Session number: 1017
Abstract title: Structure, Process, and Outcome in VA Stroke Rehabilitation
Author(s):
Pamela Duncan, PhD - Rehabilitation Outcomes and Rehabilitation Center, Gainesville VAMC
Helen Hoening, MD - Durham VAMC
Ronnie Horner, PhD - Epidemiology Research Information Center, Durham VAMC
Dean Reker, PhD - Kansas City VAMC
Greg Samsa, PhD - Duke University Medical Center
Byron Hamilton, MD, PhD - Duke University Medical Center
Tara K. Dudley, MStat - Durham VAMC
Objectives: The health services research framework of structure, process, and outcome (SPO) has been used to examine the quality of health care. It is hypothesized that structure influences process, which in turn influences outcomes; however, little empirical work has been done to test this hypothesis, particularly in medical rehabilitation. The purpose of this research is to determine if, among stroke patients, (1) structure of care is associated with process of care, and (2) if structure of care is associated with stroke outcomes after adjusting for process.
Methods: This was a two-year, prospective study of 288 acute stroke patients in 11 VA medical centers. Structure of care was measured in three domains - system organization, staffing expertise, and technological sophistication. Process of care was measured by compliance with the AHCPR post-stroke rehabilitation guidelines. Patient covariates used for case-mix adjustment included prior walking ability and motor subscale of the Functional Independence Measure (FIM) at stroke baseline. The FIM motor score at 6 months post-stroke was used as the outcome variable.
Results: Both systemic organization and technological sophistication were independent predictors of process of care (beta coefficients 0.37, p<0.001 and 0.30, p<0.001 respectively). In the full SPO model with patient covariates, process of care was statistically associated with 6 month functional outcomes (beta coefficient 0.19, p<0.01), but structure of care was not.
Conclusions: Better process of care was associated with better 6-month functional outcomes, therefore improving process of care probably would improve stroke outcomes. However, our results indicate that improving process of care for stroke patients likely will require both equipment and an organizational structure that support the process improvements.
Impact statement: The results of this study identify specific organizational structures that are associated with rehabilitation care processes, which in turn are shown to improve patient outcomes. These select structures can therefore be hypothetically linked as enablers to improvements in the critical process of rehabilitation care. Rehabilitation providers can and should use these results in their quality improvement initiatives.