Associations between structure- and process-orientated measures and stroke long term mortality - an observational study based on routine data

Dijana Ebbeler; Michael Schneider; Otto Busse; Klaus Berger; Patrik Dröge; Christian Günster; Björn Misselwitz; Nina Timmesfeld; Max Geraedts

doi:10.1016/j.jstrokecerebrovasdis.2023.107241

Associations between structure- and process-orientated measures and stroke long term mortality - an observational study based on routine data

J Stroke Cerebrovasc Dis. 2023 Sep;32(9):107241. doi: 10.1016/j.jstrokecerebrovasdis.2023.107241. Epub 2023 Jul 27.

Authors

Dijana Ebbeler¹, Michael Schneider², Otto Busse³, Klaus Berger⁴, Patrik Dröge⁵, Christian Günster⁵, Björn Misselwitz⁶, Nina Timmesfeld⁷, Max Geraedts²

Affiliations

¹ Institute for Health Services Research and Clinical Epidemiology, Philipps University of Marburg, Karl-von-Frisch-Straße 4, Marburg 35043, Germany. Electronic address: naumoska@uni-marburg.de.
² Institute for Health Services Research and Clinical Epidemiology, Philipps University of Marburg, Karl-von-Frisch-Straße 4, Marburg 35043, Germany.
³ Stroke Unit Certification Committee, German Stroke Society, Berlin 10117, Germany.
⁴ Institute of Epidemiology and Social Medicine, University of Münster, Münster 48149, Germany.
⁵ AOK Research Institute, AOK Federal Association, Berlin 10178, Germany.
⁶ Federal State Consortium of Quality Assurance Hesse (LAGQH), Eschborn 65760, Germany.
⁷ Department of Medical Informatics, Biometry and Epidemiology, Ruhr University Bochum, Bochum 44789, Germany.

PMID: 37516024
DOI: 10.1016/j.jstrokecerebrovasdis.2023.107241

Abstract

Objectives: Various measures are used to improve the quality of stroke care. In Germany, these include concentrating treatment in specialized facilities (stroke units), mandatory quality comparisons of hospitals in some German states, and treatment according to prespecified structure and process specifications (neurological complex treatment 8-981 or 8-98b). These measures have previously only been analyzed individually and regarding short-term patient outcomes. This study analyzes these measures in combination, considering patients' comorbidities as well as stroke severity in a longitudinal perspective.

Materials/methods: Analyses were based on data from 243,415 insurees of Germany's biggest health insurance (AOK) admitted to hospitals between 2007 and 2017 with cerebral infarction. Mortality risk was calculated using Cox regressions adjusted for various covariates. Kaplan-Meier analyses were differentiated by treatment site (stroke unit/external quality assurance/ Federal State Consortium of Quality Assurance Hesse - LAGQH) were performed, followed by log-rank tests and p-value adjustment. Trend analyses were performed for treatment types in combination with treatment sites.

Results: All analyses showed significant advantages for patients who received Neurological Complex Treatment, especially when the treatment was performed under external quality assurance conditions and/or in stroke units. There was an increasing frequency of specialized stroke treatment.

Conclusions: Quality-enhancing structures and processes are associated with a lower mortality risk after stroke. There appears to be evidence of a cascading benefit from the implementation of neurological complex treatment, external quality assurance, and ultimately, stroke units. Consecutively, care should be concentrated in hospitals that meet these specifications. However, since measures are often applied in combination, it remains unclear which specific measures are crucial for patient outcome.

Keywords: External quality assurance; Mortality; Neurological complex treatment; Stroke.

Publication types

Observational Study

MeSH terms

Comorbidity
Germany
Hospitalization
Hospitals
Humans
Stroke* / diagnosis
Stroke* / therapy
Treatment Outcome