ESO East Supplement 2023 - 37

Kõrv et al.
37
Patients and methods
National indicators of quality of stroke care
In 2015, nine indicators of quality of care for stroke were
chosen by the ESI. The prerequisite was that data should
have been easily obtained from the EHIF reimbursement
database. Some of the indicators were adopted from the
Danish National Indicator Project but some of them were
developed by the ESI originally.15 These indicators are calculated
every year including all stroke cases in Estonia.
The five quality indicators evaluated every year are:
1. Proportion of patients managed in central or
regional hospitals (24/7 stroke-ready hospitals with
acute stroke units and centers). Performance indicator
(PI), goal 90%.
2. Proportion of patients receiving recanalization therapies
(IVT, MT, or combined). PI, goal 30%.
3. Proportion of patients having received inpatients
rehabilitation services within 30 days after admission
with acute stroke. PI, goal 40%.
4. Proportion of patients with ischemic stroke and
atrial fibrillation having a prescription for oral anticoagulants
12 months after hospitalization from the
index stroke. PI, goal 75%.
5. Mortality of at 30 days after admission with acute
stroke. Outcome indicator, goal <15%.
The annual reports are presented to the hospitals and are
available to the public.13
However, four of the proposed indicators are time
dependant and currently not obtainable from the EHIF
reimbursement database. The indicators never collected
are: (1) Proportion of stroke patients in whom computer
tomography (CT) or magnetic resonance imaging (MRI) is
performed within an hour after admission to the hospital;
(2) Proportion of stroke patients in whom imaging of
carotid arteries is performed within 96 h of admission to the
hospital; (3) Proportion of stroke patients in whom swallowing
is tested within 24 h of admission to the hospital;
and (4) Proportion of stroke patients evaluated by a physiotherapist
within 48 h of admission to the hospital.
Hospitalized cases of acute stroke (ischemic stroke and
intracerebral hemorrhage, International Classification of
Diseases (ICD)-10 I63 and I61, respectively) including
patients ⩾19 years of age are identified and analyzed. The
EHIF reimbursement database is linked with the Estonian
Prescription Registry and Death Registry for calculation of
the results. If the patient is hospitalized repeatedly with the
diagnosis of stroke during the same year, an acute stroke
case is defined when occurring later than 30 days after the
first admission. The oral anticoagulants (OAC) are warfarin,
dabigatran, rivaroxaban, edoxaban, and apixaban and
only cases of patients surviving the first 14 days after
admission are analyzed. The patient must have an active
prescription for an OAC 12 months + 1 day after cardioembolic
stroke (ICD-10 codes I63 and I48).
RES-Q database
As the national quality indicators are reflecting only a small
part of stroke care, the RES-Q database was included as a
comprehensive tool for stroke care quality monitoring enabling
measurement and analysis between hospitals, both
nationally and internationally. Details of data composition,
collection procedure, and the full collection form are
reported elsewhere.2,14
The national steering committee has agreed to collect
the data once a year in March since 2017. Five of six strokeready
hospitals (Tartu University Hospital, North Estonia
Medical Centre, West-Tallinn Central Hospital, EastTallinn
Central Hospital, and Pärnu Hospital) are actively
participating with entering the data of all consecutive stroke
patients discharged during 1 month period a year into the
RES-Q electronic database.
The data acquired from the clinical RES-Q database and
the EHIF are anonymous therefore the Ethics Committee
license is not required.
Statistical analyses
Patient characteristics were described by relative frequencies
for categorical data and means, standard deviations
(SD), medians and interquartile ranges (IQR) for continuous
data. Chi-squared test for trend was used to analyze
changes of proportions over time. Time trend for DNT and
DGT was tested with linear regression model. All statistical
tests were conducted at a significance level of 0.05. The
data analysis was performed by Microsoft® Excel® for
Microsoft 365 MSO (Version 2202 Build 16.0.14931.20128)
and statistical software R 1.4.1 (The R Foundation for
Statistical Computing).
Data availability statement
All data generated or analyzed during this study are available
from the corresponding author upon reasonable
request.
Results
According to the EHIF reimbursement database, the number
of hospitalized stroke cases (ischemic stroke and intracerebral
hemorrhage) decreased between 2015 and 2021
from 3699 to 3351 (from 282 to 252 per 100,000 personyears,
respectively) and the proportion of patients managed
in stroke units/centers increased from 77% (95% Confidence
Interval, CI 75%-78%) to 87% (95% CI 85%-88%). The
30 days' case-fatality decreased from 21% (95% CI 20%-
23%) to 19% (95% CI 18%-20%). The proportion of IVT
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