Association between patient outcomes and key performance indicators of stroke care quality: A systematic review and meta-analysis

Purpose: Translating research evidence into clinical practice often uses key performance indicators to monitor quality of care. We conducted a systematic review to identify the stroke key performance indicators used in large registries, and to estimate their association with patient outcomes. Method: We sought publications of recent (January 2000–May 2017) national or regional stroke registers reporting the association of key performance indicators with patient outcome (adjusting for age and stroke severity). We searched Ovid Medline, EMBASE and PubMed and screened references from bibliographies. We used an inverse variance random effects meta-analysis to estimate associations (odds ratio; 95% confidence interval) with death or poor outcome (death or disability) at the end of follow-up. Findings: We identified 30 eligible studies (324,409 patients). The commonest key performance indicators were swallowing/nutritional assessment, stroke unit admission, antiplatelet use for ischaemic stroke, brain imaging and anticoagulant use for ischaemic stroke with atrial fibrillation, lipid management, deep vein thrombosis prophylaxis and early physiotherapy/mobilisation. Lower case fatality was associated with stroke unit admission (odds ratio 0.79; 0.72–0.87), swallow/nutritional assessment (odds ratio 0.78; 0.66–0.92) and antiplatelet use for ischaemic stroke (odds ratio 0.61; 0.50–0.74) or anticoagulant use for ischaemic stroke with atrial fibrillation (odds ratio 0.51; 0.43–0.64), lipid management (odds ratio 0.52; 0.38–0.71) and early physiotherapy or mobilisation (odds ratio 0.78; 0.67–0.91). Reduced poor outcome was associated with adherence to swallowing/nutritional assessment (odds ratio 0.58; 0.43–0.78) and stroke unit admission (odds ratio 0.83; 0.77–0.89). Adherence with several key performance indicators appeared to have an additive benefit. Discussion: Adherence with common key performance indicators was consistently associated with a lower risk of death or disability after stroke. Conclusion: Policy makers and health care professionals should implement and monitor those key performance indicators supported by good evidence

How to do health services research in stroke: a focus on performance measurement and quality improvement

The objective of this ‘How to’ research series article is to provide guidance on getting started in Health Services Research. The purpose of health services research is to contribute knowledge that can be used to help improve health systems and clinical services through influencing policy and practice. The methods used are broad, have varying levels of rigour and may require different specialist skills. This paper sets out practical steps for undertaking health services research. Importantly, use of the highlighted techniques can identify solutions to address inadequate knowledge translation or promote greater access to evidence-based stroke care to optimise patient outcomes

Weak Cost Register Automata are Still Powerful

We consider one of the weakest variants of cost register automata over a tropical semiring, namely copyless cost register automata over $\mathbb{N}$ with updates using $\min$ and increments. We show that this model can simulate, in some sense, the runs of counter machines with zero-tests. We deduce that a number of problems pertaining to that model are undecidable, in particular equivalence, disproving a conjecture of Alur et al. from 2012. To emphasize how weak these machines are, we also show that they can be expressed as a restricted form of linearly-ambiguous weighted automata.Comment: 16 page

EXTREMELY UNIFORM BRANCHING PROGRAMS

We propose a new descriptive complexity notion of uniformity for branching programs solving problems defined on structured data. We observe that FO[=]-uniform (n-way) branching programs are unable to solve the tree evaluation problem studied by Cook, McKenzie, Wehr, Braverman and Santhanam [8] because such programs possess a variant of their thriftiness property. Similarly, FO[=]-uniform (n-way) branching programs are unable to solve the P-complete GEN problem because such programs possess the incremental property studied by Gál, Kouck´y and McKenzie [10]. 1

Developing a corpus of strategic conversation in The Settlers of Catan

International audienceWe describe a dialogue model and an implemented annotation scheme for a pilot corpus of annotated online chats concerning bargaining negotiations in the game The Settlers of Catan. We will use this model and data to analyze how conversations proceed in the absence of strong forms of cooperativity, where agents have diverging motives. Here we concentrate on the description of our annotation scheme for negotiation dialogues, illustrated with our pilot data, and some perspectives for future research on the issue

