible by participating physicians and hospitals. Median time to document the required information for 1 patient was 5 minutes. Nationwide implementation of the new indicator set within regional registers in Germany started since April 2006. CONCLUSIONS: The development of indicators to measure hospital performance in stroke care is an important step toward improving stroke care on a national level. The chosen standardized evidence-based approach ensures maximal transparency, acceptance and sustainability of the developed indicators in Germany.

[Identification of quality indicators of stroke care]. / Identifizierung von Qualitätsindikatoren der Schlaganfallversorgung.

BACKGROUND/OBJECTIVES: The purpose of the present study was to identify existing quality indicators of stroke care and to select those that are appropriate for use in the German health care system. METHODS: A systematic literature search in databases of performance measures, clinical indicator programs, stroke guidelines and published scientific literature (published in 1993-2002) identified 151 quality indicators. This number was reduced by selecting indicators that satisfied the following quality criteria for clinical performance measures: a) consensus on the relative importance of aspects of clinical care (according to the American Heart Association/American College of Cardiology Forum), b) controllability of aspects of clinical care (according to the German "Advisory Council for the Concerted Action in Health Care") and c) internal validity (according to the stroke guideline of the Royal College of Physicians, UK). RESULTS: Of the 151 quality indicators, 31 fulfilled all three criteria for clinical performance measures. After elimination of overlapping indicators 13 quality indicators remained covering important aspects of the quality of stroke care in Germany: two of these indicators refer to the quality of structural aspects of care, six consider processes of care and five indicators are devoted to outcomes of care. These 13 indicators cover "prevention, rehabilitation, coordination and continuity of care", which are important controllable aspects of care. Whereas six indicators were considered to be highly valid, seven indicators did not convey enough information to ensure their validity. CONCLUSION: Suitable quality indicators covering several important aspects of stroke care could be selected from existing indicators for the development of an appropriate set of indicators to be used in the German health care system.

[Critical appraisal of stroke guidelines]. / Methodische Qualität von Leitlinien zur Schlaganfallversorgung.

BACKGROUND: Despite the increasing burden of disease and known deficiencies of actual stroke care there is a lack of evidence-based stroke guidelines in Germany. For future guideline development and implementation in Germany, critically appraising internationally available guidelines might be useful. OBJECTIVES: To identify and evaluate published evidence-based German and English language stroke/cerebrovascular disorder guidelines using the established "German Guideline Appraisal Instrument". METHODS: Systematic literature search (published in 1992-2002) using Medline and English-/German language guideline databases. A total of 626 hits resulted in 54 guideline articles. 13 articles (from Australia, Germany, the United Kingdom, Singapore and the USA) fulfilled specific inclusion criteria (recommended for countrywide implementation, complete guidelines for prevention and/or diagnostic/treatment and/or rehabilitation). The systematic guideline appraisal consisted of a) the assessment of the methodological quality using the established "German Guideline Appraisal Instrument" attributing scores and ranking the guidelines according to their overall quality; b) the systematic documentation of appraisal using structured abstracts. RESULTS: The methodological quality of "content and form" (10-17 of a total of 17 points) of the 13 guidelines was comparable. Regarding the domains of the "quality of the development process" (the guidelines achieved 4-15 of 17 points) and "guideline applicability" (0-3 of 6 points), though, the appraised guidelines varied impressively. The 6 best guidelines (> or = 25 of a total of 40 points) were characterized by explicitly linking recommendations and supporting evidence, by expert reviews of the guidelines prior to publication, and the provision of instructions for guideline implementation. CONCLUSION: None of the 13 appraised guidelines covered all key methodological quality criteria. The analysis shows, however, that it should be possible to compile a methodologically sound stroke guideline by using those parts of the different appraised guidelines that fitted the quality criteria best.