Yilong Wang1,2,3,4, Zixiao Li2,3,4, Xingquan Zhao3,4, Chunjuan Wang1,2,4,5, Xianwei Wang1,2, David Wang6, Li Liang7, Liping Liu8, Chunxue Wang9, Hao Li1,2, Haipeng Shen10, Janet Bettger7, Yuesong Pan1,2, Yong Jiang1,2, Xiaomeng Yang3, Changqing Zhang3, Xiujie Han11, Xia Meng1,2, Xin Yang1,2, Hong Kang12, Weiqiang Yuan13, Gregg C Fonarow14, Eric D Peterson7, Lee H Schwamm15, Ying Xian7, Yongjun Wang1,2,3,4,5. 1. Tiantan Clinical Trial and Research Center for Stroke, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. 2. China National Clinical Research Center for Neurological Diseases, Beijing, China. 3. Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. 4. Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China. 5. Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China. 6. Illinois Neurological Institute Stroke Network, OSF Healthcare System, University of Illinois College of Medicine, Peoria. 7. Duke Clinical Research Institute, Duke University, Durham, North Carolina. 8. Neuro-intensive Care Unit, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. 9. Department of Neuropsychiatry and Behavioral Neurology and Clinical Psychology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. 10. Faculty of Business and Economics, University of Hong Kong, Hong Kong, China. 11. Department of Neurology, Anshanshi Changda Hospital, Liaoning, China. 12. Department of Neurology, General Hospital of Benxi Iron and Steel, Liaoning, China. 13. Department of Neurology, People's of the Fifth Hospital of Hengshui City, Hebei, China. 14. Ahmanson/University of California, Los Angeles (UCLA), Cardiomyopathy Center, Ronald Reagan UCLA Medical Center. 15. Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston.
Abstract
Importance: In China and other parts of the world, hospital personnel adherence to evidence-based stroke care is limited. Objective: To determine whether a multifaceted quality improvement intervention can improve hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke (AIS) in China. Design, Setting, and Participants: A multicenter, cluster-randomized clinical trial among 40 public hospitals in China that enrolled 4800 patients hospitalized with AIS from August 10, 2014, through June 20, 2015, with 12-month follow-up through July 30, 2016. Interventions: Twenty hospitals received amultifaceted quality improvement intervention (intervention group; 2400 patients), including a clinical pathway, care protocols, quality coordinator oversight, and performance measure monitoring and feedback. Twenty hospitals participated in the stroke registry with usual care (control group; 2400 patients). Main Outcomes and Measures: The primary outcome was hospital personnel adherence to 9 AIS performance measures, with co-primary outcomes of a composite of percentage of performance measures adhered to, and as all-or-none. Secondary outcomes included in-hospital mortality and long-term outcomes (a new vascular event, disability [modified Rankin Scale score, 3-5], and all-cause mortality) at 3, 6, and 12 months. Results: Among 4800 patients with AIS enrolled from 40 hospitals and randomized (mean age, 65 years; women, 1757 [36.6%]), 3980 patients (82.9%) completed the 12-month follow-up of the trial. Patients in intervention group were more likely to receive performance measures than those in the control groups (composite measure, 88.2% vs 84.8%, respectively; absolute difference, 3.54% [95% CI, 0.68% to 6.40%], P = .02). The all-or-none measure did not significantly differ between the intervention and control groups (53.8% vs 47.8%, respectively; absolute difference, 6.69% [95% CI, -0.41% to 13.79%], P = .06). New clinical vascular events were significantly reduced in the intervention group compared with the control group at 3 months (3.9% vs 5.3%, respectively; difference, -2.03% [95% CI, -3.51% to -0.55%]; P = .007), 6 months (6.3% vs 7.8%, respectively; difference, -2.18% [95% CI, -4.0% to -0.35%]; P = .02) and 12 months (9.1% vs 11.8%, respectively; difference, -3.13% [95% CI, -5.28% to -0.97%]; P = .005). Conclusions and Relevance: Among 40 hospitals in China, a multifaceted quality improvement intervention compared with usual care resulted in a statistically significant but small improvement in hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke when assessed as a composite measure, but not as an all-or-none measure. Further research is needed to understand the generalizability of these findings. Trial Registration: ClinicalTrials.gov Identifier: NCT02212912.