Stroke care in Africa: a systematic review of the literature

Background: Appropriate systems of stroke care are important to manage the increasing death and disability associated with stroke in Africa. Information on existing stroke services in African countries is limited. Aim: To describe the status of stroke care in Africa. Summary of review: We undertook a systematic search of the published literature to identify recent (1 January 2006–20 June 2017) publications that described stroke care in any African country. Our initial search yielded 838 potential papers, of which 38 publications were eligible representing 14/54 African countries. Across the publications included for our review, the proportion of stroke patients reported to arrive at hospital within 3 h from stroke onset varied between 10% and 43%. The median time interval between stroke onset and hospital admission was 31 h. Poor awareness of stroke signs and symptoms, shortages of medical transportation, health care personnel, and stroke units, and the high cost of brain imaging, thrombolysis, and outpatient physiotherapy rehabilitation services were reported as major barriers to providing best-practice stroke care in Africa. Conclusions: This review provides an overview of stroke care in Africa, and highlights the paucity of available data. Stroke care in Africa usually fell below the recommended standards with variations across countries and settings. Combined efforts from policy makers and health care professionals in Africa are needed to improve, and ensure access, to organized stroke care in as many settings as possible. Mechanisms to routinely monitor usual care (i.e., registries or audits) are also needed to inform policy and practice

The health loss from ischemic stroke and intracerebral hemorrhage: evidence from the North East Melbourne Stroke Incidence Study (NEMESIS)

Background People suffering different types of stroke have differing demographic characteristics and survival. However, current estimates of disease burden are based on the same underlying assumptions irrespective of stroke type. We hypothesized that average Quality Adjusted Life Years (QALYs) lost from stroke would be different for ischemic stroke and intracerebral hemorrhage (ICH).Methods We used 1 and 5-year data collected from patients with first-ever stroke participating in the North East Melbourne Stroke Incidence Study (NEMESIS). We calculated case fatality rates, health-adjusted life expectancy, and quality-of-life (QoL) weights specific to each age and gender category. Lifetime \u27health loss\u27 for first-ever ischemic stroke and ICH surviving 28-days for the 2004 Australian population cohort was then estimated. Multivariable uncertainty analyses and sensitivity analyses (SA) were used to assess the impact of varying input parameters e.g. case fatality and QoL weights.Results Paired QoL data at 1 and 5 years were available for 237 NEMESIS participants. Extrapolating NEMESIS rates, 31,539 first-ever strokes were expected for Australia in 2004. Average discounted (3%) QALYs lost per first-ever stroke were estimated to be 5.09 (SD 0.20; SA 5.49) for ischemic stroke (n = 27,660) and 6.17 (SD 0.26; SA 6.45) for ICH (n = 4,291; p < 0.001). QALYs lost also differed according to gender for both subtypes (ischemic stroke: males 4.69 SD 0.38, females 5.51 SD 0.46; ICH: males 5.82 SD 0.67, females 6.50 SD 0.40).Discussion People with ICH incurred greater loss of health over a lifetime than people with ischemic stroke. This is explained by greater stroke related case fatality at a younger age, but longer life expectancy with disability after the first 12 months for people with ICH. Thus, studies of disease burden in stroke should account for these differences between subtype and gender. Otherwise, in countries where ICH is more common, health loss for stroke may be underestimated. Similar to other studies of this type, the generalisability of the results may be limited. Sensitivity and uncertainty analyses were used to provide a plausible range of variation for Australia. In countries with demographic and life expectancy characteristics comparable to Australia, our QoL weights may be reasonably applicable

Changes in acute hospital costs after employing clinical facilitators to improve stroke care in Victoria, Australia

BackgroundHospital costs for stroke are increasing and variability in care quality creates inefficiencies. In 2007, the Victorian Government (Australia) employed clinical facilitators for three years in eight public hospitals to improve stroke care. Literature on the cost implications of such roles is rare. We report changes in the costs of acute stroke care following implementation of this program.MethodsObservational controlled before-and-after cohort design. Standardised hospital costing data were compared pre-program (financial year 2006-07) and post-program (2010-11) for all admitted episodes of stroke or transient ischaemic attack (TIA) using ICD-10 discharge codes. Costs in Australian dollars (AUD) were adjusted to a common year 2010. Generalised linear regression models were used for adjusted comparisons.ResultsA 20% increase in stroke and TIA episodes was observed: 2624 pre-program (age>75years: 53%) and 3142 post-program (age>75years: 51%); largely explained by more TIA admissions (up from 785 to 1072). Average length of stay reduced by 22% (pre-program 7.3days to post-program 5.7days, pPeer reviewe