Structure, process, and outcomes in stroke rehabilitation

BACKGROUND. The health services research framework of structure, process, and outcome is used commonly to examine quality of care, and it indicates that structure influences process, which in turn influences outcomes. However, little empirical work has been done to test this hypothesis, particularly for medical rehabilitation. OBJECTIVES. To determine if, among stroke patients, (1) structure of care was associated with process of care, and (2) structure of care was associated with outcomes after adjusting for process. RESEARCH DESIGN. Two-year, prospective study of 288 acute stroke patients in 11 VA medical centers, of whom 128 were included in the current analysis. MEASURES. Structure of care: systemic organization, staffing expertise, and technological sophistication. Process of care: compliance with the AHCPR poststroke rehabilitation guidelines. Patient characteristics: baseline prior walking ability and Functional Independence Measure (FIM) motor subscale. Outcomes: the FIM motor subscale 6-months poststroke. RESULTS. The combination of systemic organization and staffing expertise, along with technological sophistication, were independent predictors of process of care (beta coefficients 0.21, P <0.05 and 0.37, P <0.001, respectively). When controlling simultaneously for patient characteristics, structure and process of care, structure of care did not have and process of care did have a statistically significant association (beta coefficient 0.18, P <0.01) with functional outcomes. 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 key structure of care elements might facilitate improving process of care for stroke patients.