156. Post Acute Stroke Guideline Compliance Leads to Greater Patient Satisfaction
DM Reker, Kansas City VAMC and Kansas University Med Ctr; PW Duncan, Kansas City VAMC and Kansas University Med Ctr; RD Horner, Durham VAMC and Duke University Med Ctr; H Hoenig, Durham VAMC and Duke University Med Ctr; G Samsa, Duke University Med Ctr; BB Hamilton, Duke University Med Ctr; TK Dudley, Durham VAMC
Objectives: This study will evaluate the relationship between processes of care and satisfaction outcomes among patients receiving stroke care in the VHA.
Methods: This study is a two-year, national, prospective, observational study. Eleven VA facilities representing multiple VISNs were recruited. Two hundred eighty eight subjects were enrolled across all sites with data gathered at baseline and 6 months post-stroke. Subjects were followed during the continuum of care. Process of care was measured by quantifying compliance with AHCPR post-stroke rehabilitation guidelines using chart review, abstraction criteria, and a weighted method for scoring. Primary outcome variables include functional status, health related quality of life, survival time, community dwelling days at 6 months, cost of care, and patient satisfaction with care. We risk adjusted for several major factors: pre-stroke function, age, race, co-morbidity, cognitive function, admission functional status, and social support. Patient satisfaction was measured with a stroke specific instrument measuring two dimensions of satisfaction: hospital care and home based services. A total patient satisfaction score was created by combining satisfaction scores for each of the two dimensions.
Results: Similar to the effects found for 6 month functional outcomes, compliance with AHCPR post acute guidelines were significantly positively associated with patient satisfaction measured at 6 months post stroke. The model r-square was 0.16 with a p-value of 0.03. The coefficient for post acute guideline compliance was 0.146 with a p-value of 0.002. The effects of guideline compliance were similar for individual dimensions of satisfaction as well at the combined satisfaction score. The effects of guideline compliance, as a quality of care measure, were largely independent of patient functional outcome, therefore having more of a direct effect on satisfaction rather than an indirect effect through greater functional recovery.
Conclusions: In prior analyses, compliance with AHCPR stroke guidelines in post acute care settings has been shown to increase functional outcomes. These analyses provide additional support to the benefits of stroke guideline compliance. Not only is better motor function realized with greater guideline compliance, but patient satisfaction is increased. Even after controlling for functional status at 6 months post stroke, the effect of guidelines remained.
Impact: During a period of major reorganization of VA services it is imperative that we evaluate access to services and outcomes of care. Following the Department of Veterans Affairs decentralization of authority to 22 independent VISNS within the VHA, significant changes in the structure and process of stroke rehabilitation care began to emerge. Specifically within the VHA in the past 5 years, there have been reductions in the number of acute rehabilitation bedservice units from 72 to 37 representing a 49% reduction in acute units. Similarly, the number of acute stroke rehabilitation admissions in acute rehabilitation units have dropped from 1,793 in 1995 to 1,049 in 2000, a 41% reduction. These changes have occurred largely in the absence of knowledge about the relationships of structure, process, and outcomes of stroke rehabilitation care. Results from this study indicate that the process of stroke care is significantly related to patient satisfaction.