Table 4 Quality monitoring

Parker 2012

Patients with stroke

I: Studies that evaluated the relationship between compliance with ≥ 2 quality metrics and patient centered outcomes or the public reporting of stroke metrics and QI activity, quality of care and patient centered outcomes.

Mortality, ADL function, adverse events/complications, QOL, patient satisfaction

There is some evidence of positive associations between stroke metric compliance and improved outcomes however, there are few high quality studies. Information on the impact of public reporting of stroke quality metric data is extremely limited

Design: SR

Size: 16 studies

Setting: Acute

All levels of severity

AMSTAR: 3/11

Dirks 2012

Patients with stroke

I: An intervention based on the ‘Breakthrough Series’ model to increase the rates of thrombolysis in acute stroke wards

Treatment rates of tPA, time from event to admission, death or disability, QOL

Thrombolysis rates in the intervention group rose earlier and remained higher than the control group.

C: Usual care

Design: cluster RCT

Size: N = 5515 patients from 12 hospitals

Setting: Acute

Netherlands

PEDro: 7/10

Falconer 1993

Patients with stroke

I: Care was provided based on an interdisciplinary care model and the use of a ‘critical path method (CPM) to plan care and discharge. The CPM provided the team with information and continuous feedback

Length of hospital stay, hospital charges, ADL function, patient satisfaction

The groups received comparable type, intensity and duration of treatment and there was no significant difference between groups in length of stay and hospital charges

Design: RCT

Size: N = 128

Setting: Rehabilitation

United States

PEDro: 4/10

C: Usual care in which the care model was more multidisciplinary and a CPM was not used.

Hinchey 2010

Patients with stroke

I: Multifaceted intervention targeted towards improving key performance measures: door-to-needle time for TPA, dysphagia screening, DVT prophylaxis and warfarin treatment for AF. The intervention included meetings, identification of barriers, reminder systems, education, audit and feedback.

Difference in post-intervention adherence rates

The intervention group had a significantly higher rate of patients with AF discharged on warfarin however there were no other significant differences between groups.

Design: Controlled trial

Size: N = 2071 pre-intervention patients and 1240 post-intervention patients

Setting: Acute

United States

C: Audit and feedback alone

D & B: 13/26

Johnston 2010

Patients with stroke

I: Standardised stroke discharge orders on adherence to 3 practices: normalisation of blood pressure, statin treatment and anticoagulation for AF

Management of these outcomes at 6 months

There was no significant impact of intervention at the hospital level.

Design: cluster RCT

Size: 12 hospitals (3361 patients)

Analysis at the patient level found that rates of optimal treatment increased at intervention hospitals whereas there was no change at control hospitals. Improvements were primarily related to increased statin use and improved blood pressure control.

Setting: Acute

C: Usual care (no standardised orders)

United States

PEDro: 8/10

Lakshminarayan 2010

Patients with stroke

I:Intervention to improve care quality as measured by

Ten performance measures(eg tPA use, smoking cessation counselling, PT and OT evaluation or treatment <48 hours)

There were no significant differences between groups

Design: cluster RCT

10 key performance measures. Intervention included receipt of a report on baseline quality, the use of clinical opinion leaders and assistance from study personnel to implement changes and overcome barriers

Size: 19 hospitals (1211 patients)

Setting: Acute

United States

PEDro: 8/10

C: Received report on baseline quality only

Strasser 2008

Patients with stroke

I: Both groups received summaries of their team’s performance on process measures. The intervention group received team training provided over 6 months. Comprised a 2.5 day workshop for team leaders to develop team problem-solving strategies, written action plans to address team process problems and support to implement action plans

ADL function, community discharge and length of stay

Patients in the intervention group improved significantly more on the FIM motor score than the control group (13.6% absolute difference in percentage of patients gaining more than 23 points)

Design: cluster RCT

Size: N = 487 patients

Setting: Rehabilitation

United States

PEDro: 5/10

C; Received the summary of performance only