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Evidence-Based Quality Indicators for Stroke Rehabilitation

Maike M. Grube, MPH; Christian Dohle, MD, MPhil; Diana Djouchadar, MD; Petra Rech, MD;
Karen Bienek, MD; Ursula Dietz-Fricke, MD; Michael Jöbges, MD; Martin Kohler, Dipl-Soz;
Isabelle Missala, MD; Bertram Schönherr, MD; Cordula Werner, MSc; Helen Zeytountchian, MD;
Jörg Wissel, MD, FRCP; Peter U. Heuschmann, MD, MPH

Background and Purpose—Previous stroke performance measures consider aspects of postacute treatment, but there are
only few specific quality indicators or standards for poststroke rehabilitation. The purpose of this study was to develop
a set of indicators for measuring the quality of postacute stroke rehabilitation in inpatient and outpatient facilities using
a standardized evidence-based approach.
Methods—Quality indicators were developed between January 2009 and February 2010 by an interdisciplinary board of
healthcare professionals from rehabilitation centers cooperating in the Berlin Stroke Alliance. The Berlin Stroke
Alliance is a regional network of ⬎40 providers of acute treatment, rehabilitation, and aftercare aiming to improve
stroke services within Berlin and Brandenburg. The indicators were developed according to published international
recommendations and predefined methodological requirements. The applied standards included a systematic literature
review, a rating of published evidence, an external peer review, and the evaluation in a pilot study before
implementation.
Results—Of an initial list of 33 indicators, 20 indicators were rated as being appropriate. After completion of the pilot
phase, we agreed on a set of 18 indicators. The indicators measure processes (9 indicators), outcomes (5 indicators), and
structures (4 indicators) in the following domains of stroke rehabilitation: completion of diagnostics; secondary
prevention; cognition and affect; speech and swallowing; management of complications; sensorimotor functions and
mobility; discharge status; and aftercare.
Conclusions—Documentation of evidence-based quality indicators for stroke rehabilitation in clinical routine is feasible
and can serve as a first step toward implementing standardized cross-institutional quality assurance programs for stroke
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rehabilitation. (Stroke. 2012;43:142-146.)


Key Words: quality indicators 䡲 rehabilitation 䡲 stroke care

T reatment approaches that have proved to be effective


within the settings of clinical trials must be implemented
in routine clinical practice to have a positive impact on the
An increasing number of quality initiatives for acute stroke
care have recently been established in Europe and the United
States.3– 8 Ensuring high standards of care, however, is im-
health of the population. A widely accepted procedure for portant not only for acute treatment, but also for rehabilitation
translating research evidence into clinical practice is to efforts in later stages of stroke care.
monitor quality of care using standardized performance There is evidence of the efficacy of postacute rehabilitation
measures (the terms quality indicators and performance in reducing mortality and dependency of stroke patients.9 –11
measures are used synonymously).1 Greater adherence to published rehabilitation guidelines has
Quality indicators can be used to evaluate the adherence to been demonstrated to be significantly linked with improved
current guidelines. They can both enforce and accelerate the functional outcomes of patients with stroke.12,13
transfer of new scientific evidence into everyday clinical Despite these figures, so far, there are only few quality
practice.2 indicators for stroke rehabilitation14 and only a limited

Received May 30, 2011; final revision received August 11, 2011; accepted August 23, 2011.
From the writing group of the board core data set rehabilitation of the Berlin Stroke Alliance (BSA): Center for Stroke Research Berlin (CSB; M.M.G.,
C.D., P.U.H.), Charité–Universitätsmedizin Berlin, Berlin, Germany; Median Klinik Berlin-Kladow (C.D.), Berlin, Germany; Vivantes Rehabilitation
GmbH (D.D.), Berlin, Germany; Median Klinik Berlin-Mitte (P.R.), Berlin, Germany; Reha-Tagesklinik Pankow (K.B., H.Z.), Berlin, Germany;
Geriatrische Tagesklinik Vivantes (U.D.-F.), Berlin, Germany; Brandenburg Klinik Bernau (M.J.), Bernau-Waldsiedlung, Germany; Institute of Medical
Sociology (M.K.), Charité–Universitätsmedizin Berlin, Berlin, Germany; Evangelisches Geriatriezentrum Berlin (EGZB) (I.M.), Berlin, Germany;
Median Klinik Grünheide (B.S.), Grünheide, Germany; Medical Park Berlin Humboldtmühle (C.W.), Berlin, Germany; Kliniken Beelitz GmbH (J.W.),
Beelitz, Germany; and Institute for Clinical Epidemiology and Biometry (P.U.H.), University of Würzburg, Würzburg, Germany.
The online-only Data Supplement is available at http://stroke.ahajournals.org/lookup/suppl/doi:10.1161/STROKEAHA.111.627679/-/DC1.
Coinvestigators: Charité–Universitätsmedizin Berlin: Andreas Meisel, MD, and Meike Sieveking; Median Klinik Berlin-Kladow: Anne-Kathrin
zur-Horst-Meyer, MD; Median Klinik Berlin-Mitte: Nidal Mansour, MD.
Correspondence to Maike M. Grube, MPH, Center for Stroke Research Berlin (CSB), Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin,
Germany. E-mail maike.grube@charite.de
© 2011 American Heart Association, Inc.
Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STROKEAHA.111.627679

