Hospitals Overestimate Their Ability to Deliver Timely tPA

Miriam E. Tucker

August 06, 2015

Hospitals may be overly optimistic when it comes to estimating their own ability to deliver timely thrombolytic therapy to stroke patients, new research shows.

In telephone surveys of stroke team members at 141 hospitals participating in the Get With the Guidelines-Stroke (GWTG-Stroke) program, less than a third were able to accurately quantify their ability to provide intravenous tissue plasminogen activator (tPA) treatment to stroke patients within a "door to needle (DTN)" time of 60 minutes, with most of them overestimating.

"Our findings indicate the need to routinely provide comparative provider performance rates as a key step to improving the quality of acute stroke care," Cheryl B. Lin, MD, from Tufts Medical Center, Boston, Massachusetts, and colleagues write.

The findings were published online July 22 in the Journal of the American Heart Association.

Asked to comment, Ethan Cumbler, MD, president of the medical staff and director of the Acute Care for the Elderly Unit at the University of Colorado Hospital, Aurora, told Medscape Medical News, "This study raises the question of how information on performance filters down to the level of providers within healthcare systems."

Dr Cumbler, who has done work in quality improvement related to in-hospital stroke care, added, "The implications are important. A potential consequence of overestimation of performance is complacency. If hospitals view their performance through rose-colored glasses, does this diminish the urgency to improve?"

Perception vs Reality

The 300 hospitals originally chosen for the survey were selected from top, middle, and low performers. Overall, they had a median 20% DTN of 60 minutes or less among all treated patients. A total of 48,201 patients received tPA during the study period.

Respondents in the 70-item, 15-minute phone survey were mostly nursing staff (85%) and had been working on the hospital's stroke team for an average of 4 years.

Nearly two thirds (65%) were able to accurately estimate the overall percentage of eligible patients who received tPA. However, just 29% accurately quantified their hospital's ability to deliver tPA within 60 minutes.

The median rate of DTN within 60 minutes was 57% among the top-performing hospitals, but two thirds of those respondents estimated their rates to be greater than 60%. Among the low-performing hospitals, two thirds perceived their ability to deliver tPA within 60 minutes to be greater than 20% when it was actually 0%.

The survey also asked respondents to rank their performance in relation to other hospitals nationwide. The majority (82%) of the top-performing hospitals recognized themselves as above average. However, 85% of the low performers rated their relative ability to deliver timely tPA as average, above average, or top compared with other US hospitals.

Among the total 92 middle- and low-performing hospitals surveyed, overestimation of DTN performance occurred at 56 sites (61%). Nearly 5% of the low performers believed their DTN performance was "superior" on a national level.

Overestimation of DTN performance was inversely related to annual tPA volume. In multivariate analysis, sites were less likely to overestimate their performance for every 10-case increase in annual tPA volume (odds ratio, 0.31) and for every 10–percentage point increase in the percentage of DTN times within 60 minutes of arrival (odds ratio, 0.59). Other factors were not significantly associated with overestimation of relative performance.

Impetus for Change

Addressing the misperceptions will be necessary for hospitals to improve performance, Lin and colleagues say.

"Such overestimation may have important implications for the low motivation to investigate improvement barriers and to implement site-specific quality-improvement initiatives… Potential changes in benchmarked performance feedback reports should be considered to ensure broader distribution of improvement initiatives," they conclude.

"The authors are to be commended for examining more than relative performance data but to extend the inquiry to the relationship of healthcare workers with their data," Dr Cumbler commented. "This study finds a disconnect between how we feel we are doing and what the data show. The Get-With-the-Guidelines-Stroke database proves the statistical truism that not all of us are above average…this study demonstrates that more than half of us think we are."

He added, "Benjamin Franklin, roughly paraphrased, commented that three of the hardest things on earth are: steel, diamonds, and accurate self-assessment."

This project was supported by the Agency for Healthcare Research and Quality. Dr Lin has disclosed no relevant financial relationships. Dr Cumbler has participated in research using the GWTG-Stroke database but was not involved in the current study.

J Am Heart Assoc. Published online July 22, 2015. Abstract

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