Healthcare data and benchmarking of stroke centers save the lives of patients with cerebrovascular strokes

Healthcare data and benchmarking of stroke centers save the lives of patients with cerebrovascular strokes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Healthcare data and benchmarking of stroke centers save the lives of patients with cerebrovascular strokes Marian Rybář, Aleš Tomek, Robert Mikulík, Martin Šrámek, Ondřej Škoda, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6991532/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background: In 2019, the Czech Republic implemented a national benchmarking system to improve the quality of stroke care through the integration of administrative health insurance data and clinical registry information. The system was designed to engage all relevant stakeholders—including stroke centers, the Ministry of Health, health insurance funds, and professional societies—in a framework of shared accountability and data-driven governance. Methods: A retrospective analysis was conducted using nationwide data from 2019–2023. Quality indicators were derived from the National Registry of Reimbursed Health Services (NRRHS) and the Registry of Stroke Care Quality (RES-Q). We assessed changes in 5-, 30-, and 90-day case fatality rates; treatment rates (intravenous thrombolysis and mechanical thrombectomy); process times; intensive care access rates; and secondary prevention prescription rates. Statistical significance was evaluated via chi-square and Mann‒Whitney U tests. Risk-standardized mortality rates were calculated via logistic regression adjusted for age, sex, and comorbidities. Results: Between the initial year, 2019, and the last year, 2023, significant improvements were observed in most indicators. The 30-day case fatality rate decreased from 12.40–11.45% (p < 0.001), and the 90-day fatality rate decreased from 18.50–15.99% (p < 0.001). The rate of intravenous thrombolysis increased from 34.29–40.58%, and that of mechanical thrombectomy increased from 10.12–12.68% (both p < 0.001). Intensive care management increased from 61.82–69.05%, and prescriptions for statins, antihypertensive drugs, and anticoagulants also improved significantly. The median door-to-needle time (DNT) remained stable at 22 minutes, whereas the door-to-imaging time (DIT) and groin-to-recanalization time (GRT) significantly decreased (p < 0.001). The 5-day case fatality rate increased slightly (5.04–5.32%, p < 0.001). Conclusions: The implementation of a national benchmarking system integrating administrative and registry data and engaging all relevant stakeholders was associated with measurable improvements in stroke care quality in the Czech Republic. The model promotes continuous quality improvement despite limited financial resources and offers a scalable and transferable framework for other healthcare systems. Ongoing enhancements—including the inclusion of NIHSS scores, mRS90 outcomes, and refined time-based metrics—will further support transparency and effectiveness in stroke care delivery. Stroke care benchmarking quality indicators RES-Q registry administrative data health insurance claims mortality intravenous thrombolysis mechanical thrombectomy NIHSS mRS90 modified Rankin scale at 90 days health data integration healthcare quality improvement poststroke rehabilitation Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Cerebrovascular accidents (strokes) remain one of the leading causes of mortality and disability in developed countries. The quality of care provided to stroke patients directly affects survival and long-term functional independence. Consequently, some countries have introduced national registries, quality indicators, and benchmarking systems as tools to improve care standards and promote health system transparency. In Germany, administrative data from 2019–2021 were used to monitor developments in acute stroke care and to identify regional disparities, which led to targeted system-level interventions [ 1 ]. Another German study further demonstrated that access to high-quality stroke care varies significantly by region, with notable differences in the availability of reperfusion therapies and patient outcomes [ 2 ]. These findings underscore the importance of monitoring not only national averages but also regional-level variations in care delivery. Similarly, the Netherlands implemented a national audit of acute stroke care that enabled hospitals to improve outcomes through comparative quality indicators [ 3 ]. However, a key insight from this initiative was that tracking outcomes alone is insufficient—without a strong focus on process indicators, comprehensive quality improvement cannot be achieved [ 3 , 4 ]. Japan’s registry-based approach highlights the importance of long-term data collection, which supports the evaluation of not only acute care but also the subsequent rehabilitation phase and its impact on functional outcomes [ 5 ]. In China, a composite score based on process indicators has been successfully used to identify underperforming hospitals, prompting targeted interventions. The same study proposed replacing multiple individual indicators with a single composite metric—a concept not yet widely adopted internationally [ 6 ]. Central and Eastern European countries have also made notable progress. In Estonia, a national stroke care quality initiative has resulted in improved access to stroke units, faster treatment times, and greater use of reperfusion therapies, supported by the implementation of clear national guidelines and regular performance reviews [ 7 ]. Likewise, Slovakia has reported improvements over the past five years in thrombolysis rates, increased use of thrombectomy, and the development of a comprehensive stroke network, although challenges remain in ensuring uniform care quality across all regions [ 8 ]. A systematic review of national stroke registries [ 9 ] confirmed significant variability across countries in terms of digitalization, monitored metrics, and data accessibility. According to the authors, close collaboration between stakeholders—healthcare providers, regulators, payers, and professional societies—is essential for success. Recent European reviews [ 10 , 11 ] have shown that although the number of reperfusion treatments (thrombolysis and thrombectomy) increased from 2019–2020, considerable intercountry differences persist. The absence of harmonized data continues to hinder accurate international comparisons. To support coordinated efforts in stroke care, the Action Plan for Stroke in Europe 2018–2030, which was jointly developed by the European Stroke Organization (ESO) and Stroke Alliance for Europe (SAFE), established ten overarching goals, including access to stroke units, implementation of national stroke plans, and routine measurement of quality indicators [ 12 ]. In this context, the Czech Republic launched a national benchmarking system in 2019 based on the integration of administrative and registry data via the RES-Q. This benchmarking model involves all key stakeholders—care providers, professional societies, health insurance funds (HIFs), and the Ministry of Health (MoH)—and is grounded in shared accountability and data-driven decision-making. Rather than operating in silos, collaboration is institutionalized through a national governing structure: the Commission for Quality in Stroke Care. This study aims to perform its first evaluation of the impact of the Czech national benchmarking system and stakeholders involved in key stroke care quality indicators since its establishment, covering the period from 2019–2023. Patients and methods Stakeholders Since 2011, the MoH has certified 47 specialized stroke centers [13]. These include 34 primary stroke centers (hospitals administering intravenous thrombolysis) and 13 secondary stroke centers (hospitals with additional capabilities for endovascular treatment and neurosurgery) (Fig. 5). Within the MoH, the Commission for Quality in Stroke Care was established, which has the authority to monitor quality indicators for stroke as defined in the ministry’s bulletin [14]. The Commission includes representatives from the MoH, HIFs, and professional societies in stroke, neurosurgery, interventional radiology, and rehabilitation. The MoH represents the position of legislative regulator within the Commission overseeing Czech healthcare and acts as the organization ultimately responsible for quality assurance in healthcare centers. The legislative foundation for quality control is Act No. 372/2011 Coll., on Health Services and Conditions of Their Provision (the Health Services Act), which delineates the principles of quality indicator control across all centers for highly specialized care, including but not limited to stroke centers. The MoH issues a certificate of accreditation for stroke centers every five years for the subsequent period. The issuance of the certificate is contingent upon meeting the required thresholds for all quality indicators. HIFs participate in the Commission from the perspective of health care payers, financing care through contributions collected from individuals and employers. There are a total of seven HIFs in the Czech Republic, all of which have agreed on a unified approach to collaborate on quality control within the Commission. All seven HIFs have entrusted the quality measurement agenda to the Czech Health Insurance Bureau, which processes the data of these HIFs for the MoH [15]. Professional societies play an expert role within the Commission. Each of the four professional societies—cerebrovascular, neurosurgical, interventional radiology, and rehabilitation—provides expert recommendations related to their specific quality indicators. Data management The quality indicators were created by the National Registry of Reimbursed Health Services (NRRHS) provided by Czech HIFs [15] and the Registry of Stroke Care Quality (RES-Q) [16]. Registry of Stroke Care Quality (RES-Q) The Registry of Stroke Care Quality (RES-Q) was launched in the Czech Republic in 2016. Since then, it has been adopted by numerous countries as a platform for quality monitoring. As of 2025, the RES-Q has supported quality monitoring for more than 1 million stroke patients across more than 2,000 hospitals in 83 countries. [16]. The platform enables hospitals to monitor their performance in real time through online dashboards and downloadable reports. Each hospital retains access to its source data. National coordinators have access to national source data to support research and quality improvement activities [17]. The data governance structure is available on the RES-Q website (www.qualityregistry.org). A key advantage of the RES-Q is its adaptability: the data collection form is regularly updated to reflect the latest clinical evidence and guidelines. As a result, analyses and visualizations—such as dashboards—provide timely, evidence-aligned feedback. This level of responsiveness would be difficult, if not impossible, to achieve using administrative databases, which are better suited to tracking long-term, stable indicators. RES-Q data are also used in the ESO and WSO Angels Awards programs, which are supported by the Angels Initiative, which recognizes hospitals for excellence in stroke care with Gold, Platinum, or Diamond awards on the basis primarily of RES-Q or other approved registry data [18]. This serves as an incentive for continuous quality improvement. RES-Q is fully compliant with the GDPR and ensures secure handling of patient data. More information is available at www.qualityregistry.org. The RES-Q automatically generated reports are used by the Czech Stroke Society, which communicates these results to all stroke centers in the country independently from the Commission. The Commission is focused on the most robust indicators of quality. We derived the following quality indicators from RES-Q: the median times for Door to Needle Time (DNT), Door In Door Out Time (DIDO), Door To Groin Time (DGT), Door To Imaging Time (DIT), and Groin To Recanalization Time (GRT). The quality indicators for the percentage of intravenous thrombolysis and mechanical thrombectomy were calculated via combined data from the RES-Q registry and the total patient numbers reported in the NRRHS [15]. National Registry of Reimbursed Health Services (NRRHS) provided by Czech HIFs NRRHS is a key component of the Czech healthcare data infrastructure. It is a comprehensive database containing information on all healthcare services reimbursed to providers through the public health insurance system in the Czech Republic. The registry includes data on medical procedures, diagnoses, pharmaceuticals, and other healthcare services. All 7 HIFs have entrusted the quality measurement agenda to the Health Insurance Bureau Companies, which processes the data of these seven HIFs for the MoH [15]. From the NRRHS, we derived the following quality indicators: 5-, 30- and 90-day case fatality; the proportion of patients managed in intensive care units; and prescriptions for statins, antihypertensives, or anticoagulants. We derived the quality indicators for the proportion of intravenous thrombolysis and mechanical thrombectomy by using a combination of data from the NRRHS (total number of patients) and the RES-Q (number of procedures performed). The data file thus contained complete data on all insured individuals in the Czech Republic for the years 2019–2023. Importantly, all the quality indicator results are attributed to the facility where the patient was first admitted for hospital care [15]. This means that outcomes from any subsequent transfers are assigned to the initial admitting facility. This approach reflects the assumption that the first facility is responsible for key decisions regarding initial treatment and the patient’s subsequent pathway through the healthcare system [16]. The benchmarking system The Commission has been convening annually and setting target levels for quality indicators that all monitored facilities are expected to meet in the given year. For example, the 2023 target for the 30-day case fatality rate required that no monitored stroke center exceed a threshold of 15%. The proportion of patients treated in intensive care units was at least 50%. Intravenous thrombolysis was administered in at least 20% of the patients, and mechanical thrombectomy was administered in at least 10% of the patients. The use rates of statins, antihypertensives, and anticoagulants in patients with atrial fibrillation were at least 70%, 60%, and 80%, respectively. The median times for Door-to-Needle Time (DNT), Door-In–Door-Out Time (DIDO), Door-to-Groin Time (DGT), Door-to-Imaging Time (DIT), and Groin-to-Recanalization Time (GRT) did not exceed 30, 45, 90, 20, and 60 minutes, respectively. If any of the indicators are not met, the Commission requires the healthcare facility to submit an analysis explaining the causes of noncompliance, to propose appropriate corrective actions, and to suggest collaborative steps in alignment with the MoH. If quality indicators are repeatedly unmet, the Commission is authorized to revoke the facility’s status as a certified specialized center (Fig. 6) [14]. Indicator results are shared with facilities in a semiopen format: rankings are not published, and each facility sees only its own results in comparison with the national average and anonymized results of other facilities. The MoH, HIFs, and professional societies, on the other hand, can see the results of all facilities. Patients only see deidentified results. Statistical analysis Relative frequencies and medians were compared via an inferential test (chi-square test and Mann‒Whitney U test, respectively) in R version 4.3.1 to assess the significance of changes between the initial year of 2019 and the final year of 2023. We compared only the first and last years to avoid COVID-19-related heterogeneity and the need for complex trend modeling; trends are shown graphically (Figs. 1 to 4). Given the necessity of accurate facility comparisons concerning 5-day, 30-day, and 90-day mortality indicators, we standardized the measured outcomes to account for potential variations in patient demographics. A logistic multivariable regression model, as outlined by the Agency for Healthcare Research and Quality (AHRQ) [19], was utilized, incorporating age, sex, and fundamental comorbidities as covariates. Results Over a five-year period, we assessed key quality indicators for stroke care in the Czech Republic, covering 2019–2023. The analysis revealed that nearly all the evaluated quality indicators either improved or remained stable in 2023 compared with the baseline year of 2019, as illustrated in Table 1 . Case fatality rate During the benchmark period from 2019–2023, the 30-day case fatality rate declined from 12.40–11.45% (p < 0.001). Concurrently, the 90-day case fatality rate decreased from 18.50–15.99% (p < 0.001). In contrast, the 5-day case fatality rate slightly increased from 5.04–5.32% (p < 0.001) (Fig. 1 ). Organization of medical care The proportion of patients managed in stroke centers increased from 77.31–82.57% (p < 0.001). Similarly, the proportion of patients managed in intensive care units rose from 61.82–69.05% (p < 0.001). The rate of intravenous thrombolysis increased from 34.29–40.58% (p < 0.001), and the use of mechanical thrombectomy increased from 10.12–12.68% (p < 0.001) (Fig. 2 ). Secondary prevention The prescription rate for statins at discharge increased from 69.37–79.94% (p < 0.001), that for antihypertensives increased from 71.29–75.95% (p < 0.001), and that for anticoagulants increased from 80.58–87.41% (p < 0.001) (Fig. 3 ). Treatment Times The median door-to-needle time (DNT) remained unchanged at 22 minutes for both 2019 and 2023 (p = 0.23). The median Door In Door Out Time (DIDO) decreased from 55 minutes to 53 minutes (p < 0.001), whereas the Door To Groin Time (DGT) median increased from 65 minutes to 67 minutes (p < 0.001). Additionally, the median door-to-imaging time (DIT) decreased from 14 minutes to 10 minutes (p < 0.001), and the median groin-to-recanalization time (GRT) decreased from 38 minutes to 36 minutes (p < 0.001) (Fig. 4 ). Table 1 Comparative analysis of selected indicators. 2019 vs. 2023 Indicator category Indicator 2019 2023 p value Case-fatality 5 day case-fatality 5.04% 5.32% p < 0.001 30 day case-fatality 12.40% 11.45% p < 0.001 90 day case-fatality 18.50% 15.99% p < 0.001 Organization of care Patients managed in stroke centers 77.31% 82.57% p < 0.001 Proportion Intensive care unit 61.82% 69.05% p < 0.001 Intravenous trombolysis 34.29% 40.58% p < 0.001 Mechanical trombectomy 10.12% 12.68% p < 0.001 Secondary prevention Prescription for statins 69.37% 79.94% p < 0.001 Prescription for antihypertensives 71.29% 75.95% p < 0.001 Prescription for anticoagulants 80.58% 87.41% p < 0.001 Treatment Times Door To Needle Time (DNT. median) 22 min 22 min p = 0.23 Door In Door Out Time (DIDO. median) 55 min 53 min p < 0.001 Door To Groin Time (DGT. median) 65 min 67 min p < 0.001 Door To Imaging Time (DIT. median) 14 min 10 min p < 0.001 Groin To Recanal. Time (GRT. median) 38 min 36 min p < 0.001 Discussion The implementation of a nationwide quality monitoring system for stroke care in the Czech Republic represents a decade-long evolution from the initial certification of stroke centers in 2011 to the establishment of a comprehensive benchmarking framework in 2019. This system was built through a bottom-up approach initiated by stroke specialists and gradually institutionalized with the active engagement of the MoH, HIFs, and professional medical societies. The inclusion of all key stakeholders fosters mutual accountability and commitment to continuous improvement in care. Our analysis demonstrates that this collaborative framework has led to significant advances in multiple quality indicators, with measurable improvements in patient outcomes across the nation. These findings are in line with international experiences, such as those reported from Germany [ 1 , 2 ], the Netherlands [ 3 ], and Japan [ 5 ], where systematic benchmarking and centralization of stroke services similarly contributed to measurable enhancements in care quality and regional equity. A major success factor in the Czech stroke care system is the near-universal admission of stroke patients to certified stroke centers—an achievement made possible through a two-pronged approach: mandatory certification and a national emergency medical services directive requiring the transport of stroke patients exclusively to certified centers. As a result, the proportion of stroke patients treated in these specialized centers increased from 77–83% between 2019 and 2023. This structural intervention, combined with systematic benchmarking, directly contributed to the observed decline in the 30- and 90-day case fatality rates. Given that stroke remains one of the leading causes of death and disability, these outcomes have substantial socioeconomic and societal impacts. Similar centralization strategies in Slovakia and Estonia have demonstrated comparable benefits [ 7 , 8 ], underscoring the broader relevance of this organizational model in Central and Eastern Europe. The improvement in quality indicators, such as intravenous thrombolysis rates, prescriptions for secondary prevention medications, and access to intensive care, should be viewed in the context of long-term efforts that predate the formal benchmarking system. Some indicators, particularly the door-to-needle time (DNT), began improving as early as 2010 because of multiple factors, including the widespread implementation of simulation-based training. Approximately one-third of all stroke centers have undergone such training, highlighting the importance of education and experiential learning in achieving system-wide improvements. Moreover, the Czech benchmarking model aligns with the principles of the Action Plan for Stroke in Europe 2018–2030 [ 12 ], especially with respect to transparency, stakeholder collaboration, and data-driven care improvement. This convergence suggests that the Czech experience may inform broader European strategies. One of the unique features of the Czech model is the dual-source data collection system, which combines the completeness of administrative data from health insurance claims with the clinical depth and flexibility of the RES-Q. This hybrid approach allows for robust national analysis while remaining responsive to evolving clinical guidelines and international benchmarking practices. The public‒private partnership between government agencies, insurance companies, and nonprofit organizations such as RES-Q exemplifies an efficient and scalable model of health data integration for quality improvement. Despite these successes, the system faces significant challenges—chief, among them, the lack of dedicated financial support. Neither the hospitals nor the RES-Q registry currently receive funding specifically allocated for quality monitoring. As a result, data collection relies heavily on voluntary effort, which threatens the long-term sustainability of the benchmarking system. Establishing permanent funding mechanisms and financial incentives is essential to ensure continued engagement, data quality, and innovation in improving stroke care quality. The sustainability concern is not unique to the Czech Republic and has been noted in other national registries, such as the Dutch Acute Stroke Audit [ 3 ] and Japanese registry systems [ 5 ], which underlines the need for stable financing models to secure long-term quality gains. Openness in publishing results Insurance-based benchmarking remains semiopen: each facility sees its data against anonymised peers and the national average. Full transparency risks data manipulation and may undermine data quality. A survey among American interventional cardiologists supported these concerns [ 20 ]. A majority (79%) of the cardiologists surveyed acknowledged that the publication of mortality statistics sometimes influences their clinical decisions, particularly with regard to performing angioplasties on critically ill patients with high expected mortality rates. This hesitancy highlights the potential adverse effects of publicizing detailed performance metrics. These findings emphasize the need for careful consideration in future policies regarding the extent of data publication in healthcare. Legislative measures may be required to determine which data should be fully disclosed and which should primarily be accessible to healthcare professionals, HIFs, the MoH, and stroke centers. In contrast, the RES-Q registry follows a more transparent model by publishing center-level performance data, where individual hospitals are identifiable (subject to country-specific policies). This approach, adopted in the Czech Republic on the basis of a decision by the Czech Stroke Society, has become a widely accepted standard among stroke centers despite initial reservations. Importantly, because the RES-Q focuses on quality-of-care indicators and process metrics—rather than raw outcome measures such as case fatality alone—there is less risk that clinicians would alter treatment decisions or selectively avoid severe cases in an attempt to improve their reported patient outcomes. Data standardization via the NIHSS scale A significant limitation of the current quality indicators in the Czech Republic is their lack of standardization, primarily due to incomplete data on the initial severity of neurological deficits assessed via the National Institutes of Health Stroke Scale (NIHSS) [ 21 ]. Since 2024, the mandatory inclusion of NIHSS stages in administrative data has been implemented. Facilities failing to document the initial NIHSS stage will face reduced reimbursement for the affected hospitalization cases. This change ensures that data from 2024 onward adhere to this vital standardization parameter. Furthermore, efforts are underway to develop a standardized medical report specifically for stroke patient care. This initiative aims to facilitate the seamless integration of essential health statistical data from hospital information systems into the administrative datasets used by health insurers and to increase the quality of detailed clinical information transmitted to the RES-Q. The implementation of standardized medical reports is expected to significantly improve the accuracy and utility of stroke care data. Similar transitions toward mandatory NIHSS recording have taken place in other benchmarking systems, such as in Germany and the Netherlands [ 1 , 3 ], demonstrating how standardized severity adjustment improves interfacility comparability and prevents misleading interpretations of mortality and treatment rates. Reflecting the patient's outcome posttreatment via the MRS90 scale The modified Rankin scale at 90 days (mRS90) [ 22 ] represents the most informative measure for assessing patient outcomes posttreatment, yet these data are currently unavailable in the Czech Republic. The commonly used 30-day case-fatality metric does not capture the patient’s ultimate functional status. There are scenarios where a facility may achieve a high recovery rate, with a majority of patients reaching a self-sufficient state categorized between MRS90s 1–4; however, higher mortality rates may still be reported. Conversely, another facility might demonstrate better 30-day case fatality statistics while leaving a significant number of patients in a severely disabled state, classified as MRS90 5–6. The critical importance of the mRS90 has been emphasized in multiple sources [ 4 , 10 , 12 ], particularly in international quality frameworks that prioritize patient-centered outcomes over crude mortality figures. The integration of mRS90 data into the administrative database would enhance the alignment of the Czech system with these international standards. The RES-Q has a developer application that should be able to collect not only mRS90 directly from patients but also other conditions, such as depression and other comorbid conditions. Testing of this application is underway. Use of benchmarking by type of care A fundamental question in the development of quality indicators is whether to establish separate measures for different subsets of patients on the basis of their treatment modality—specifically, mechanical thrombectomy, intravenous thrombolysis, or conservative treatment only. Stratifying outcomes by treatment type may increase clinical relevance and enhance the granularity of benchmarking outputs. On the other hand, it also introduces greater complexity into the benchmarking process, which may hinder data interpretation and limit comparability across facilities. Replacing median times with the proportion of patients exceeding critical time thresholds Currently, benchmarking in the Czech Republic uses median values for process time indicators such as Door to Needle Time (DNT), Door In Door Out Time (DIDO), Door To Groin Time (DGT), Door To Imaging Time (DIT), and Groin To Recanalization Time (GRT). While medians provide a central tendency, they do not account for the range of patient times, particularly those significantly exceeding the median. For example, two facilities may report the same median of 20 minutes; however, one facility might have times slightly above this median, whereas the other could have extreme delays, with times reaching up to 100 minutes. To address this issue, in the future, the benchmarking strategy will be enhanced by incorporating the proportion of patients whose treatment times surpass a predetermined critical threshold. This adjustment aims to provide a more comprehensive assessment of patient care efficiency and timeliness across facilities. Monitoring indicators of subsequent rehabilitation care The treatment of stroke patients extends beyond the acute phase of care, with subsequent rehabilitation playing a critical role in enhancing patients' long-term self-sufficiency. In response, the Czech Republic is developing a comprehensive set of indicators to assess the quality of poststroke rehabilitation care. These indicators include: The proportion of patients admitted to acute rehabilitation beds at each facility. The number of patients with focal dystonia who received botulinum toxin treatments. Scores on the extended and basic Barthel Index, which measures the degree of independence in daily activities. The elapsed time from the stroke incident to the patient's admission to a rehabilitation bed. The proportion of patients who received comprehensive rehabilitative services, including physiotherapy, swallowing assessments, occupational therapy, and speech therapy. This initiative aims to provide a robust framework for evaluating the effectiveness of rehabilitation services and to ensure that these critical aspects of stroke recovery are adequately addressed across healthcare facilities. The RES-Q pilotes the collection of quality/performance data from rehabilitation facilities in the Czech Republic, and the results will be reported elsewhere. Limitations Although the findings of this study suggest substantial improvements in the quality of stroke care following the introduction of national benchmarking, several limitations must be acknowledged. First, not all improvements in quality indicators can be directly attributed to the benchmarking initiative launched in 2019. Some indicators—particularly time-sensitive logistics, such as door-to-needle time (DNT)—had already improved prior to benchmarking, driven by focused clinical education, simulation-based training, and earlier quality improvement initiatives. This complicates causal attribution and underscores the multifactorial nature of quality enhancement in stroke care. Some changes in indicators may also have been influenced by the COVID-19 pandemic [ 23 , 24 ]. This aspect, however, was not addressed in the present study. Second, despite the advantages of combining administrative and registry data, the absence of standardized clinical variables—most notably initial stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS)—has historically limited the ability to adjust for baseline patient characteristics. This gap is only partially mitigated by the recent inclusion of mandatory NIHSS documentation in administrative datasets since 2024. Similarly, the lack of consistent postdischarge functional outcome data beyond mortality—such as 90-day modified Rankin scale (mRS90) scores—limits our ability to assess longer-term recovery. Finally, although the benchmarking framework is methodologically sound, it currently relies on median values for process metrics. While useful, this approach may mask outliers and delay distributions that are critical for patient outcomes. Planned enhancements—such as incorporating threshold-based metrics (e.g., the proportion of patients exceeding critical time windows)—represent an important refinement for accurately assessing performance. Conclusion Over the last five years, the Czech Republic has successfully implemented a nationwide benchmarking system for stroke centers that integrates administrative and clinical registry data, engages all major healthcare stakeholders, and fosters a culture of shared accountability. This model has led to measurable improvements in most key quality indicators and an important decline in mortality rates, offering a strong example of how data-driven governance can improve healthcare outcomes. However, to sustain and further develop this system—particularly in areas such as rehabilitation and potentially other medical fields—dedicated funding is urgently needed. With continued political, financial, and professional commitment, the Czech stroke care benchmarking system can serve not only as a model for other clinical domains within the country but also as a transferable framework for other nations seeking to improve stroke care through data and collaboration. Given the alignment with European strategic goals [ 12 ] and the operational success of comparable registries in more than 50 countries [ 17 ], the Czech experience offers valuable lessons for designing scalable and sustainable quality improvement infrastructures worldwide. Declarations Ethics approval and consent to participate Not applicable Consent for publication Not applicable Availability of data and materials The data on the results of individual measured quality indicators for the years 2019–2023 are available on Figshare under the URL: https://figshare.com/s/22571b6be79a88a95994, DOI: https://doi.org/10.6084/m9.figshare.29473346.v1 Competing interests The authors declare that they have no competing interests. Funding Ales Tomek, Robert Mikulík and Ales Tichopád were supported by the Ministry of Health of the Czech Republic in cooperation with the Czech Health Research Council under project No. NW24-09-00215. Authors' contributions Marian Rybář contributed to the conception and design of the study, acquisition and interpretation of data, and drafting of the manuscript. Aleš Tomek, Robert Mikulík, Martin Šrámek, Ondřej Škoda, and Vladimir Rogalewicz contributed to the acquisition and interpretation of data, as well as the critical revision of the manuscript for important intellectual content. Aleš Tichopád contributed to the statistical analysis, interpretation of results, and critical revision of the manuscript. All authors approved the final submitted version of the manuscript and agree to be personally accountable for their own contributions and for ensuring the accuracy and integrity of the work, including any parts in which they were not personally involved. Acknowledgements The authors wish to thank all participating stroke centers and the Czech Stroke Society for their contributions to the RES-Q registry. References Ungerer MN, Bartig D, Richter D, et al. The evolution of acute stroke care in Germany from 2019 to 2021: analysis of nation-wide administrative datasets. Neurol Res Pract. 