142
Grube et al Quality Indicators for Stroke Rehabilitation 143

number of specific standards for postacute rehabilitation of of healthcare quality.17 Structure refers to features and resources of
patients with stroke such as the standards of the Stroke a given institution. Process refers to the use of appropriate therapeu-
tic and diagnostic procedures. Outcome indicators assess the influ-
Speciality Program of the Commission of Accreditation of
ence of healthcare delivery on the individual patient’s health.2
Rehabilitation Facilities.15 Therefore, we decided to de- In addition, the working group defined the following major
velop a set of indicators that allow measuring the perfor- components of stroke rehabilitation to be covered by the set of
mance of inpatient and outpatient stroke rehabilitation. We indicators: completion of diagnostics, secondary prevention, cogni-
used a standardized evidence-based approach to develop tion and affect, speech and swallowing, management of complica-
tions, sensorimotor functions and mobility, and discharge status and
these indicators and tested their feasibility in clinical aftercare.
routine in a pilot study. The following summary reports the The 3 dimensions of healthcare quality and the 7 components of
theoretical background, the methods applied to develop stroke rehabilitation constituted a framework for defining possible
quality indicators for stroke rehabilitation, and the results quality indicators without either overemphasizing or neglecting
of the pilot study. certain aspects of care. For each of the components of stroke
rehabilitation, the working group defined a set of possible indicators
representing structures, processes, and outcomes of care.
Methods
Constitution of the Consensus Group Evaluating the Quality of Scientific Evidence
The Berlin Stroke Alliance (BSA) is a regional network of ⬎40 For each possible indicator, a literature search was performed using
providers of acute treatment, rehabilitation, and aftercare of patients standardized search algorithms in PubMed and the Cochrane Data-
with stroke established to improve stroke services in Berlin and base of Systematic Reviews. In addition, guideline databases and
Brandenburg. In 2009, the BSA initiated an interdisciplinary board to Web sites of neurological associations were searched for guidelines
develop evidence-based quality indicators for stroke rehabilitation. for stroke treatment. The results of this research were presented to
Representatives with long-term working experience from inpatient as the working group in standardized reports for each indicator. We
well as outpatient rehabilitation institutions were involved in the gave priority to studies with a higher level of evidence and higher
development process. The majority of the board members were methodological quality. If there was no scientific evidence available,
physicians holding either specialist training in physical and rehabil- consensus or expert statements were taken into account instead.
itative medicine or in different medical disciplines (eg, neurology, Clinical guidelines were evaluated with a standardized tool for the
geriatrics, internal medicine) with approximately half of them having assessment of methodological guideline quality recently proposed in
an additional certified qualification in rehabilitation medicine. The Germany (Deutsches Instrument zur methodischen Leitlinien-
group also included a sociologist and a rehabilitation psychologist. Bewertung [DELBI]) before their recommendations were considered
The working group members discussed the developed proposals in the reports.18
within the multidisciplinary team of the respective facility and fed Scientific evidence was graded using an adapted version of the
back their comments to the whole group. criteria issued by the Oxford Centre for Evidence-Based Medicine.19
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Methodological Approach Specification and Rating of the Indicators


