Jiawen Xu1, Yanan Xie1, Kun Fang1, Xin Wang2, Shengdi Chen3, Xueyuan Liu4, Yuwu Zhao5, Yangtai Guan6, Dingfang Cai7, Gang Li8, Jianmin Liu9, JianRen Liu10, Jianhua Zhuang11, Ying Xian12, Haipeng Shen13, Hao Li14, David Z Wang15, Bruce Cv Campbell16, Mark W Parsons17, Yi Dong1, Qiang Dong1. 1. Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China. 2. Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China. 3. Department of Neurology, Ruijin Hospital affiliated to Shanghai Jiaotong University, Shanghai, China. 4. Department of Neurology, The Tenth Peoples Hospital affiliated to Shanghai Jiaotong University, Shanghai, China. 5. Department of Neurology, The Sixth Peoples Hospital affiliated to Shanghai Jiaotong University, Shanghai, China. 6. Department of Neurology, RenJi Hospital affiliated to Shanghai Jiaotong University, Shanghai, China. 7. Department of Neurology, ShuGuang Hospital Affiliated to University of Chinese Medicine, Shanghai, China. 8. Department of Neurology, Shanghai East Hospital, Shanghai, China. 9. Department of Neurology, Changhai Hospital of Shanghai, Shanghai, China. 10. Department of Neurology, Shanghai Ninth People's Hospital, Shanghai, China. 11. Department of Neurology, Shanghai Changzheng Hospital, Shanghai, China. 12. Duke Clinical Research Institute, Duke University, Durham, NC, USA. 13. Faculty of Business and Economics, University of Hong Kong, Pokfulam, Hongkong. 14. China National Clinical Research Center for Neurological Diseases, Beijing, China. 15. Neurovascular Division, Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA. 16. Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia. 17. Department of Neurology, Liverpool Hospital, South Western Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia.
Abstract
BACKGROUND: In China, disparities in the quality of stroke care still exist and implementing quality improvement is still a challenge. AIM: The aim of the study was to determine whether the intervention by Shanghai Stroke Service System (4S) has helped improve adherence to stroke care guidelines and patient outcome. METHODS: The 4S is a regional stroke network with real-time data extraction among its 61 stroke centers in Shanghai. A total of 11 key performance indicators (KPIs) were evaluated. The primary outcomes were a composite measure and an all-or-none measure of adherence to 11 KPIs. The secondary outcomes were length of hospital stay and in-hospital mortality. RESULTS: The study enrolled 92,395 patients (mean age 69.0 ± 12.5 years, 65.2% men) with acute ischemic stroke hospitalized within 7 days of onset in Shanghai from January 2015 to December 2020. More patients received guideline recommended care between 2018 and 2020 than those between 2015 and 2017 (composite measure 87.1% vs 83.6%; absolute difference 2.9%, 95% confidence interval (CI) = [2.7%, 3.2%], p < 0.001; all-or-none measure 49.2% vs 44.8% patients; absolute difference 3.5%, 95% CI = [2.7%, 4.2%], p < 0.001). Further analysis of individual KPIs showed an absolute increase in six KPIs ranging from 3.4% to 8.9% (p < 0.001 for all comparisons). Compared with 2015-2017, hospital length of stay was shorter (10.95 vs 11.90 days; absolute difference -1.08, 95% CI = [-1.18, -0.99], p < 0.001), and in-hospital mortality was significantly reduced (risk ratio (RR) = 0.88, 95% CI = [0.79, 0.98], p = 0.01) in 2018-2020. CONCLUSION: The 4S intervention was associated with increased adherence to the stroke care guidelines, which further translated to improved clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02735226.
BACKGROUND: In China, disparities in the quality of stroke care still exist and implementing quality improvement is still a challenge. AIM: The aim of the study was to determine whether the intervention by Shanghai Stroke Service System (4S) has helped improve adherence to stroke care guidelines and patient outcome. METHODS: The 4S is a regional stroke network with real-time data extraction among its 61 stroke centers in Shanghai. A total of 11 key performance indicators (KPIs) were evaluated. The primary outcomes were a composite measure and an all-or-none measure of adherence to 11 KPIs. The secondary outcomes were length of hospital stay and in-hospital mortality. RESULTS: The study enrolled 92,395 patients (mean age 69.0 ± 12.5 years, 65.2% men) with acute ischemic stroke hospitalized within 7 days of onset in Shanghai from January 2015 to December 2020. More patients received guideline recommended care between 2018 and 2020 than those between 2015 and 2017 (composite measure 87.1% vs 83.6%; absolute difference 2.9%, 95% confidence interval (CI) = [2.7%, 3.2%], p < 0.001; all-or-none measure 49.2% vs 44.8% patients; absolute difference 3.5%, 95% CI = [2.7%, 4.2%], p < 0.001). Further analysis of individual KPIs showed an absolute increase in six KPIs ranging from 3.4% to 8.9% (p < 0.001 for all comparisons). Compared with 2015-2017, hospital length of stay was shorter (10.95 vs 11.90 days; absolute difference -1.08, 95% CI = [-1.18, -0.99], p < 0.001), and in-hospital mortality was significantly reduced (risk ratio (RR) = 0.88, 95% CI = [0.79, 0.98], p = 0.01) in 2018-2020. CONCLUSION: The 4S intervention was associated with increased adherence to the stroke care guidelines, which further translated to improved clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02735226.