RCT Entities:
Importance: In China and other parts of the world, hospital personnel adherence to evidence-based stroke care is limited. Objective: To determine whether a multifaceted quality improvement intervention can improve hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke (AIS) in China. Design, Setting, and Participants: A multicenter, cluster-randomized clinical trial among 40 public hospitals in China that enrolled 4800 patients hospitalized with AIS from August 10, 2014, through June 20, 2015, with 12-month follow-up through July 30, 2016. Interventions: Twenty hospitals received a multifaceted quality improvement intervention (intervention group; 2400 patients), including a clinical pathway, care protocols, quality coordinator oversight, and performance measure monitoring and feedback. Twenty hospitals participated in the stroke registry with usual care (control group; 2400 patients). Main Outcomes and Measures: The primary outcome was hospital personnel adherence to 9 AIS performance measures, with co-primary outcomes of a composite of percentage of performance measures adhered to, and as all-or-none. Secondary outcomes included in-hospital mortality and long-term outcomes (a new vascular event, disability [modified Rankin Scale score, 3-5], and all-cause mortality) at 3, 6, and 12 months. Results: Among 4800 patients with AIS enrolled from 40 hospitals and randomized (mean age, 65 years; women, 1757 [36.6%]), 3980 patients (82.9%) completed the 12-month follow-up of the trial. Patients in intervention group were more likely to receive performance measures than those in the control groups (composite measure, 88.2% vs 84.8%, respectively; absolute difference, 3.54% [95% CI, 0.68% to 6.40%], P = .02). The all-or-none measure did not significantly differ between the intervention and control groups (53.8% vs 47.8%, respectively; absolute difference, 6.69% [95% CI, -0.41% to 13.79%], P = .06). New clinical vascular events were significantly reduced in the intervention group compared with the control group at 3 months (3.9% vs 5.3%, respectively; difference, -2.03% [95% CI, -3.51% to -0.55%]; P = .007), 6 months (6.3% vs 7.8%, respectively; difference, -2.18% [95% CI, -4.0% to -0.35%]; P = .02) and 12 months (9.1% vs 11.8%, respectively; difference, -3.13% [95% CI, -5.28% to -0.97%]; P = .005). Conclusions and Relevance: Among 40 hospitals in China, a multifaceted quality improvement intervention compared with usual care resulted in a statistically significant but small improvement in hospital personnel adherence to evidence-based performance measures in patients with acute ischemic stroke when assessed as a composite measure, but not as an all-or-none measure. Further research is needed to understand the generalizability of these findings. Trial Registration: ClinicalTrials.gov Identifier: NCT02212912.
Authors: Lijing L Yan; Enying Gong; Wanbing Gu; Elizabeth L Turner; John A Gallis; Yun Zhou; Zixiao Li; Kara E McCormack; Li-Qun Xu; Janet P Bettger; Shenglan Tang; Yilong Wang; Brian Oldenburg Journal: PLoS Med Date: 2021-04-28 Impact factor: 11.069
Authors: Paula Muñoz Venturelli; Xian Li; Sandy Middleton; Caroline Watkins; Pablo M Lavados; Verónica V Olavarría; Alejandro Brunser; Octavio Pontes-Neto; Taiza E G Santos; Hisatomi Arima; Laurent Billot; Maree L Hackett; Lily Song; Thompson Robinson; Craig S Anderson Journal: J Am Heart Assoc Date: 2019-06-25 Impact factor: 5.501
Authors: Steven R Messé; Michael T Mullen; Margueritte Cox; Gregg C Fonarow; Eric E Smith; Jeffrey L Saver; Mathew J Reeves; Deepak L Bhatt; Roland Matsouaka; Lee H Schwamm Journal: J Am Heart Assoc Date: 2018-11-06 Impact factor: 5.501