Is there evidence that performance measurement in stroke has influenced health policy and changes to health systems?

O ver the past 20 years or more, use of meta-analysis and establishment of clinical guidelines for stroke have provided a strong evidence base for performance measurement. Performance measurement, defined as the evaluation of organizational or clinical practice activities and outcomes against agreed standards, 1,2 has been used to identify care gaps. With the associated development in health services research, this has laid the foundation for providing evidence for health policy decisions. Performance measures may be designed to assess the structural environment (eg, the organizational features of health facilities), processes of care (such as adherence to recommended clinical interventions), or outcomes (eg, mortality). Furthermore, performance measures may be used to monitor the quality of care within an individual institution or across the health care system, to compare different institutions over time (benchmarking), to provide information to the consumers in choosing health care providers, or to promote quality improvement activities. 3,4 Performance measurement results provide valuable information for strategic planning by organizations , policy-makers, and funding providers. 2 Health policy may be broadly defined as a statement of actions to achieve goals for health care usually reflecting priorities and values for increasing well-being in a society and/ or the optimal allocation of health resources. 5 It is generally agreed that health policy should be based on the best and most current scientific evidence. 5 Performance measurement offers policy-makers information to make judgments on the extent to which various aspects of the health system meet policy goals. 2 However, it is uncertain what impact efforts to monitor health care performance have had on policy and/or health systems in the area of stroke. Examples in which performance measurement can be linked to stroke policy may include policy documents on clinical guidelines or strategic plans, financial incentives or reimbursement criteria for stroke care, creden-tialing standards for health care organizations or clinicians, regulations or legislation for how care between different sectors of the health system operate, and programs of routine (or mandated) data collection such as registries. The purpose of this review was to explore what evidence exists that performance measurement in stroke has influenced health policy and health systems. We assumed that there would be studies designed to measure temporal relationships between measuring performance followed by changes to health policy or health systems (Figure 1); however, many of these concepts are interwoven and not necessarily linear. It was not possible to cover all aspects …