Getting the Right Benchmarks For Stroke Care

Late last week, thanks to Liz Kowalczyk (@globeLizK) of the Boston Globe, I discovered the statewide report on quality of stroke care in Massachusetts.  It’s a plain document, mostly in black and white, much of what you might expect from a state government report.  Yet, this 4-page document is a reminder of how we have come to accept mediocrity as the standard in our healthcare delivery system.

The report is about 1,082 men and women in Massachusetts unfortunate enough to have a stroke but lucky (or vigilant) enough to get to one of the 69 Massachusetts hospitals designated as Primary Stroke Service (PSS) in a timely fashion. Indeed, all these patients arrived within 2 hours of onset of symptoms and none had a contradiction to IV-tPA, a powerful “clot busting” drug that has been known to dramatically improve outcomes in patients with ischemic stroke, a condition in which a blood clot is cutting off blood supply to the brain.  For many patient-ts, t-PA is the difference between living a highly functional life versus being debilitated and spending the rest of their lives in a nursing home.  There are very few things we do in medicine where minutes count – and tPA for stroke is one of them.

So what does this report tell us?  That during 2009-2010, patients who showed up to the ER in time to get this life-altering drug received in 83.3% of the time.  Most of us who study “quality of care” look at that number and think – well, that’s pretty good.  It surely could have been worse.

Pretty good?  Could have been worse?  Take a step back for a moment:  if your parent or spouse was having a stroke (horrible clot lodged in brain, killing brain cells by the minute) – you recognized it right away, called 911, and got your loved one to a Primary Stroke Service hospital in a fabulously short period of time, are you happy with a 1 in 5 chance that they won’t get the one life-altering drug we know works?  Only 1 in 5 chance that they might spend their life in a nursing home instead of coming home?  Is “pretty good” good enough for your loved one?

The Massachusetts Department of Health has put substantial effort in this area and the numbers have steadily improved.  By many accounts, this is a success story (the number was 66% in 2008, rising to 83.5% in 2011).  But this level of performance is not nearly good enough.

There are plenty of hospitals that seem to get it right.  I counted 14 that were at 100% and another dozen or so that might have missed it on one patient.  But here’s the problem.  From a clinical perspective, so few patients with stroke ever show up in the magic window of less than 4.5 hours of the onset of symptoms (that’s the cut-off for using t-PA) that the average hospital in Massachusetts sees about 8 such patients per year (less than one a month).  If you were unfortunate enough to end up at Lowell General, there was nearly a 40% chance (depending on which campus) that you won’t get tPA.  At Milton hospital, there was a 60% chance that you wouldn’t get tPA.  These numbers may be getting better slowly, but that’s cold comfort to those permanently disabled because hospitals haven’t yet put in the systems needed to reliably provide a therapy we’ve known is effective since 1995.

So what might state and federal policymakers do if they wanted to get serious about improving these rates?  There are lots of potential solutions, including greater training, more oversight, even robust pay-for-performance.  I have a simpler request:

Stop setting the benchmark at the state average.

In this report (like almost every other report card), you are judged against the “average”.  So, if your state is lousy, a lot of mediocre hospitals can look fine.  Instead, set a goal for what you want to achieve.  In this case, the goal is 100%.  Period.  Tell me which hospitals were “statistically” worse than 100%.  That’s a lot more meaningful than which hospitals were “statistically” worse than average.

In this report, 64 out of 69 hospitals were labeled “equal” because they weren’t statistically worse than average, including South Shore Hospital, which failed to provide t-PA to 8 of their 31 patients (26% failure rate).  Lucky for them, that’s not statistically worse than the state average of 17% failure – but perhaps not so lucky for those 8 patients.  For the 64 hospitals that are labeled as “equal”, such as South Shore, there is little motivation to improve.  Yet, I’m confident that South Shore would be having a very different set of internal discussions if the benchmark was 100%.

If we’re going to use transparency to improve, we need to choose the right benchmarks.  In situations in which strong, evidence-based processes are involved (like providing a life-saving drug), the benchmark should be 100%.  Benchmarking to the average is benchmarking to a “C”.  We spend a LOT of money on healthcare – we deserve better, and our hospitals can do better.  With all the knowledge and expertise in the medical field, we don’t have to settle for a “C”.  We should demand that our hospitals provide “A” care consistently and reliably to all their patients.

Ashish Jha, MD, MPH is the C. Boyden Gray Associate Professor of Health Policy and Management at the Harvard School of Public Health. He blogs at An Ounce of Evidence.This post first appeared at the Health Affairs Blog.

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  8. Re. the benefits of tPA – please do read what I have actually written. I have never claimed that tPA is of no benefit, just that the author is overstating the benefit. I even quoted the statement in question.

  9. Interesting. In our program, we had a 60% door to needle time. That improved to 89.9% with education to prehospital providers using one simple (Cincinnati stroke scale) tool. Early notification to the Emergency Department and treating these “Brain Attack’s” with the same level of urgency as trauma and STEMI. A unified team approach that starts with prehospital, correlated with ED, CT, Lab and the neurologist proves a better outcome. If you want to talk about patient satisfaction and HCAPS improvement, this demographic will score you a 9 or 10 if they (or family) see and organized rapid response (even with a less than desirable outcome).

  10. Several good points here –

    1. One plane accident and there would be a ton of media attention and review of processes, etc. The bar is set much higher but that has something to do with the fact that 100’s of lives are impacted with one mistake as opposed to one.

    2. re the benefits of IVtpa – colleagues from several large academic centers who are Neurologists are extremely clear about the benefits. If not life altering, then at the very least, of significant impact. So, yes, its use is supported by the literature.

    3. the volume issue is an interesting one – only a small number of patients make it to the hospital, so there is less experience and protocols for people to know well. Maybe it would be reasonable to implement educational programs for staff and EMS providers, and assign centers of excellence for Stroke care so that the volume of cases reach a level to allow for development of expertise.

    4. The bell curve distribution (and goal of average) is the way the numbers work out. The problem becomes that quality is so poor by the measures being used that its simply the way the outcomes look across the country. While it is a great idea to strive for more, not quite sure how we get to the same standards as the airline industry given the smaller numbers on an individual basis.

  11. I don’t necessarily disagree with most of this post, but:
    (1) the benefits of IVtPA are clearly overstated in that receiving the drug is equated with a good outcome (“are you happy with a 1 in 5 chance that they won’t get the one life-altering drug we know works? Only 1 in 5 chance that they might spend their life in a nursing home instead of coming home?”). This is not supported by the literature. I would ask the quality controllers to produce posts of particularly high quality.
    (2) don’t you always have to weigh input and output of certain policies (such as policies to improve the frequency of administering tPA to the right patients)? You cannot do everything at once and you don’t have endless resources for everything. Maybe there are even lower hanging fruit like hand hygiene, or community education that patients get to the ER more timely? (“so few patients with stroke ever show up in the magic window of less than 4.5 hours of the onset of symptoms (that’s the cut-off for using t-PA) that the average hospital in Massachusetts sees about 8 such patients per year (less than one a month).”)