Towards a national system for monitoring the quality of hospital-based stroke services

Background and Purpose-We sought to evaluate a system for monitoring the qu ality of hospital-based stroke services that uses routinely collected case fatality data, adjusted for case mix, as well as simple measures of the pro cess of stroke care. Methods-We compared the process of care and case fatality after stroke betw een 5 Scottish hospitals (A through E) during 1995-1997. We retrospectively identified 2724 patients with acute stroke using routine discharge data an d obtained case mix and process of care data from the medical record. We as certained case fatality by record linkage and adjusted for case mix using a simple, externally validated regression model. Results-Crude case fatality varied by 21 deaths per 100 admissions between the 5 hospitals. After adjustment, case fatality still differed significant ly (P=0.047), with 5 to 7 more deaths per 100 admissions at Hospital A than at Hospitals B through E. There were major shortcomings in the specializat ion and organization of care, the use of CT scanning, and the completeness of documentation at Hospital A compared with the other hospitals. There wer e smaller, but clinically important, differences in care between Hospitals B through E but no significant differences in adjusted case fatality. Conclusions-Once adjusted for important prognostic variables, routinely col lected case fatality data might identify hospitals with major shortcomings in the processes of stroke care. More moderate, but still clinically import ant, variations in stroke care can only be identified by monitoring the pro cess of care directly.