2024;6(1):4. Hengel P, Nimptsch U, Blümel M, et al. Regional variation in access to and quality of acute stroke care: results of Germany’s Health System Performance Assessment pilot, 2014–2020. Res Health Serv Reg. 2024;3:9. Kuhrij LS, van den Wouters MWJM, et al. The Dutch Acute Stroke Audit: Benchmarking acute stroke care in the Netherlands. Eur Stroke J. 2018;3(4):361–8. Amini M, van Leeuwen N, Eijkenaar F, et al. Improving quality of stroke care through benchmarking center performance: why focusing on outcomes is not enough. BMC Health Serv Res. 2020;20:998. Matsuo R. Stroke registry studies in Japan: past, present, and future perspectives. J Atheroscler Thromb. 2023;30:1095–103. Wang C, Su S, Li X, et al. Identifying performance outliers for stroke care based on composite score of process indicators: an observational study in China. J Gen Intern Med. 2020;35(9):2621–8. Kõrv J, Antsov K, Gross-Paju K, et al. Developments in quality of stroke care in Estonia. Eur Stroke J. 2023;8(1S):35–43. Gdovinova Z, Kovačik M, Urbani D, et al. How stroke care has changed in Slovakia in the last 5 years. Eur Stroke J. 2023;8(1S):52–8. Leigh C, Gill J, Razak Z, et al. A systematic review of current national hospital-based stroke registries monitoring access to evidence-based care and patient outcomes. Eur Stroke J. 2025;00:1–9. Aguiar de Sousa D, Wilkie A, Norrving B, et al. Delivery of acute ischemic stroke treatments in the European region in 2019 and 2020. Eur Stroke J. 2023;8(3):618–28. Lowther HJ, Harrison J, Hill JE, et al. The effectiveness of quality improvement collaboratives in improving stroke care and the facilitators and barriers to their implementation: a systematic review. Implement Sci. 2021;16:95. Norrving B, Barrick J, Davalos A, et al. Action plan for stroke in Europe 2018–2030. Eur Stroke J. 2018;3:309–36. Bryndová L, Bar M, Herzig R, et al. Concentrating stroke care provision in the Czech Republic: the establishment of stroke centers in 2011 has led to improved outcomes. Health Policy. 2021;125:520–5. Ministry of Health of Czech Republic. Bulletin No. 10/2021 - List of Highly Specialized Cerebrovascular Care Centers and Quality Indicators of Provided Healthcare. Available at: https://mzd.gov.cz/vestnik/vestnik-c-10-2021/ Health Insurance Bureau. Set of Quality Indicators for the Care of Patients with Cerebrovascular Accidents. Available at: https://puk.kzp.cz Mikulik R, Bar M, Grecu A, et al. The registry of stroke care quality (RES-Q): the first nation-wide data on stroke care quality. J Neurol Sci. 2017;381:91. Fasugba O, Sedani R, Mikulik R, Dale S, Varecha M, Coughlan K, McElduff B, McInnes E, Hladikova S, Cadilhac DA, Middleton S. How registry data are used to inform activities for stroke care quality improvement across 55 countries: A cross-sectional survey of Registry of Stroke Care Quality (RES-Q) hospitals. Eur J Neurol. 2024;31(1):e16024. Caso V, Mikulik R, Bornstein N, Fischer U, Gąsecki D, Lees KR, Toni D, Wahlgren N. The ESO and WSO Angels Awards program: Influencing quality improvement in stroke care worldwide. Eur Stroke J. 2023;8(1):6–12. AHRQ Quality Indicators. ICD-9-CM Specification Version 6.0, Inpatient Quality Indicator 17 (IQI 17) Acute Stroke Mortality Rate, 2017. Available at: https://www.qualityindicators.ahrq.gov/Downloads/ Narrins CR, et al. The influence of public reporting of outcome data on medical decision making by physicians. Arch Intern Med. 2005;165:83–7. National Institutes of Health Stroke Scale NIHSS - Cerebrovascular Manual. Available at: https://www.manual-cmp.cz/nihss/ Specifications Manual for Joint Commission National Quality Measures. Modified Rankin Score (mRS). The Joint Commission, 2016. Available at: https://manual.jointcommission.org/releases/TJC2016B/DataElem0569.html Gdovinová Z, Vitková M, Baráková A, et al. The impact of the COVID-19 outbreak on acute stroke care in Slovakia: data from across the country. Eur J Neurol. 2021;28:3263–6. Gdovinová Z, Vitková M, Baráková A et al. Did the severity of the COVID-19 outbreak affect the quality of acute stroke care? (data from across the country). Eur Stroke J. 2022; 7. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers invited by journal 11 Aug, 2025 Editor invited by journal 09 Jul, 2025 Editor assigned by journal 09 Jul, 2025 Submission checks completed at journal 09 Jul, 2025 First submitted to journal 27 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6991532","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":501328557,"identity":"d2909be5-ff01-4df8-b37d-04dff7a0ead3","order_by":0,"name":"Marian Rybář","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAuklEQVRIiWNgGAWjYFACHjBZz0+ylgTJBiB5gCQtBgeI1WI+I/fg58ocuzzj42fMpD8w2NkT1CJzIy9Z8uy25GKzMzlmEgcYkpkJapGQyDGQbNzGzLjtBlsaUMsBNmK0GP9s3FbPuHkGRAsPMVrMgLYcTtwgwXwMpEWCsBaed2mWjduOG0ucST5sccYg2YCwFvbcwzcbt1XL8bcfbLxRUUFEiDEIJCDzCNsBBPwHiFE1CkbBKBgFIxoAAIxKN+q7ZJYjAAAAAElFTkSuQmCC","orcid":"","institution":"Czech Technical University in Prague","correspondingAuthor":true,"prefix":"","firstName":"Marian","middleName":"","lastName":"Rybář","suffix":""},{"id":501328558,"identity":"316bea70-ac4e-4f31-92e4-64df56f3aca3","order_by":1,"name":"Aleš Tomek","email":"","orcid":"","institution":"Charles University and University Hospital Motol","correspondingAuthor":false,"prefix":"","firstName":"Aleš","middleName":"","lastName":"Tomek","suffix":""},{"id":501328559,"identity":"5ac05500-1626-4665-ab37-3d5251dbc55b","order_by":2,"name":"Robert Mikulík","email":"","orcid":"","institution":"Health Management Institute, St. Anne’s University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Robert","middleName":"","lastName":"Mikulík","suffix":""},{"id":501328560,"identity":"1223976f-07a9-4726-8742-3761b3bccea5","order_by":3,"name":"Martin Šrámek","email":"","orcid":"","institution":"Military University Hospital Prague","correspondingAuthor":false,"prefix":"","firstName":"Martin","middleName":"","lastName":"Šrámek","suffix":""},{"id":501328561,"identity":"72ed8a1b-76a6-496c-8ccf-14948aaa3f6f","order_by":4,"name":"Ondřej Škoda","email":"","orcid":"","institution":"Hospital Jihlava","correspondingAuthor":false,"prefix":"","firstName":"Ondřej","middleName":"","lastName":"Škoda","suffix":""},{"id":501328562,"identity":"79fa8f20-d533-4dbd-b514-76d2966497b4","order_by":5,"name":"Vladimir Rogalewicz","email":"","orcid":"","institution":"Czech Technical University in Prague","correspondingAuthor":false,"prefix":"","firstName":"Vladimir","middleName":"","lastName":"Rogalewicz","suffix":""},{"id":501328563,"identity":"9ef97242-4a1d-456f-ad6e-fd2503a9b783","order_by":6,"name":"Aleš Tichopád","email":"","orcid":"","institution":"Czech Technical University in Prague","correspondingAuthor":false,"prefix":"","firstName":"Aleš","middleName":"","lastName":"Tichopád","suffix":""}],"badges":[],"createdAt":"2025-06-27 12:23:08","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6991532/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6991532/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":89450978,"identity":"e96ec25c-3fcf-444f-9894-69e8f3a17ac2","added_by":"auto","created_at":"2025-08-20 06:15:00","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":68489,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003e5-, 30- and 90-day case fatality indicators for the period 2019-2023\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-6991532/v1/568129b2a835e68fe81b07f1.png"},{"id":89450985,"identity":"4252efde-be55-45de-ae06-3c0dd4a2ec66","added_by":"auto","created_at":"2025-08-20 06:15:00","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":62763,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eOrganization of medical care indicators for the period 2019-2023\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-6991532/v1/27a9d6cef7664a052502dd82.png"},{"id":89450979,"identity":"e0753883-4742-4c8d-bae6-90d904f9ac01","added_by":"auto","created_at":"2025-08-20 06:15:00","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":62835,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSecondary prevention indicators for the period 2019-2023\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-6991532/v1/765f8eb008389733273de8c8.png"},{"id":89451601,"identity":"1b548add-bfc0-4000-8deb-53a8a0f63c5c","added_by":"auto","created_at":"2025-08-20 06:23:00","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":62057,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eTreatment time indicators for the period 2019-2023\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-6991532/v1/687b9abb6dee4f2891a8583b.png"},{"id":89450989,"identity":"b6f739c9-6f5a-4cde-82c7-03f73f83709f","added_by":"auto","created_at":"2025-08-20 06:15:00","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":327479,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eDistribution of stroke centers in the Czech Republic, 2024. This figure illustrates the organization of stroke centers across the Czech Republic. The green circles represent the 13 secondary stroke centers, which are equipped to provide both intravenous thrombolysis and endovascular treatments. Yellow circles denote the 34 primary stroke centers that administer intravenous thrombolysis. The blue circles indicate facilities that have neurology departments but are not designated stroke centers, whereas the brown circles represent healthcare facilities without neurology services. The brown background color represents the level of centrality in a given region [15].\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure5.png","url":"https://assets-eu.researchsquare.com/files/rs-6991532/v1/28fcfa4c683f3b4e506cf4ff.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Healthcare data and benchmarking of stroke centers save the lives of patients with cerebrovascular strokes","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCerebrovascular accidents (strokes) remain one of the leading causes of mortality and disability in developed countries. The quality of care provided to stroke patients directly affects survival and long-term functional independence. Consequently, some countries have introduced national registries, quality indicators, and benchmarking systems as tools to improve care standards and promote health system transparency.\u003c/p\u003e\u003cp\u003eIn Germany, administrative data from 2019\u0026ndash;2021 were used to monitor developments in acute stroke care and to identify regional disparities, which led to targeted system-level interventions [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Another German study further demonstrated that access to high-quality stroke care varies significantly by region, with notable differences in the availability of reperfusion therapies and patient outcomes [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. These findings underscore the importance of monitoring not only national averages but also regional-level variations in care delivery.