The standardized approach chosen by the working group members to To decide on a final set of indicators, all potential indicators were
develop quality indicators was based on the recommendations of the rated by the members of the consensus group on a 5-point Likert
“First Scientific Forum on Assessment of Quality of Care and scale from 1 (definitely not applicable) to 5 (definitely applicable)
Outcomes Research in Cardiovascular Disease and Stroke” of the taking into account the predefined methodological requirements and
American Heart Association2 and the requirements for clinical the strength of scientific evidence. Only indicators that scored at
performance measures for use in the German healthcare system.16 least 4 of 5 points on this scale were included in the final set of
These included a systematic literature review, a rating of published indicators.
evidence, and an external peer review. A similar approach to develop Indicators related to processes and outcomes were defined as
quality indicators for acute stroke treatment was recently chosen by proportions of populations with accurately defined numerators and
the German Stroke Registers Study Group (ADSR), a voluntary denominators. The numerator includes all patients who receive the
network of regional stroke registers for monitoring quality of acute intervention of interest or who show the defined outcome, whereas
stroke care.4 the denominator comprises all patients who are expected to benefit
from the intervention or who are at risk to show the considered
outcome.
Methodological Requirements of Subsequently, the indicators underwent an external review by an
Quality Indicators independent expert in neurological rehabilitation for completeness
Based on previous recommendations, the following methodological and meaningfulness of the chosen set.
requirements for quality indicators were agreed on by the working
group2,16: the indicators should be based on the best scientific Ethics
evidence available. Outcomes measured should be meaningful for The study was approved by the ethics committee of the Charité–
the patients or closely linked to relevant outcomes. Measures should Universitätsmedizin Berlin (EA1/170/10). The data management
be reliable and allow for case-mix adjustment of the participating concept was positively evaluated by the corresponding data
institutions to ensure that observed differences are related to perfor- protection officer.
mance differences rather than disparities in patient characteristics.
Furthermore, they should be sensitive to changes in the provision of
care to encourage healthcare providers to improve their services. It Results
should be feasible for staff members of the participating rehabilita- Development of a Preliminary Set of
tion centers to collect the data and the effort required for the data
collection should be kept at a minimal level.
Quality Indicators
The development of quality indicators for stroke rehabilita-
Dimensions of Quality and Components of tion took place during 8 workshops from January 2009 until
Stroke Rehabilitation February 2010. A detailed time table of the process is
The working group chose to follow the Donabedian concept, which presented in Supplemental Table I (http://stroke.ahajournals.
differentiates among structure, process, and outcome as dimensions org). Using the framework of predefined components of
144 Stroke January 2012

stroke rehabilitation and dimensions of health care, an initial Table. Performance of the 3 Pilot Centers
list of 33 possible indicators was generated. A standardized Quality Indicators Related to Processes Range Among
literature research was performed for each of the potential and Outcomes Percent the 3 Centers, %
indicators. Of 4790 titles identified in PubMed and the
Carotid artery imaging in patients with 0 ...
Cochrane Database of Systematic Reviews, approximately ischemic stroke/TIA (excluded after the
800 abstracts were screened and 134 publications were pilot study)
analyzed in detail. Twenty-nine guidelines were identified Long-term cardiac monitoring in 18 0–33
of which 11 guidelines were considered in the reports. The patients with possible cardioembolic
selection of the final set of indicators took place during 3 stroke
working group meetings. Of the 33 potential indicators, 20 Nutrition counselling in obese patients 71 0–91
indicators were rated appropriate. The initial set along with Control of blood pressure 85 76–93
the final set of indicators is presented in Supplemental Screening of cognitive function at 74 66–95
Table IV. admission
Screening for depression 62 11–79
External Review
Screening for swallowing function at 39 26–64
Ten of these 20 indicators related to processes, 6 indicators
admission
related to outcomes, and 4 indicators related to structural
Assessment by a speech therapist 90 87–100
characteristics of the institution. An independent expert in
stroke rehabilitation not previously involved in the develop- Management to reduce spasticity 65 23–97
ment process was asked to review the development process Falls and fall prevention (excluded 3 0–8
and the set of indicators. He was provided with a report after the pilot study)
including a description of methodological proceedings and a Recovery of mobility 9 0–23
detailed presentation of the indicators. An example of how Recovery of walking function 30 26–50
the indicators were presented is shown in Supplemental Table Recovery of assistive upper limb 13 0–100
IV. The overall judgment of the indicators was positive; function
remarks were mostly related to the presentation of the Recovery of functional upper limb 18 11–33
indicators and led only to minor modifications. function
Application for/ facilitation of further 81 41–98
Pilot Study rehabilitation or therapy
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A pilot study to test the feasibility of the indicators related to Counselling in social law issues 61 36–79
processes and outcomes and the variations in performance
Adherence of the
was conducted in 3 rehabilitation facilities of the BSA (1 3 Rehabilitation
inpatient neurological unit, 1 inpatient geriatric unit, and 1 Quality Indicators Related to Structures Facilities
outpatient neurological unit). All patients with a diagnosis of
Provision of smoking cessation training Yes: 2 No: 1
stroke (International Classification of Diseases 10 G45, I60,
Management of malnutrition Yes: 1 No: 2
I61, I63, I64) who were admitted between September 2010
and November 2010 were included in the study. A case report Record of complications Yes: 3 No: 0
form listing variables necessary for calculating the indicators Possibility of family involvement Yes: 1 No: 2
was drafted. The form also comprised inclusion and exclusion TIA indicates transient ischemic attack.
criteria and potential case-mix variables. A standardized
manual of operation was developed and served as a guide to outcome events (“percentage of patients with documented
the data collection. We also contacted the 3 rehabilitation falls during rehabilitation”).
facilities to inquire about the indicators related to institutional It was further agreed to compare the results of the indica-
structures. During the recruitment period, 162 patients were tors measuring outcomes such as recovery of walking and
included in the pilot study. The mean age of the patients was upper limb function stratified by the degree of the patients’
68 years (SD, 14); 40% of the patients were females. functional deficits using the phases of neurological rehabili-
Eighty-six percent of the patients had cerebral infarction, 6% tation (B, C, and D) as defined by the German “Federal
intracerebral hemorrhage, and 3% subarachnoid hemorrhage. Working group on Rehabilitation.”20
The mean Barthel Index on admission to rehabilitation was Feedback from the participating centers on feasibility and
79 out of a 100-point scale (SD, 31); the mean time between content of the case report form and the manual was mainly
the onset of symptoms and admission to a rehabilitation positive and the items were rated comprehensible and sensi-
facility was 5 weeks (SD, 9 weeks); the average length of stay ble. The average time to complete the form for 1 patient was
in a rehabilitation center was 5 weeks (SD, 2 weeks). Average 3 to 5 minutes. The final set of quality indicators is shown in
performance for the different indicators and variance between Supplemental Table IV.
the participating centers vary widely (Table).
Based on the results of the pilot study, it was decided to Implementation
discard 2 of the indicators due to a very small population in The case report form and the manual have been revised
the denominator (“carotid artery imaging in patients with according to the results of the pilot study. The attending
ischemic stroke/transient ischemic attack”) and to very few rehabilitation facilities agreed to implement the indicator set
Grube et al Quality Indicators for Stroke Rehabilitation 145

