The Canadian Stroke Quality of Care Study: establishing indicators for optimal acute stroke care

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Abstract
E very 10 minutes someone in Canada suffers a "brain attack," making stroke the most common serious neurological condition requiring hospital admission. Each year, about 50 000 Canadians are admitted to hospital because of stroke, with an estimated cost to the health care system of $2.7 billion. 1 As the management of acute ischemic stroke advances, widespread implementation of optimal stroke care continues to pose enormous challenges for health care systems. There are tremendous variations in the practice of care across regions, and national practice guidelines for stroke management are lacking. To achieve "best practice" stroke care across the country, continuous surveillance of the quality of stroke care (e.g., practice audits with feedback) will become increasingly important. But how should quality of stroke care be defined and measured? What are the performance indicators by which hospitals and regions should be judged? It is imperative that we adopt a national approach to measuring stroke care using performance indicators that are clinically relevant, scientifically sound and empirically feasible. 2-4 To address this issue, the Canadian Stroke Quality of Care Study was launched to identify a core set of indicators that represent optimal care and will facilitate uniform measurement and benchmarking of the quality of acute stroke care at the local, provincial and national levels. A description of the study is available online at www.cmaj.ca/cgi/ content/full/172/3/363/DC1). This study builds on the acute stroke care indicators developed by Holloway and colleagues in the United States and reflects changes in stroke management practices since 1999 and differences between the US and Canadian health care systems. 5 The expert advisory panel convened for the study consisted of 14 multidisciplinary members from across Canada who were nominated by their peers for their knowledge and expertise in acute stroke care and performance measurement. Panel members evaluated 51 stroke quality-ofcare indicators using 6 criteria: validity, feasibility, relevance, opportunity for improvement, expected impact of improvement and overall utility. 5 Using a modified Delphi process, 23 of these indicators were selected on the basis of high ratings by the majority of panel members to form a final core set of performance measures for acute stroke care (Table 1). The highest rated indicators focused on maximizing tissue plasminogen activator (tPA) administration for eligible patients, admission of patients to a specialized stroke unit and in-hospital initiation of secondary stroke