\u003c/p\u003e\u003cp\u003eSimilarly, the Netherlands implemented a national audit of acute stroke care that enabled hospitals to improve outcomes through comparative quality indicators [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, a key insight from this initiative was that tracking outcomes alone is insufficient\u0026mdash;without a strong focus on process indicators, comprehensive quality improvement cannot be achieved [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eJapan\u0026rsquo;s registry-based approach highlights the importance of long-term data collection, which supports the evaluation of not only acute care but also the subsequent rehabilitation phase and its impact on functional outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In China, a composite score based on process indicators has been successfully used to identify underperforming hospitals, prompting targeted interventions. The same study proposed replacing multiple individual indicators with a single composite metric\u0026mdash;a concept not yet widely adopted internationally [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCentral and Eastern European countries have also made notable progress. In Estonia, a national stroke care quality initiative has resulted in improved access to stroke units, faster treatment times, and greater use of reperfusion therapies, supported by the implementation of clear national guidelines and regular performance reviews [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Likewise, Slovakia has reported improvements over the past five years in thrombolysis rates, increased use of thrombectomy, and the development of a comprehensive stroke network, although challenges remain in ensuring uniform care quality across all regions [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eA systematic review of national stroke registries [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] confirmed significant variability across countries in terms of digitalization, monitored metrics, and data accessibility. According to the authors, close collaboration between stakeholders\u0026mdash;healthcare providers, regulators, payers, and professional societies\u0026mdash;is essential for success.\u003c/p\u003e\u003cp\u003eRecent European reviews [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] have shown that although the number of reperfusion treatments (thrombolysis and thrombectomy) increased from 2019\u0026ndash;2020, considerable intercountry differences persist. The absence of harmonized data continues to hinder accurate international comparisons. To support coordinated efforts in stroke care, the Action Plan for Stroke in Europe 2018\u0026ndash;2030, which was jointly developed by the European Stroke Organization (ESO) and Stroke Alliance for Europe (SAFE), established ten overarching goals, including access to stroke units, implementation of national stroke plans, and routine measurement of quality indicators [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn this context, the Czech Republic launched a national benchmarking system in 2019 based on the integration of administrative and registry data via the RES-Q. This benchmarking model involves all key stakeholders\u0026mdash;care providers, professional societies, health insurance funds (HIFs), and the Ministry of Health (MoH)\u0026mdash;and is grounded in shared accountability and data-driven decision-making. Rather than operating in silos, collaboration is institutionalized through a national governing structure: the Commission for Quality in Stroke Care.\u003c/p\u003e\u003cp\u003e This study aims to perform its first evaluation of the impact of the Czech national benchmarking system and stakeholders involved in key stroke care quality indicators since its establishment, covering the period from 2019\u0026ndash;2023.\u003c/p\u003e"},{"header":"Patients and methods","content":"\u003cp\u003e\u003cstrong\u003eStakeholders\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSince 2011, the MoH has certified 47 specialized stroke centers [13]. These include 34 primary stroke centers (hospitals administering intravenous thrombolysis) and 13 secondary stroke centers (hospitals with additional capabilities for endovascular treatment and neurosurgery) (Fig.\u0026nbsp;5). Within the MoH, the Commission for Quality in Stroke Care was established, which has the authority to monitor quality indicators for stroke as defined in the ministry\u0026rsquo;s bulletin [14]. The Commission includes representatives from the MoH, HIFs, and professional societies in stroke, neurosurgery, interventional radiology, and rehabilitation.\u003c/p\u003e\n\u003cp\u003eThe MoH represents the position of legislative regulator within the Commission overseeing Czech healthcare and acts as the organization ultimately responsible for quality assurance in healthcare centers. The legislative foundation for quality control is Act No. 372/2011 Coll., on Health Services and Conditions of Their Provision (the Health Services Act), which delineates the principles of quality indicator control across all centers for highly specialized care, including but not limited to stroke centers. The MoH issues a certificate of accreditation for stroke centers every five years for the subsequent period. The issuance of the certificate is contingent upon meeting the required thresholds for all quality indicators.\u003c/p\u003e\n\u003cp\u003eHIFs participate in the Commission from the perspective of health care payers, financing care through contributions collected from individuals and employers. There are a total of seven HIFs in the Czech Republic, all of which have agreed on a unified approach to collaborate on quality control within the Commission. All seven HIFs have entrusted the quality measurement agenda to the Czech Health Insurance Bureau, which processes the data of these HIFs for the MoH [15].\u003c/p\u003e\n\u003cp\u003eProfessional societies play an expert role within the Commission. Each of the four professional societies\u0026mdash;cerebrovascular, neurosurgical, interventional radiology, and rehabilitation\u0026mdash;provides expert recommendations related to their specific quality indicators.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData management\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe quality indicators were created by the National Registry of Reimbursed Health Services (NRRHS) provided by Czech HIFs [15] and the Registry of Stroke Care Quality (RES-Q) [16].\u003c/p\u003e\n\u003cp\u003eRegistry of Stroke Care Quality (RES-Q)\u003c/p\u003e\n\u003cp\u003eThe Registry of Stroke Care Quality (RES-Q) was launched in the Czech Republic in 2016. Since then, it has been adopted by numerous countries as a platform for quality monitoring. As of 2025, the RES-Q has supported quality monitoring for more than 1 million stroke patients across more than 2,000 hospitals in 83 countries. [16]. The platform enables hospitals to monitor their performance in real time through online dashboards and downloadable reports. Each hospital retains access to its source data. National coordinators have access to national source data to support research and quality improvement activities [17]. The data governance structure is available on the RES-Q website (www.qualityregistry.org). A key advantage of the RES-Q is its adaptability: the data collection form is regularly updated to reflect the latest clinical evidence and guidelines. As a result, analyses and visualizations\u0026mdash;such as dashboards\u0026mdash;provide timely, evidence-aligned feedback. This level of responsiveness would be difficult, if not impossible, to achieve using administrative databases, which are better suited to tracking long-term, stable indicators. RES-Q data are also used in the ESO and WSO Angels Awards programs, which are supported by the Angels Initiative, which recognizes hospitals for excellence in stroke care with Gold, Platinum, or Diamond awards on the basis primarily of RES-Q or other approved registry data [18]. This serves as an incentive for continuous quality improvement. RES-Q is fully compliant with the GDPR and ensures secure handling of patient data. More information is available at www.qualityregistry.org. The RES-Q automatically generated reports are used by the Czech Stroke Society, which communicates these results to all stroke centers in the country independently from the Commission. The Commission is focused on the most robust indicators of quality. We derived the following quality indicators from RES-Q: the median times for Door to Needle Time (DNT), Door In Door Out Time (DIDO), Door To Groin Time (DGT), Door To Imaging Time (DIT), and Groin To Recanalization Time (GRT). The quality indicators for the percentage of intravenous thrombolysis and mechanical thrombectomy were calculated via combined data from the RES-Q registry and the total patient numbers reported in the NRRHS [15].\u003c/p\u003e\n\u003cp\u003eNational Registry of Reimbursed Health Services (NRRHS) provided by Czech HIFs\u003c/p\u003e\n\u003cp\u003eNRRHS is a key component of the Czech healthcare data infrastructure. It is a comprehensive database containing information on all healthcare services reimbursed to providers through the public health insurance system in the Czech Republic. The registry includes data on medical procedures, diagnoses, pharmaceuticals, and other healthcare services. All 7 HIFs have entrusted the quality measurement agenda to the Health Insurance Bureau Companies, which processes the data of these seven HIFs for the MoH [15]. From the NRRHS, we derived the following quality indicators: 5-, 30- and 90-day case fatality; the proportion of patients managed in intensive care units; and prescriptions for statins, antihypertensives, or anticoagulants. We derived the quality indicators for the proportion of intravenous thrombolysis and mechanical thrombectomy by using a combination of data from the NRRHS (total number of patients) and the RES-Q (number of procedures performed).\u003c/p\u003e\n\u003cp\u003eThe data file thus contained complete data on all insured individuals in the Czech Republic for the years 2019\u0026ndash;2023. Importantly, all the quality indicator results are attributed to the facility where the patient was first admitted for hospital care [15]. This means that outcomes from any subsequent transfers are assigned to the initial admitting facility. This approach reflects the assumption that the first facility is responsible for key decisions regarding initial treatment and the patient\u0026rsquo;s subsequent pathway through the healthcare system [16].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe benchmarking system\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Commission has been convening annually and setting target levels for quality indicators that all monitored facilities are expected to meet in the given year.\u003c/p\u003e\n\u003cp\u003eFor example, the 2023 target for the 30-day case fatality rate required that no monitored stroke center exceed a threshold of 15%. The proportion of patients treated in intensive care units was at least 50%. Intravenous thrombolysis was administered in at least 20% of the patients, and mechanical thrombectomy was administered in at least 10% of the patients. The use rates of statins, antihypertensives, and anticoagulants in patients with atrial fibrillation were at least 70%, 60%, and 80%, respectively. The median times for Door-to-Needle Time (DNT), Door-In\u0026ndash;Door-Out Time (DIDO), Door-to-Groin Time (DGT), Door-to-Imaging Time (DIT), and Groin-to-Recanalization Time (GRT) did not exceed 30, 45, 90, 20, and 60 minutes, respectively.\u003c/p\u003e\n\u003cp\u003eIf any of the indicators are not met, the Commission requires the healthcare facility to submit an analysis explaining the causes of noncompliance, to propose appropriate corrective actions, and to suggest collaborative steps in alignment with the MoH. If quality indicators are repeatedly unmet, the Commission is authorized to revoke the facility\u0026rsquo;s status as a certified specialized center (Fig.\u0026nbsp;6) [14].\u003c/p\u003e\n\u003cp\u003eIndicator results are shared with facilities in a semiopen format: rankings are not published, and each facility sees only its own results in comparison with the national average and anonymized results of other facilities.\u003c/p\u003e\n\u003cp\u003eThe MoH, HIFs, and professional societies, on the other hand, can see the results of all facilities. Patients only see deidentified results.\u003c/p\u003e\n\u003cdiv id=\"Sec2\"\u003e\n \u003ch2\u003eStatistical analysis\u003c/h2\u003e\n \u003cp\u003eRelative frequencies and medians were compared via an inferential test (chi-square test and Mann‒Whitney U test, respectively) in R version 4.3.1 to assess the significance of changes between the initial year of 2019 and the final year of 2023. We compared only the first and last years to avoid COVID-19-related heterogeneity and the need for complex trend modeling; trends are shown graphically (Figs.