Indian Journal of Critical Care Medicine
Volume 27 | Issue 11 | Year 2023

Quality Metrics in Acute Stroke: Time to Own

Asif Ahmedhttps://orcid.org/0000-0001-8117-7753

Department of Critical Care Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India

Corresponding Author: Asif Ahmed, Department of Critical Care Medicine, Tata Main Hospital, Jamshedpur, Jharkhand, India, Phone: +91 6572423530, e-mail: drasif14@rediffmail.com

How to cite this article: Ahmed A. Quality Metrics in Acute Stroke: Time to Own. Indian J Crit Care Med 2023;27(11):786–787.

Source of support: Nil

Conflict of interest: None

Keywords: Acute stroke, Management and Outcome, Quality metrics.

Stroke is now one of the leading causes of death and disability worldwide. According to the World Health Organization, stroke accounts for nearly 6 million deaths annually, and to add on over and above, the long-term disabilities experienced by the survivors.1 A higher incidence, prevalence, and disability is reported from the low-income and middle-income countries as compared to the high-income countries, and it also reflects in the high mortality figures. Studies from India have reported a prevalence rate estimated between 45 and 487/100,000 and an incidence rate between 33 and 123/100,000 for the urban population, the rural numbers not being very different.2 The direct and indirect impact of stroke, ranging from acute medical care to long-term rehabilitation and loss of productivity, impose a significant economic burden on healthcare systems.3

Quality indicators are measured units for determining the level of adherence to standards in health-care and the level of achieved result.4 These ensure a degree of reliable and standardized care to the patients with an aim to improve the outcome, and its importance and graveness were realized more than 2 decades ago. Although started initially for diseases with high morbidity and mortality such as diabetes mellitus, hypertension, and cancer, the need for its use has extended to other diseases such as stroke, quality indices can provide transparent quality-performance information resulting in accountability and improvements.5

To standardize stroke care, guidelines have been introduced by expert panels and regulatory bodies, for its prevention, management, and control. These comprise of acute care quality metrics, which are based on early management of stroke guidelines of the American Heart Association (AHA)/American Stroke Association (ASA), published in 2018 and re-emphasized in 2021.6,7 It includes management by a stroke unit within 10 min, door-to-computerized tomography (CT) scan time in less than 25 minutes, and door-to-needle time in less than 45 minutes for intervention. Deep vein thrombosis prophylaxis, dysphagia screening, antithrombotic therapy, anticoagulation for atrial fibrillation, antihypertensive therapy, antidiabetic medication, smoking cessation, low salt intake, statin therapy, patient and family education are important for secondary prevention,7 while rehabilitation metrics and mortality rates can help in improving long-term prognosis with stroke.

Based on recent studies, four pillars of the stroke quadrangle have also been suggested. It highlights the importance of surveillance, apart from the previously described prevention, acute care, and rehabilitation.8

Despite the availability of guidelines for management along with the national prevention and control program, the challenges are too many. Infrastructural weakness, lack of stroke hospitals and intensive care units (ICUs), lack of awareness and implementation, restricted access to prehospital care, and non-availability of poststroke rehabilitation services can hinder the timely and effective management of stroke.9

The number of people getting stroke has doubled in the last three decades and more younger individuals (<55 years), are getting affected by stroke worldwide.10 The adherence to quality metrics of stroke has huge variations both within and country and beyond. A recent study reported that India and China, which account for one-third of the world population, have different risk factors and age distribution for stroke. Indian patients had greater stroke severity, higher rates of thrombolysis within 3 hours, greater in-hospital mortality, and worse outcomes than patients in China.11 In European countries like Italy, poststroke rehabilitation of patients was found to be a major limitation to stroke care.12 Prompt patient transportation, acute reperfusion therapies, and stroke unit hospitalization were found more widely accessible in Greece, and these parameters helped in improving the functional outcomes of stroke patients.13 In the USA, the implementation of quality metrics based on 11–100 parameters decreased hospital mortality leading to better outcomes.14 What is evident from the literature is that several methodological difficulties, make the interpretation of data from various sources, quite challenging.

Panda BK et al. performed a single center prospective study in stroke patients with 12 quality performance measures, which included 5 acute and 7 discharge criteria to study the correlation of quality metrics in acute stroke care with clinical outcomes, and the adherence to quality metrics here, was assessed earnestly by all or none principle.15

This study strived to achieve a door-to-needle time of 55 minutes which was comparable to other studies.16 Remarkably, 92.8% of patients received intravenous recombinant tissue plasminogen activator (IV-rTPA) within the prescribed 4.5 hours. The adherence to the National Institutes of Health Stroke Scale (NIHSS) score documentation was 100% and the functional outcome assessed at 28-days postdischarge was significantly improved. It also highlights that a focused multiple quality indices-based approach is highly possible and does promise good results and quality care.

This study was conducted in an urban center in India, where the best facilities were available, and the results were encouraging but the findings cannot be generalized all across, and it could be a limiting factor. The 28-days-postdischarge neurofunctional outcome assessment done here might not fully capture, the long-term effects.

It is important that one should be aware of the drawbacks of these quality indices. The quality metrics often focus on specific aspects of stroke care that are relevant, but such an approach can have a narrowed focus, potentially overlooking other aspects of care that are equally vital, and it can be at the expense of overall quality. It could also lead to disparity in allocation of resources and some areas might receive less attention. Excessive focus on metrics can also pressurize the healthcare personnel to meet the specific targets. These quality metrics tend to focus on short-term outcomes such as 30-day mortality and they may not be able to assess the long-term impact of stroke on patients’ lives and their functional status. Also, the quality metrics should be aligned with changing guidelines and best practices, which could be challenging.17

It is therefore essential that these metrics are used carefully and judiciously with a comprehensive approach that includes monitoring, evaluation, and clinical judgment.