in the rehabilitation centers of the BSA starting from Sep- Our indicator set can facilitate the transfer from scientific
tember 2011. Standardized feedback of performance will be evidence into clinical routine. It will thus extend monitoring
given to the participating centers at regular intervals. Regular efforts in Germany already established in acute stroke care to
audits are intended to ensure correct data documentation. the rehabilitation sector. To meet these demands, the indica-
tors need to be constantly evaluated and updated to make sure
Discussion they correspond with the current state of research. An
This report describes the development of quality indicators to enhanced interdisciplinary dialogue on quality of care both
measure the performance in postacute stroke rehabilitation by between and within the participating centers as well as feedback,
a consortium of in and outpatient rehabilitation centers in which actively involves the participating clinicians, will help to
Berlin and Brandenburg. The working group presented a final initiate changes in care delivery.1,26 If successful in improving
set of 18 indicators related to processes (9 indicators), quality of stroke care in the participating centers in and
outcomes (5 indicators), and structures (4 indicators) of around Berlin, the project might also lead to progress in other
stroke rehabilitation. The indicators were developed and regional networks of stroke rehabilitation.
evaluated according to published evidence and predefined There are several limitations of the study. First, the
methodological requirements. They underwent an external evidence base for different components of stroke rehabilita-
tion varies considerably. Therefore, a significant proportion
review by an independent expert in stroke rehabilitation and
of the developed indicators is based on a rather low level of
have been tested in a prospective pilot study that demon-
evidence, on extrapolations of related research findings from
strated their feasibility before being implemented in the
acute care settings, or on expert opinions. This is the case
participating centers.
especially for the indicators related to social counseling
Other stroke performance measures are mostly limited to
issues, but also for interventions concerning cognitive, affec-
acute hospital care, whereas indicators focusing on stroke tive, or speech deficits of patients with stroke. This reflects
rehabilitation are currently lacking.3– 8 Some indicator proj- the state of evidence-based medicine in the rehabilitation
ects, for example, in Denmark21 and Finland,22 however, have sector and clearly demonstrates the need for clinical trials
included follow-up surveys to evaluate long-term outcomes within the setting of stroke rehabilitation. There is still further
of patients with stroke as well. Furthermore, there are need to develop indicators related to cognitive and affective
initiatives that have widened their scope by also covering interventions that are suitable for aphasic patients. However,
ambulatory settings, for instance, the Swedish Stroke Regis- we may not have identified all relevant studies because we
ter Riks-Stroke.23 did not perform an independent literature research by a
A recently published review that analyzed commonly cited
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second rater. Second, our working group included rehabilita-