\u0026nbsp;1 to 4).\u003c/p\u003e\n \u003cp\u003eGiven the necessity of accurate facility comparisons concerning 5-day, 30-day, and 90-day mortality indicators, we standardized the measured outcomes to account for potential variations in patient demographics. A logistic multivariable regression model, as outlined by the Agency for Healthcare Research and Quality (AHRQ) [19], was utilized, incorporating age, sex, and fundamental comorbidities as covariates.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e Over a five-year period, we assessed key quality indicators for stroke care in the Czech Republic, covering 2019\u0026ndash;2023. The analysis revealed that nearly all the evaluated quality indicators either improved or remained stable in 2023 compared with the baseline year of 2019, as illustrated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase fatality rate\u003c/b\u003e\u003c/p\u003e\u003cp\u003eDuring the benchmark period from 2019\u0026ndash;2023, the 30-day case fatality rate declined from 12.40\u0026ndash;11.45% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Concurrently, the 90-day case fatality rate decreased from 18.50\u0026ndash;15.99% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). In contrast, the 5-day case fatality rate slightly increased from 5.04\u0026ndash;5.32% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eOrganization of medical care\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe proportion of patients managed in stroke centers increased from 77.31\u0026ndash;82.57% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, the proportion of patients managed in intensive care units rose from 61.82\u0026ndash;69.05% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The rate of intravenous thrombolysis increased from 34.29\u0026ndash;40.58% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the use of mechanical thrombectomy increased from 10.12\u0026ndash;12.68% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSecondary prevention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe prescription rate for statins at discharge increased from 69.37\u0026ndash;79.94% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), that for antihypertensives increased from 71.29\u0026ndash;75.95% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and that for anticoagulants increased from 80.58\u0026ndash;87.41% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTreatment Times\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe median door-to-needle time (DNT) remained unchanged at 22 minutes for both 2019 and 2023 (p\u0026thinsp;=\u0026thinsp;0.23). The median Door In Door Out Time (DIDO) decreased from 55 minutes to 53 minutes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), whereas the Door To Groin Time (DGT) median increased from 65 minutes to 67 minutes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, the median door-to-imaging time (DIT) decreased from 14 minutes to 10 minutes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the median groin-to-recanalization time (GRT) decreased from 38 minutes to 36 minutes (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparative analysis of selected indicators. 2019 vs. 2023\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIndicator category\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndicator\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCase-fatality\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5 day case-fatality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.04%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.32%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30 day case-fatality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12.40%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.45%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 day case-fatality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.50%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.99%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOrganization of care\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePatients managed in stroke centers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77.31%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e82.57%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProportion Intensive care unit\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61.82%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69.05%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntravenous trombolysis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.29%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40.58%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMechanical trombectomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10.12%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.68%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSecondary prevention\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrescription for statins\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e69.37%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e79.94%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrescription for antihypertensives\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71.29%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75.95%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrescription for anticoagulants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80.58%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87.41%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTreatment Times\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDoor To Needle Time (DNT. median)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;=\u0026thinsp;0.23\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDoor In Door Out Time (DIDO. median)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDoor To Groin Time (DGT. median)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e67 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDoor To Imaging Time (DIT. median)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGroin To Recanal. Time (GRT. median)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36 min\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e The implementation of a nationwide quality monitoring system for stroke care in the Czech Republic represents a decade-long evolution from the initial certification of stroke centers in 2011 to the establishment of a comprehensive benchmarking framework in 2019. This system was built through a bottom-up approach initiated by stroke specialists and gradually institutionalized with the active engagement of the MoH, HIFs, and professional medical societies. The inclusion of all key stakeholders fosters mutual accountability and commitment to continuous improvement in care. Our analysis demonstrates that this collaborative framework has led to significant advances in multiple quality indicators, with measurable improvements in patient outcomes across the nation. These findings are in line with international experiences, such as those reported from Germany [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], the Netherlands [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and Japan [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], where systematic benchmarking and centralization of stroke services similarly contributed to measurable enhancements in care quality and regional equity.\u003c/p\u003e\u003cp\u003eA major success factor in the Czech stroke care system is the near-universal admission of stroke patients to certified stroke centers\u0026mdash;an achievement made possible through a two-pronged approach: mandatory certification and a national emergency medical services directive requiring the transport of stroke patients exclusively to certified centers. As a result, the proportion of stroke patients treated in these specialized centers increased from 77\u0026ndash;83% between 2019 and 2023. This structural intervention, combined with systematic benchmarking, directly contributed to the observed decline in the 30- and 90-day case fatality rates. Given that stroke remains one of the leading causes of death and disability, these outcomes have substantial socioeconomic and societal impacts. Similar centralization strategies in Slovakia and Estonia have demonstrated comparable benefits [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], underscoring the broader relevance of this organizational model in Central and Eastern Europe.\u003c/p\u003e\u003cp\u003eThe improvement in quality indicators, such as intravenous thrombolysis rates, prescriptions for secondary prevention medications, and access to intensive care, should be viewed in the context of long-term efforts that predate the formal benchmarking system. Some indicators, particularly the door-to-needle time (DNT), began improving as early as 2010 because of multiple factors, including the widespread implementation of simulation-based training. Approximately one-third of all stroke centers have undergone such training, highlighting the importance of education and experiential learning in achieving system-wide improvements. Moreover, the Czech benchmarking model aligns with the principles of the Action Plan for Stroke in Europe 2018\u0026ndash;2030 [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], especially with respect to transparency, stakeholder collaboration, and data-driven care improvement. This convergence suggests that the Czech experience may inform broader European strategies.\u003c/p\u003e\u003cp\u003eOne of the unique features of the Czech model is the dual-source data collection system, which combines the completeness of administrative data from health insurance claims with the clinical depth and flexibility of the RES-Q. This hybrid approach allows for robust national analysis while remaining responsive to evolving clinical guidelines and international benchmarking practices. The public‒private partnership between government agencies, insurance companies, and nonprofit organizations such as RES-Q exemplifies an efficient and scalable model of health data integration for quality improvement.\u003c/p\u003e\u003cp\u003eDespite these successes, the system faces significant challenges\u0026mdash;chief, among them, the lack of dedicated financial support. Neither the hospitals nor the RES-Q registry currently receive funding specifically allocated for quality monitoring. As a result, data collection relies heavily on voluntary effort, which threatens the long-term sustainability of the benchmarking system. Establishing permanent funding mechanisms and financial incentives is essential to ensure continued engagement, data quality, and innovation in improving stroke care quality. The sustainability concern is not unique to the Czech Republic and has been noted in other national registries, such as the Dutch Acute Stroke Audit [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and Japanese registry systems [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], which underlines the need for stable financing models to secure long-term quality gains.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOpenness in publishing results\u003c/b\u003e\u003c/p\u003e\u003cp\u003eInsurance-based benchmarking remains semiopen: each facility sees its data against anonymised peers and the national average. Full transparency risks data manipulation and may undermine data quality. A survey among American interventional cardiologists supported these concerns [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. A majority (79%) of the cardiologists surveyed acknowledged that the publication of mortality statistics sometimes influences their clinical decisions, particularly with regard to performing angioplasties on critically ill patients with high expected mortality rates. This hesitancy highlights the potential adverse effects of publicizing detailed performance metrics. These findings emphasize the need for careful consideration in future policies regarding the extent of data publication in healthcare. Legislative measures may be required to determine which data should be fully disclosed and which should primarily be accessible to healthcare professionals, HIFs, the MoH, and stroke centers.