Systematic Review of Process Indicators: Including Early Rehabilitation Interventions Used to Measure Quality of Acute Stroke Care

Abstract

Background Stroke is a leading cause of disease burden. The quality of care provided in hospitals can affect outcome. Therefore, examining adherence to clinically important processes of care can help improve care delivery and patient outcomes. However, knowing which process indicators to measure is essential. Aim Systematically review process indicators used to evaluate acute stroke services, including early rehabilitation interventions, and assess whether published indicators conform to clinical guidelines. Methods Publications (1985-2006) were identified by systematically searching databases (e.g. Medline and Cochrane Library), and the internet using free text terms: ‘stroke unit’, ‘process’, ‘quality’, ‘mobilisation’, ‘acute’, and ‘early rehabilitation’. Publications describing process indicators relating to the first 2 weeks of in-patient stroke care were included. Process indicators were categorised according to six clinical process domains covering the acute stroke admission. Commonly cited indicators (≥6 publications) were then mapped to the 2003 Australian clinical guidelines. Results Sixty potential studies were found from title and abstract. Following full text review, 32 publications were retained. Of the 161 process indicators identified, 43 were commonly cited. Seventy-nine per cent of commonly cited indicators were found in the guidelines. The level of evidence underpinning each indicator ranged from low ‘expert opinion’ (59%), to high, ‘level 1’ (12%) evidence. Indicators related to rehabilitation were rare. Conclusion Many acute stroke process indicators have been published. However, a quarter did not align with current clinical guidelines. Developing an ‘ideal set’ of process indicators to reflect the evidence base seems sensible and should include rehabilitation interventions.