The impact of standardized stroke orders on adherence to best practices

摘要

I read with great interest the article by the CalifornianAcute Stroke Pilot Registry (CASPR) Investigators. The investigators should be commended for performing such a well-designed, large-scaled multicenter before-and-after study to test the effectiveness of standardized orders for admission and discharge of stroke patients. Physicians often struggle to find practical ways of improving quality of stroke care, and the implementation of standardized orders seems to be a logical step toward bringing evidence-based stroke treatments closer to the bedside. However, there are several methodologic issues about this study that deserve clarification.First, one of the major confounding factors in this study is the retrospective nature of data collection through case notes examination. Year 2 data were presumably retrieved through examination of the standardized orders in the case notes, and the quality of documentation was presumably extremely high. However, since the standardized orders did not exist in Year 1, data retrieval was presumably achieved through examination of the conventional case notes. It is possible that the observed differences in outcome merely reflected poor documentation in the Year 1 case notes (since if an intervention was not documented, it was presumed not to have occurred), rather than a real change in practice.Secondly, since the authors used an intention-to-treat method of data analysis, it would be helpful if the authors reported the data for compliance with the standardized orders (i.e., what proportion of patients was managed using the standardized orders, were there differences among the six hospitals, when were the standardized orders used, and how completely were they filled in). Moreover, it would be interesting to explore the correlation between compliance and outcome.