process indicators for stroke care criticized a medical bias in tion facilities in Berlin and its surrounding areas only;
most of the indicator sets with very few indicators evaluating national medical societies have not been involved, which in
nonmedical aspects of care.24 The indicators presented here turn could impede or complicate widespread acceptance. The
display a broader range of health care, including neuropsy- fact that we did not formally request the participating facili-
chology, speech therapy, physiotherapy, social work, and ties to dispatch any members of nonmedical disciplines (ie,
nursing care. We accounted for those aspects of care by social workers or speech therapists) at the time of establishing
defining a priori important components of stroke rehabilita- the working group is clearly a limitation to our approach.
tion, which should be covered by the indicators. Therefore, Third, rehabilitation and acute care in Germany are offered in
the indicator set presented in this article stands out among separate units due to the high fragmentation of German health
other performance measures for stroke care. care. Therefore, the indicators are of limited transferability to
The majority of the indicators measure processes of care, other healthcare systems. However, the indicators might help
which are expected to translate into patient outcomes. As- to identify areas that are underrepresented in indicator sets
sessing processes that are closely linked to meaningful currently implemented in other healthcare systems. Finally,
outcomes is often preferred to observing outcomes mainly further evidence that better adherence to indicators measuring
due to 2 reasons. First, the comparison of outcomes requires processes of rehabilitation care is linked to improved out-
risk adjustment for patient variability between the participat- comes is still needed.
ing centers, which often lacks completeness because relevant
confounders may be either unknown or immeasurable. In- Conclusions
The development of quality indicators for postacute rehabil-
complete risk-adjustment strategies severely reduce compa-
itation of patients with stroke addresses an existing gap in
rability of performance. Second, process measures are often
quality assurance of stroke treatment in Germany. Definition
more readily accepted by providers and clinicians because
of quality indicators has been a first step toward implement-
they state clearly how to reach performance improvements.
ing cross-institutional quality assurance programs. Our proj-
However, they must be constantly updated to correspond to
ect may serve as an example for initiating similar national or
current knowledge.25 international initiatives for measuring and improving quality
Our indicator set also includes measures that are related to of stroke rehabilitation.
outcomes. These measures mainly focus on the restoration of
functional deficits. This is due to the fact that these are the Acknowledgments
ones most likely to be influenced by the quality of postacute We wish to thank Prof Dr Christian Dettmers, Kliniken Schmieder
rehabilitation. Konstanz, for his support in reviewing the indicators. Furthermore,
146 Stroke January 2012

we wish to thank the healthcare professionals of Median Klinik 12. Hoenig H, Duncan PW, Horner RD, Reker DM, Samsa GP, Dudley TK,
Berlin-Kladow, Median Klinik Berlin-Mitte, and Vivantes Rehabil- et al. Structure, process, and outcomes in stroke rehabilitation. Med Care.
itation GmbH for their support in the pilot study. 2002;40:1036 –1047.
13. Duncan PW, Horner RD, Reker DM, Samsa GP, Hoenig H, Hamilton B,
et al. Adherence to postacute rehabilitation guidelines is associated with
Sources of Funding functional recovery in stroke. Stroke. 2002;33:167–177.
This study was supported by the Federal Ministry of Education and 14. Zorowitz RD. Stroke rehabilitation quality indicators: raising the bar in
Research (BMBF) through the Center for Stroke Research Berlin (01 the inpatient rehabilitation facility. Topics in Stroke Rehabilitation. 2010;
EO 0801). 17:294 –304.
15. Commission on Accreditation of Rehabilitation Facilities. Medical reha-
Disclosures bilitation. Available at: http://carf.org/Programs/Medical/. Accessed
August 2011.
P.U.H. receives research support from the German Ministry of 16. Geraedts M, Selbmann HK, Ollenschlaeger G. Critical appraisal of
Education an Research (BMBF) within the Center for Stroke clinical performance measures in Germany. Int J Qual Health Care.
Research Berlin. 2003;15:79 – 85.
17. Donabedian A. An Introduction to Quality Assurance in Health Care.
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