\u003c/p\u003e\u003cp\u003eIn contrast, the RES-Q registry follows a more transparent model by publishing center-level performance data, where individual hospitals are identifiable (subject to country-specific policies). This approach, adopted in the Czech Republic on the basis of a decision by the Czech Stroke Society, has become a widely accepted standard among stroke centers despite initial reservations. Importantly, because the RES-Q focuses on quality-of-care indicators and process metrics\u0026mdash;rather than raw outcome measures such as case fatality alone\u0026mdash;there is less risk that clinicians would alter treatment decisions or selectively avoid severe cases in an attempt to improve their reported patient outcomes.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData standardization via the NIHSS scale\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA significant limitation of the current quality indicators in the Czech Republic is their lack of standardization, primarily due to incomplete data on the initial severity of neurological deficits assessed via the National Institutes of Health Stroke Scale (NIHSS) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Since 2024, the mandatory inclusion of NIHSS stages in administrative data has been implemented. Facilities failing to document the initial NIHSS stage will face reduced reimbursement for the affected hospitalization cases. This change ensures that data from 2024 onward adhere to this vital standardization parameter.\u003c/p\u003e\u003cp\u003eFurthermore, efforts are underway to develop a standardized medical report specifically for stroke patient care. This initiative aims to facilitate the seamless integration of essential health statistical data from hospital information systems into the administrative datasets used by health insurers and to increase the quality of detailed clinical information transmitted to the RES-Q. The implementation of standardized medical reports is expected to significantly improve the accuracy and utility of stroke care data. Similar transitions toward mandatory NIHSS recording have taken place in other benchmarking systems, such as in Germany and the Netherlands [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], demonstrating how standardized severity adjustment improves interfacility comparability and prevents misleading interpretations of mortality and treatment rates.\u003c/p\u003e\u003cp\u003e\u003cb\u003eReflecting the patient's outcome posttreatment via the MRS90 scale\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe modified Rankin scale at 90 days (mRS90) [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] represents the most informative measure for assessing patient outcomes posttreatment, yet these data are currently unavailable in the Czech Republic. The commonly used 30-day case-fatality metric does not capture the patient\u0026rsquo;s ultimate functional status. There are scenarios where a facility may achieve a high recovery rate, with a majority of patients reaching a self-sufficient state categorized between MRS90s 1\u0026ndash;4; however, higher mortality rates may still be reported. Conversely, another facility might demonstrate better 30-day case fatality statistics while leaving a significant number of patients in a severely disabled state, classified as MRS90 5\u0026ndash;6. The critical importance of the mRS90 has been emphasized in multiple sources [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], particularly in international quality frameworks that prioritize patient-centered outcomes over crude mortality figures. The integration of mRS90 data into the administrative database would enhance the alignment of the Czech system with these international standards. The RES-Q has a developer application that should be able to collect not only mRS90 directly from patients but also other conditions, such as depression and other comorbid conditions. Testing of this application is underway.\u003c/p\u003e\u003cp\u003e\u003cb\u003eUse of benchmarking by type of care\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA fundamental question in the development of quality indicators is whether to establish separate measures for different subsets of patients on the basis of their treatment modality\u0026mdash;specifically, mechanical thrombectomy, intravenous thrombolysis, or conservative treatment only. Stratifying outcomes by treatment type may increase clinical relevance and enhance the granularity of benchmarking outputs. On the other hand, it also introduces greater complexity into the benchmarking process, which may hinder data interpretation and limit comparability across facilities.\u003c/p\u003e\u003cp\u003e\u003cb\u003eReplacing median times with the proportion of patients exceeding critical time thresholds\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCurrently, benchmarking in the Czech Republic uses median values for process time indicators such as Door to Needle Time (DNT), Door In Door Out Time (DIDO), Door To Groin Time (DGT), Door To Imaging Time (DIT), and Groin To Recanalization Time (GRT). While medians provide a central tendency, they do not account for the range of patient times, particularly those significantly exceeding the median. For example, two facilities may report the same median of 20 minutes; however, one facility might have times slightly above this median, whereas the other could have extreme delays, with times reaching up to 100 minutes.\u003c/p\u003e\u003cp\u003eTo address this issue, in the future, the benchmarking strategy will be enhanced by incorporating the proportion of patients whose treatment times surpass a predetermined critical threshold. This adjustment aims to provide a more comprehensive assessment of patient care efficiency and timeliness across facilities.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMonitoring indicators of subsequent rehabilitation care\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe treatment of stroke patients extends beyond the acute phase of care, with subsequent rehabilitation playing a critical role in enhancing patients' long-term self-sufficiency. In response, the Czech Republic is developing a comprehensive set of indicators to assess the quality of poststroke rehabilitation care. These indicators include:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe proportion of patients admitted to acute rehabilitation beds at each facility.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe number of patients with focal dystonia who received botulinum toxin treatments.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eScores on the extended and basic Barthel Index, which measures the degree of independence in daily activities.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe elapsed time from the stroke incident to the patient's admission to a rehabilitation bed.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe proportion of patients who received comprehensive rehabilitative services, including physiotherapy, swallowing assessments, occupational therapy, and speech therapy.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThis initiative aims to provide a robust framework for evaluating the effectiveness of rehabilitation services and to ensure that these critical aspects of stroke recovery are adequately addressed across healthcare facilities. The RES-Q pilotes the collection of quality/performance data from rehabilitation facilities in the Czech Republic, and the results will be reported elsewhere.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAlthough the findings of this study suggest substantial improvements in the quality of stroke care following the introduction of national benchmarking, several limitations must be acknowledged.\u003c/p\u003e\u003cp\u003eFirst, not all improvements in quality indicators can be directly attributed to the benchmarking initiative launched in 2019. Some indicators\u0026mdash;particularly time-sensitive logistics, such as door-to-needle time (DNT)\u0026mdash;had already improved prior to benchmarking, driven by focused clinical education, simulation-based training, and earlier quality improvement initiatives. This complicates causal attribution and underscores the multifactorial nature of quality enhancement in stroke care. Some changes in indicators may also have been influenced by the COVID-19 pandemic [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This aspect, however, was not addressed in the present study.\u003c/p\u003e\u003cp\u003eSecond, despite the advantages of combining administrative and registry data, the absence of standardized clinical variables\u0026mdash;most notably initial stroke severity as measured by the National Institutes of Health Stroke Scale (NIHSS)\u0026mdash;has historically limited the ability to adjust for baseline patient characteristics. This gap is only partially mitigated by the recent inclusion of mandatory NIHSS documentation in administrative datasets since 2024. Similarly, the lack of consistent postdischarge functional outcome data beyond mortality\u0026mdash;such as 90-day modified Rankin scale (mRS90) scores\u0026mdash;limits our ability to assess longer-term recovery.\u003c/p\u003e\u003cp\u003eFinally, although the benchmarking framework is methodologically sound, it currently relies on median values for process metrics. While useful, this approach may mask outliers and delay distributions that are critical for patient outcomes. Planned enhancements\u0026mdash;such as incorporating threshold-based metrics (e.g., the proportion of patients exceeding critical time windows)\u0026mdash;represent an important refinement for accurately assessing performance.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOver the last five years, the Czech Republic has successfully implemented a nationwide benchmarking system for stroke centers that integrates administrative and clinical registry data, engages all major healthcare stakeholders, and fosters a culture of shared accountability. This model has led to measurable improvements in most key quality indicators and an important decline in mortality rates, offering a strong example of how data-driven governance can improve healthcare outcomes. However, to sustain and further develop this system\u0026mdash;particularly in areas such as rehabilitation and potentially other medical fields\u0026mdash;dedicated funding is urgently needed. With continued political, financial, and professional commitment, the Czech stroke care benchmarking system can serve not only as a model for other clinical domains within the country but also as a transferable framework for other nations seeking to improve stroke care through data and collaboration. Given the alignment with European strategic goals [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and the operational success of comparable registries in more than 50 countries [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], the Czech experience offers valuable lessons for designing scalable and sustainable quality improvement infrastructures worldwide.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data on the results of individual measured quality indicators for the years 2019\u0026ndash;2023 are available on Figshare under the URL: https://figshare.com/s/22571b6be79a88a95994, DOI: https://doi.org/10.6084/m9.figshare.29473346.v1\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAles Tomek, Robert Mikul\u0026iacute;k and Ales Tichop\u0026aacute;d were supported by the Ministry of Health of the Czech Republic in cooperation with the Czech Health Research Council under project No. NW24-09-00215.