Although significant strides in improving stroke care are being seen which emphasize the importance of quality metrics, however, ensuring high-quality care all across could be quite challenging, but that is what is required.

Given the significant morbidity, mortality, and societal impact associated with stroke, quality metrics are not mere numbers but represent a critical tool in the ongoing effort to reduce the burden of stroke and improve the lives of those affected. The application of indices for stroke patients is essential to evaluate and ensure the best care for individuals suffering from or at risk for stroke.

The various upcoming studies will also help us understand better the current practices across the country, the level of quality care being given, along with the variations and their extent, thereby giving better clarity on the various facilitators and barriers, which can be used as tools for further improvement.


Asif Ahmed https://orcid.org/0000-0001-8117-7753


1. World Health Organization. Stroke, Cerebrovascular accident. Available at: https://www.emro.who.int/health-topics/stroke-cerebrovascular-accident/index.html. Accessed on: 14 October 2023.

2. Ramesh S, Kosalram K. The burden of non-communicable diseases: A scoping review focus on the context of India. J Educ Health Promot 2023;12:41. DOI: 10.4103/jehp.jehp_1113_22.

3. Taylor TN, Davis PH, Corner JC, Holmes J, Meyer JW, Jacobson MF. Lifetime cost of stroke in the United States. Stroke 19196;27:1459–1466. DOI: 10.1161/01.STR.27.9.1459.

4. Muzigaba M, Chitashvili T, Choudhury A, Wilson MW, Diaz T, Kathleen L, et al. Global core indicators for measuring WHO’s paediatric quality-of-care standards in health facilities: Development and expert consensus. BMC Health Serv Res 2022;22(1):887. DOI: 10.1186/s12913-022-08234-5.

5. Jacobs BD, Schreiber M, Seshamani M, Tsai D, Fowler E, Fleisher LA. Aligning quality measures across CMS: The Universal Foundation. N Engl J Med 2023;388(9):776–779. DOI: 10.1056/NEJMp2215539.

6. Powers WJ, Rabinstein AA, Ackerson T, Adeoye OM, Bambakidis NC, Becker K, et al. 2018 Guidelines for the early management of patients with acute ischemic stroke a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018;49(3):e46–e99. DOI: 10.1161/STR.0000000000000158.

7. Kleindorfer DO, Towfighi A, Chaturvedi S, Cockroft KM, Gutierrez J, Hill DL, et al. 2021 Guideline for the prevention of stroke in patients with stroke and transient ischemic attack: A guideline from the American Heart Association/American Stroke Association. Stroke 2021;52(7):e364–e467. DOI: 10.1161/STR.0000000000000375.

8. Feign VL, Owolabi MO, World Stroke Organization–Lancet Neurology Commission Stroke Collaboration Group. Pragmatic solutions to reduce the global burden of stroke: A World Stroke Organization–Lancet Neurology Commission. Lancet Neurol 2023:S1474-4422(23)00277-6. DOI: 10.1016/S1474-4422(23)00277-6.

9. Salunkhe M, Haldar P, Bhatia R, Prasad D, Gupta S, Srivastava MVP, et al. IMPETUS stroke: Assessment of hospital infrastructure and workflow for implementation of uniform stroke care pathway in India. Int J Stroke 2023;17474930231189395. DOI: 10.1177/17474930231189395.

10. Feigin IL, Stark BA, Johnson CO, Roth GA, Bisignano C, Abady GG, et al. Global, regional, and national burden of stroke and its risk factors, 1990–2019: A systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol 2021;20(10):795–820. DOI: 10.1016/S1474-4422(21)00252-0.

11. Li Z, Pandian J, Sylaja PN, Wang Y, Zhao X, Liu L, et al. Quality of care for ischemic stroke in China vs India: Findings from national clinical registries. Neurology 2018;91(14):e1348–e1354. DOI: 10.1212/WNL.0000000000006291.

12. De Cola MC, Ielo A, Corallo F, Addario S, Scondotto SP, Allotta A, et al. Development of a set of indicators for measuring and improving quality of rehabilitation care after ischemic stroke. Healthcare 2023;11(14):2065. DOI: 10.3390/healthcare11142065.

13. Palaiodimou L, Kargiotis O, Katsanos AH, Kiamili A, Bakola E, Komnos A, et al. Quality metrics in the management of acute stroke in Greece during the first 5 years of Registry of Stroke Care Quality (RES-Q) implementation. Eur Stroke J 2023;8(Suppl. 1):5–15. DOI: 10.1177/23969873221103474.

14. Parker C, Schwamm LH, Fonarow GC, Smith EE, Reeves MJ. Stroke quality metrics systematic reviews of the relationships to patient-centered outcomes and impact of public reporting. Stroke 2012;43(1):155–162. DOI: 10.1161/STROKEAHA.111.635011.

15. Panda BK, Suryawanshi VR, Attarde G, Borkar N, Iyer S, Shah J. Correlation of quality metrics of acute stroke care with clinical Outcomes in an Indian Tertiary-care University Hospital: A Prospective evidence-based Study. Indian J Crit Care Med 2023;27(11):806–815.

16. Zhang X, Li Z, Zhao X, Xian Y, Liu L, Wang C, et al. Relationship between hospital performance measures and outcomes in patients with acute ischaemic stroke: A prospective cohort study. BMJ Open 2018;8(7):e020467. DOI: 10.1136/bmjopen-2017-020467.

17. Poisson SN, Josephson SA. Quality measures in stroke. Neurohospitalist 2011;1(2):71–77. DOI: 10.1177/1941875210392052.

© The Author(s). 2023 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.