The VA is interested in developing methods of performance measure assessment that do not require chart review. To our knowledge there has been no attempt to develop stroke performance measures from administrative data. The present study determines whether or not three inpatient stroke quality performance indicators (atrial fibrillation management, deep vein thrombosis [DVT] prophylaxis and lipid management) can be accurately replicated by comparing Veterans Health Administration (VHA) VistA (administrative) data to "gold standard" data collected by chart review.
Primary aims determined the success rates (defined as the number meeting the quality criterion divided by the number eligible to meet the criterion) for three Joint Commission (JC) Inpatient Stroke Quality performance measures (atrial fibrillation management, deep vein thrombosis [DVT] prophylaxis and lipid management) using administrative data from VHA VistA. Secondary aims determined the sensitivity and specificity for the administrative indicators of the three aforementioned JC measures.
Medical records were abstracted for 405 patients with a primary ICD diagnosis of stroke and who received care from 2 facilities in 2 VISNs during 9/05-10/1/09. We also extracted sociodemographic variables (e.g., race/ethnicity), stroke severity (NIH Stroke Scale [NIHSS]), medical comorbidity (Charlson index), and illness severity (APACHE). Following the chart abstraction, VistA-based performance measure algorithms were aligned with those that were used during the chart abstraction. To imitate the chart abstraction methodology, data extraction algorithms were retrospectively keyed into VistA data elements, including pharmacy data, laboratory data, admission orders, and inpatient and outpatient ICD-9 codes for assessment of diagnoses. An interrater reliability analysis using the Kappa statistic (for categorical variables) and concordance correlation coefficient (CCC) statistics (for continuous variables) were performed to determine consistency among the different raters. A success rate for each VistA-based performance measure was calculated as the number of patients for each specific measure correctly identified by the VistA-based methodology divided by the total number of patients identified by the VistA-based approach. The sensitivity and specificity were estimated for the thresholds established within the performance measures.
Patients included in the study had a mean age of 66.8 years (SD = 11.6 years), 58.8% were White, non-Hispanic, and 41.7% were married. The mean scores for the NIHSS, Charlson and APACHE were 5.5 (SD=6.0), 5.7 (SD=2.6), and 13.4 (SD=13.0), respectively. A 10% random sample of charts was reviewed for inter-rater reliability of the 4 chart abstractors. The overall mean kappa coefficient (% agreement) for all three performance measures was .75. The kappa coefficient for the individual variables comprising the NIHSS ranged from 0.32 to 1 with a mean of 0.63. The observed CCC for the continuous variables comprising the APACHE score ranged from .7 to .998 with a mean of 0.93. Two of the three inpatient performance measures were accurately replicated by comparing VA's VistA data to the chart review data. The success rate for the VistA-based atrial fibrillation indicator was 90% (sensitivity =74% and specificity = 91% for inclusion in denominator; sensitivity = 88% and specificity = 71% for inclusion in numerator). The success rate for lipid management was 77% (sensitivity = 77% and 87% for inclusion in the denominator and sensitivity = 56% and specificity = 90% for the numerator). The success rate for DVT was 48% (sensitivity = 74% and specificity = 34% for inclusion in the denominator and sensitivity = 67% and specificity = 55% for inclusion in the numerator).
Stroke is a high volume, high impact condition for the VHA. There is a growing interest by VA planners and policy makers that there are no quality indicators to accurately assess the quality of acute stroke care. The current procedure for evaluating performance against quality measures associated with acute stroke involve extensive and expensive chart abstraction collected via chart abstractors, and as a result are only conducted on a limited random sample of the overall patient population. Our findings suggest that using VistA-based performance measures for atrial fibrillation and lipid management rather than chart review abstraction is a feasible alternative and is a reasonably accurate mechanism to improve quality of care for stroke patients. Our findings offer VHA planners, managers and policy makers and mangers an alternative, straightforward efficient method to evaluate VHA quality measures instead of relying solely on chart abstractors. In sum, the present study offers an efficient method to collect two JC based indicators for stroke.
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Health Systems, Sensory Loss, Aging, Older Veterans' Health and Care
Treatment - Observational
Quality assessment, Stroke
Quality of Health Care