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMarian Ryb\u0026aacute;ř contributed to the conception and design of the study, acquisition and interpretation of data, and drafting of the manuscript. Ale\u0026scaron; Tomek, Robert Mikul\u0026iacute;k, Martin \u0026Scaron;r\u0026aacute;mek, Ondřej \u0026Scaron;koda, and Vladimir Rogalewicz contributed to the acquisition and interpretation of data, as well as the critical revision of the manuscript for important intellectual content. Ale\u0026scaron; Tichop\u0026aacute;d contributed to the statistical analysis, interpretation of results, and critical revision of the manuscript. All authors approved the final submitted version of the manuscript and agree to be personally accountable for their own contributions and for ensuring the accuracy and integrity of the work, including any parts in which they were not personally involved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to thank all participating stroke centers and the Czech Stroke Society for their contributions to the RES-Q registry.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUngerer MN, Bartig D, Richter D, et al. The evolution of acute stroke care in Germany from 2019 to 2021: analysis of nation-wide administrative datasets. Neurol Res Pract. 2024;6(1):4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHengel P, Nimptsch U, Bl\u0026uuml;mel M, et al. Regional variation in access to and quality of acute stroke care: results of Germany\u0026rsquo;s Health System Performance Assessment pilot, 2014\u0026ndash;2020. Res Health Serv Reg. 2024;3:9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKuhrij LS, van den Wouters MWJM, et al. The Dutch Acute Stroke Audit: Benchmarking acute stroke care in the Netherlands. Eur Stroke J. 2018;3(4):361\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmini M, van Leeuwen N, Eijkenaar F, et al. Improving quality of stroke care through benchmarking center performance: why focusing on outcomes is not enough. BMC Health Serv Res. 2020;20:998.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMatsuo R. Stroke registry studies in Japan: past, present, and future perspectives. J Atheroscler Thromb. 2023;30:1095\u0026ndash;103.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang C, Su S, Li X, et al. Identifying performance outliers for stroke care based on composite score of process indicators: an observational study in China. J Gen Intern Med. 2020;35(9):2621\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eK\u0026otilde;rv J, Antsov K, Gross-Paju K, et al. Developments in quality of stroke care in Estonia. Eur Stroke J. 2023;8(1S):35\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGdovinova Z, Kovačik M, Urbani D, et al. How stroke care has changed in Slovakia in the last 5 years. Eur Stroke J. 2023;8(1S):52\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLeigh C, Gill J, Razak Z, et al. A systematic review of current national hospital-based stroke registries monitoring access to evidence-based care and patient outcomes. Eur Stroke J. 2025;00:1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAguiar de Sousa D, Wilkie A, Norrving B, et al. Delivery of acute ischemic stroke treatments in the European region in 2019 and 2020. Eur Stroke J. 2023;8(3):618\u0026ndash;28.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLowther HJ, Harrison J, Hill JE, et al. The effectiveness of quality improvement collaboratives in improving stroke care and the facilitators and barriers to their implementation: a systematic review. Implement Sci. 2021;16:95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNorrving B, Barrick J, Davalos A, et al. Action plan for stroke in Europe 2018\u0026ndash;2030. Eur Stroke J. 2018;3:309\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBryndov\u0026aacute; L, Bar M, Herzig R, et al. Concentrating stroke care provision in the Czech Republic: the establishment of stroke centers in 2011 has led to improved outcomes. Health Policy. 2021;125:520\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMinistry of Health of Czech Republic. Bulletin No. 10/2021 - List of Highly Specialized Cerebrovascular Care Centers and Quality Indicators of Provided Healthcare. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://mzd.gov.cz/vestnik/vestnik-c-10-2021/\u003c/span\u003e\u003cspan address=\"https://mzd.gov.cz/vestnik/vestnik-c-10-2021/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHealth Insurance Bureau. Set of Quality Indicators for the Care of Patients with Cerebrovascular Accidents. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://puk.kzp.cz\u003c/span\u003e\u003cspan address=\"https://puk.kzp.cz\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMikulik R, Bar M, Grecu A, et al. The registry of stroke care quality (RES-Q): the first nation-wide data on stroke care quality. J Neurol Sci. 2017;381:91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFasugba O, Sedani R, Mikulik R, Dale S, Varecha M, Coughlan K, McElduff B, McInnes E, Hladikova S, Cadilhac DA, Middleton S. How registry data are used to inform activities for stroke care quality improvement across 55 countries: A cross-sectional survey of Registry of Stroke Care Quality (RES-Q) hospitals. Eur J Neurol. 2024;31(1):e16024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCaso V, Mikulik R, Bornstein N, Fischer U, Gąsecki D, Lees KR, Toni D, Wahlgren N. The ESO and WSO Angels Awards program: Influencing quality improvement in stroke care worldwide. Eur Stroke J. 2023;8(1):6\u0026ndash;12.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAHRQ Quality Indicators. ICD-9-CM Specification Version 6.0, Inpatient Quality Indicator 17 (IQI 17) Acute Stroke Mortality Rate, 2017. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.qualityindicators.ahrq.gov/Downloads/\u003c/span\u003e\u003cspan address=\"https://www.qualityindicators.ahrq.gov/Downloads/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNarrins CR, et al. The influence of public reporting of outcome data on medical decision making by physicians. Arch Intern Med. 2005;165:83\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNational Institutes of Health Stroke Scale NIHSS - Cerebrovascular Manual. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.manual-cmp.cz/nihss/\u003c/span\u003e\u003cspan address=\"https://www.manual-cmp.cz/nihss/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpecifications Manual for Joint Commission National Quality Measures. Modified Rankin Score (mRS). The Joint Commission, 2016. Available at: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://manual.jointcommission.org/releases/TJC2016B/DataElem0569.html\u003c/span\u003e\u003cspan address=\"https://manual.jointcommission.org/releases/TJC2016B/DataElem0569.html\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGdovinov\u0026aacute; Z, Vitkov\u0026aacute; M, Bar\u0026aacute;kov\u0026aacute; A, et al. The impact of the COVID-19 outbreak on acute stroke care in Slovakia: data from across the country. Eur J Neurol. 2021;28:3263\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGdovinov\u0026aacute; Z, Vitkov\u0026aacute; M, Bar\u0026aacute;kov\u0026aacute; A et al. Did the severity of the COVID-19 outbreak affect the quality of acute stroke care? (data from across the country). Eur Stroke J. 2022; 7.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Stroke care, benchmarking, quality indicators, RES-Q registry, administrative data, health insurance claims, mortality, intravenous thrombolysis, mechanical thrombectomy, NIHSS, mRS90, modified Rankin scale at 90 days, health data integration, healthcare quality improvement, poststroke rehabilitation","lastPublishedDoi":"10.21203/rs.3.rs-6991532/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6991532/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e\u003cp\u003eIn 2019, the Czech Republic implemented a national benchmarking system to improve the quality of stroke care through the integration of administrative health insurance data and clinical registry information. The system was designed to engage all relevant stakeholders\u0026mdash;including stroke centers, the Ministry of Health, health insurance funds, and professional societies\u0026mdash;in a framework of shared accountability and data-driven governance.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e\u003cp\u003eA retrospective analysis was conducted using nationwide data from 2019\u0026ndash;2023. Quality indicators were derived from the National Registry of Reimbursed Health Services (NRRHS) and the Registry of Stroke Care Quality (RES-Q). We assessed changes in 5-, 30-, and 90-day case fatality rates; treatment rates (intravenous thrombolysis and mechanical thrombectomy); process times; intensive care access rates; and secondary prevention prescription rates. Statistical significance was evaluated via chi-square and Mann‒Whitney U tests. Risk-standardized mortality rates were calculated via logistic regression adjusted for age, sex, and comorbidities.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e\u003cp\u003eBetween the initial year, 2019, and the last year, 2023, significant improvements were observed in most indicators. The 30-day case fatality rate decreased from 12.40\u0026ndash;11.45% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the 90-day fatality rate decreased from 18.50\u0026ndash;15.99% (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The rate of intravenous thrombolysis increased from 34.29\u0026ndash;40.58%, and that of mechanical thrombectomy increased from 10.12\u0026ndash;12.68% (both p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Intensive care management increased from 61.82\u0026ndash;69.05%, and prescriptions for statins, antihypertensive drugs, and anticoagulants also improved significantly. The median door-to-needle time (DNT) remained stable at 22 minutes, whereas the door-to-imaging time (DIT) and groin-to-recanalization time (GRT) significantly decreased (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The 5-day case fatality rate increased slightly (5.04\u0026ndash;5.32%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e\u003cp\u003e The implementation of a national benchmarking system integrating administrative and registry data and engaging all relevant stakeholders was associated with measurable improvements in stroke care quality in the Czech Republic. The model promotes continuous quality improvement despite limited financial resources and offers a scalable and transferable framework for other healthcare systems. Ongoing enhancements\u0026mdash;including the inclusion of NIHSS scores, mRS90 outcomes, and refined time-based metrics\u0026mdash;will further support transparency and effectiveness in stroke care delivery.\u003c/p\u003e","manuscriptTitle":"Healthcare data and benchmarking of stroke centers save the lives of patients with cerebrovascular strokes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-20 06:14:55","doi":"10.21203/rs.3.rs-6991532/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-08-11T12:33:22+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-09T08:53:56+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-09T08:35:24+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-09T08:32:12+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-06-27T12:09:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"70298607-dcb1-4e4c-8be1-70cb0e85682f","owner":[],"postedDate":"August 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-08-20T06:14:56+00:00","versionOfRecord":[],"versionCreatedAt":"2025-08-20 06:14:55","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6991532","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6991532","identity":"rs-6991532","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}