Review: Quality improvement advances in stroke care

Reviewed by Danielle Ellis, B.Sc.May 18 2023

Every 40 seconds, someone in the U.S. has a stroke. Every 3.5 minutes, someone in the U.S. dies of a stroke. Stroke patients have multifaceted needs, requiring complicated care delivered by multidisciplinary teams.

In the journal Stroke's annual review of quality improvement advances in stroke care studies, Regenstrief Institute Research Scientist Dawn Bravata, M.D., and colleagues update researchers, clinicians and healthcare administrators on advances in the field, highlighting the challenges of scalability and sustainability.

"Quality improvement exists to ensure that every patient with stroke or at risk of stroke is getting the care that they are eligible to receive. Quality improvement activities can happen at a clinic level or hospital level or nationwide level," says Dr. Bravata, a national leader in stroke care improvement, an internist who cares for stroke patients and a researcher with the U.S. Department of Veteran Affairs. "Stroke is a complex disease and stroke patients often require care by a variety of clinicians – neurologists, internists, nurses, pharmacists, physical therapists, rehab specialists and others. All can make contributions to quality improvement. Innovations that are multidimensional and multicomponent are often the ones that were successful in improving quality of care."

Studies published in 2022 cover the continuum of care, from prehospitalization to acute care to rehabilitation settings. As in prior years, the overwhelming majority of quality improvement for stroke care research focused on the hyperacute (immediate post-stroke) period. Most studies continued to be from urban settings within developed nations with only one study of a rural population. Studies cover the spectrum from single hospital reports to regional and national care evaluations.

The review authors identify five gaps in stroke quality improvement research:

• studies are needed to describe quality improvement initiatives from rural healthcare settings, small facilities and underrepresented countries;
• segments of the continuum of care require attention, especially transitions of care, primary care and risk-factor management;
• studies on quality improvement for hemorrhagic stroke and transient ischemic attack are needed, as most studies focused on acute ischemic stroke;
• approaches to support scalability and sustainability of quality improvement initiatives should be evaluated; and
• de-implementation projects should be undertaken to reduce inappropriate care.

They also write that, from a policy evaluation perspective, comparison of stroke care quality across hospitals "before" versus "after" the public reporting of hospital performance data is critical to motivating quality improvement.