We use specific national and international examples from the field of stroke to discuss the opportunities for greater physiotherapy engagement and the risks if we do not. However, the issue goes beyond any one disease group or care setting. National audits and disease registries are designed to help set benchmarks across the country, to monitor and ultimately improve the quality of care provided to patients. Each of these tools requires markers or indicators

of quality. Indicators need to be clinically relevant, feasible, valid, reliable, and applicable across a range of health care systems (Rubin SCR7 in vivo et al 2001); although they may measure process or outcome, it is the process of care indicators that allow us to measure specific interventions or activity within a system. An indicator is only useful if there is sufficient evidence to support a link between an activity or intervention and

positive patient outcomes because this link creates confidence that improvement in a measured process will translate into improvement in outcome. Consensus on defining ‘best practice’ Ku 0059436 interventions is paramount as it enhances decision making, facilitates development of quality indicators (particularly where evidence alone is insufficient), assists us to synthesise professional norms, and helps us identify and subsequently measure areas where there is uncertainty or incomplete evidence. Preferably, process indicators should be based on evidence-based clinical guidelines; however, when scientific evidence is limited, an extended family of evidence, including expert opinion, may be needed Oxymatrine as part of the indicator development process (Campbell et al 2002). Examples of process indicators in acute stroke care national audits include: brain CT scan within 24 hours of admission; and secondary prevention medication started by discharge (National Stroke Foundation 2007). What is striking in examining many national audit tools is that, despite the key role physiotherapists play in stroke care, indicators reflecting the practice of physiotherapy are rare.

A recent systematic review of process of care indicators used worldwide in acute stroke found that of the 161 indicators in use, only two relate to physiotherapy: assessment by a physiotherapist (varying from 24 to 72 hours of admission), and early mobilisation out of bed (which may or may not involve physiotherapists). No other physiotherapy specific indicators were found (Purvis et al 2009). Post acute care national stroke audits in Australia also measure items related to assessment of impairments, which may involve physiotherapists (National Stroke Foundation 2008). This is despite evidence that many physiotherapy interventions for people with stroke are effective, as shown in the national clinical guidelines for stroke management (National Stroke Foundation 2010). A similar bias is seen in quality of care audits in Sweden in which indicators predominantly reflect medical care.