Acute Ischemic Stroke
Towards Further Development of a Quality Improvement System for Stroke Practice in Japan
2021 Volume 85 Issue 2 Pages 210-212
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2021 Volume 85 Issue 2 Pages 210-212
Stroke is the major cause of death and the leading cause of long-term disability and confinement to bed among elderly people in Japan. The gap between evidence-based guidelines and daily clinical practice is a critical issue that needs to be resolved in order to improve the quality of health care and clinical outcomes. There is an urgent need to close these gaps in stroke practice and care, especially in an aging society such as Japan.
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In the US, the Get with the Guidelines (GWTG)-Stroke program was developed as a nationwide stroke quality improvement program of the American Heart Association (AHA)/American Stroke Association (ASA) to facilitate adherence to guidelines for stroke practice in hospitals.1 Participation in the GWTG-Stroke program from 2003 through 2007 was reported to be associated with increased guideline adherence to acute stroke management and care, including intravenous recombinant tissue plasminogen activator (IV rt-PA) treatment in the acute phase, and secondary prevention, including the use of anticoagulants at discharge in patients with cardioembolic stroke, eventually leading to better clinical outcomes for patients.1 Importantly, improved adherence was sustained in participating hospitals regardless of bed capacity, geography, and teaching status over 4 years. Similar programs or systems have also been established in other countries, as summarized by Nishimura et al.2
The establishment of primary stroke centers (PSCs) and comprehensive stroke centers (CSCs) was recommended worldwide in the early 2000s.3,4 However, certification of PSCs has only just started recently in Japan, and that of CSCs has not yet been initiated. Iihara et al launched the J-ASPECT study (a Nationwide survey of Acute Stroke care capacity for Proper dEsignation of Comprehensive stroke cenTer in Japan) in 2010 as the first nationwide survey of acute stroke and neurosurgical clinical practices using data obtained from the Diagnosis Procedure Combination (DPC) database with the aim of establishing and certifying PSCs and CSCs in Japan. The J-ASPECT Study Group analyzed and reported hospital characteristics (number of beds, academic status, geographic location etc.) and a wide variety of stroke management options and outcomes for PSCs and CSCs.5,6 Recently, the J-ASPECT Study Group further launched the Close The Gap-Stroke (CTGS) program, a nationwide quality improvement initiative in Japan to develop quality indicators (QIs) for both PSCs and CSCs. Nishimura et al2 conducted a systematic review and developed 17 QIs for PSCs that included documentation of the initial severity measure (Indicator 1), diagnosis (Indicators 2–4), coordination of care (Indicator 5), acute medication (Indicators 6–8), initiation of secondary prevention for recurrent stroke (Indicators 9–12), prevention of complications (Indicators 13, 14), rehabilitation (Indicator 15), and patient education (Indicators 16, 17), as well as 12 QIs for CSCs that included diagnosis (Indicator 1), intravenous thrombolysis/endovascular recanalization (Indicators 2–7), documentation of initial severity measure for subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH; Indicator 8), treatment for SAH (Indicators 9, 10) or ICH (Indicator 11), and diagnostic angiography (Indicator 12). Using the available DPC database consisting of 396,350 patients with ischemic stroke, ICH, and SAH from the J-ASPECT study, Nishimura et al measured adherence rates of 4 QIs for PSCs and 2 QIs for CSCs in the participating hospitals.2 Because the DPC database lacked data about time (onset, arrival, or imaging), the National Institutes of Health Stroke Scale (NIHSS) score, and blood test values, Nishimura et al were only able to calculate 6 of the 29 developed QIs in their study (Figure).2
Brief overview of the Close The Gap-Stroke (CTGS) program. A systematic review was conducted, and 17 quality indicators (QIs) for primary stroke centers (PSCs) and 12 QIs for comprehensive stroke centers (CSCs) were selected for the CTGS program. Using the Diagnosis Procedure Combination (DPC) database, only 6 QIs were measured, because the DPC database lacked data about time (onset, arrival, or imaging), the National Institutes of Health Stroke Scale (NIHSS) score, and blood test values.2 Using the newly developed CTGS QI Measurement Tool, into which individual data from the DPC database are entered in advance and any missing information is added in by the hospital, all 25 target QIs were successfully measured.7 ICH, intracerebral hemorrhage; IV rt-PA, intravenous recombinant tissue plasminogen activator; SAH, subarachnoid hemorrhage; TIA, transient ischemic attack.
In this issue of the Journal, Ren et al reported a novel strategy to overcome this limitation.7 These authors developed the CTGS QI Measurement Tool to facilitate the efficient measurement of QIs. Briefly, target patients are identified, with approximately 60% of the data required for the measurement of QIs obtained from the DPC database and then put into the CTGS QI Measurement Tool in advance to reduce the burden on physicians in participating hospitals. The CTGS QI Measurement Tool is then sent to the participating hospitals, and responsible physicians or people review the preset DPC data and add further information obtained from patients’ electronic medical records to compensate for any information lacking in the DPC database, such as time, NIHSS score, and blood test values. Using this novel approach, Ren et al evaluated the feasibility and validity of measuring QIs for acute ischemic stroke patients (n=8,206) from 172 hospitals who received IV rt-PA or endovascular therapy. Among a total of 29 QIs, 4 related to SAH and ICH for CSCs (Indicators 8–11) were excluded. The remaining 25 QIs were successfully measured with low rates of missing data, with the exception of one QI for CSCs (door-to-brain and vascular imaging time ≤30 min), which had 24.5% missing values. Adherence rates were found to be low (<50%) for 5 QI measures for PSCs, including door-to-needle time ≤1 h, and for 1 QI measure for CSCs (door-to-brain and vascular imaging time ≤30 min).7 These findings suggest that further efforts in these QIs in the participating hospitals are required for quality improvement of stroke practice. Conversely, the accuracy of the preset DPC data was approximately 90%, with the exception of one QI for PSCs (smoking cessation), which showed 56.7% accuracy. This suggests that further improvement of the procedure is required with regard to this QI, as discussed by the authors. It should be noted that there was a great variability among hospitals in most QIs, as detailed in the supplementary material for the paper.7 These data will be of considerable importance for the evaluation of hospital quality and will provide essential information for the certification of CSCs.
Continuous monitoring of QIs in hospitals using the CTGS QI Measurement Tool developed by Ren et al is a first step for establishing a quality improvement system for stroke practice in Japan. Although QI measurement were successful in ischemic stroke patients treated with IV rt-PA or endovascular therapy in the study of Ren et al,7 the application of the CTGS QI Measurement Tool to other stroke patients is keenly awaited. The CTGS program will help close the gaps between evidence-based guidelines and daily clinical practice in hospitals, and will facilitate better stroke practice and care in Japan. Further considerable efforts aimed at quality improvement of stroke practice and care are clearly required.
H.T. has received research funding from Boehringer Ingelheim, Bayer, Daiichi-Sankyo, and Pfizer, and speakers bureau fees/honoraria from Boehringer Ingelheim, Bayer, Daiichi-Sankyo, and Bristol-Myers Squibb.
