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Variation between hospitals in patient outcome after stroke is only partly explained by differences in quality of care. Data from the Netherlands Stroke Survey
  1. Hester F. Lingsma (h.lingsma{at}
  1. Erasmus MC, Netherlands
    1. Diederik W. J. Dippel (d.dippel{at}
    1. Erasmus Medical Center, Netherlands
      1. Sanne Hoeks (s.hoeks{at}
      1. Erasmus Medical Center, Netherlands
        1. Ewout W. Steyerberg (e.steyerberg{at}
        1. Erasmus Medical Center, Netherlands
          1. Cees L. Franke (corneli{at}
          1. Atrium Medical Center, Netherlands
            1. Robert J. van Oostenbrugge (r.vanoostenrbrugge{at}
            1. Universital Hospital Maastricht, Netherlands
              1. Gosse de Jong ({at}
              1. Isala Clinics-Weezenlanden, Netherlands
                1. Maarten L. Simoons (m.simoons{at}
                1. Erasmus Medical Center, Netherlands
                  1. Wilma J.M. Scholte op Reimer (w.j.m.scholte.op.reimer{at}
                  1. Erasmus Medical Center, Netherlands


                    Background and purpose:Patient outcome is often used as an indicator of quality of hospital care. The aim of this study is to investigate whether there is a straightforward relationship between quality of care and outcome and whether outcome measures could be used to assess quality of care after stroke.

                    Methods:In 10 centers in the Netherlands, 579 patients with acute ischemic stroke were prospectively and consecutively enrolled. Poor outcome was defined as a score on the modified Rankin scale ≥ 3 at 1 year. Quality of the care was assessed by relating diagnostic, therapeutic and preventive procedures to indication. Multiple logistic regression models were used to compare observed proportions of patients with poor outcome with expected proportions, after adjustment for patient characteristics and quality of care parameters.

                    Results:271 (53%) patients were dead or disabled at 1 year. Poor outcome varied across the centers from 29% to 78%. Large differences between centers were also observed in clinical characteristics, prognostic factors and quality of care. For example, between hospital quartiles based on outcome, age ≥ 70 varied from 50% to 65%, presence of vascular risk factors from 88% to 96%, intravenous fluids when indicated from 35% to 81%, and antihypertensive therapy when indicated from 60% to 85%. The largest part of variation in patient outcome between centers was explained by differences in patient characteristics(Akaike’s Information Criterion (AIC) = 134.0). Quality of care parameters explained a small part of the variation in patient outcome (AIC = 5.5).

                    Conclusions:Patient outcome after stroke varies largely between centers and is for a substantial part explained by differences in patient characteristics at time of hospital admission. Only a small part of the hospital variation in patient outcome is related to differences in quality of care. Unadjusted proportions of poor outcome after stroke are not valid as indicators of quality of care.

                    • Outcome
                    • Quality of care
                    • Stroke

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