Effect of a Multifaceted Quality Improvement Intervention on Hospital Personnel Adherence to Performance Measures in Patients With Acute Ischemic Stroke in China: A Randomized Clinical Trial

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

[1]  Farmer Ja.  High-Dose Atorvastatin after Stroke or Transient Ischemic Attack. , 2018, The New England journal of medicine.

[2]  L. Schwamm,et al.  The American Heart Association’s Get With the Guidelines (GWTG)-Stroke development and impact on stroke care , 2017, Stroke and Vascular Neurology.

[3]  L. Schwamm,et al.  Behavioral Interventions for Stroke Prevention: The Need for a New Conceptual Model , 2017, Stroke.

[4]  M. Jeyaraman,et al.  Behavior change interventions and policies influencing primary healthcare professionals’ practice—an overview of reviews , 2017, Implementation Science.

[5]  Yong Jiang,et al.  Prevalence, Incidence, and Mortality of Stroke in China: Results from a Nationwide Population-Based Survey of 480 687 Adults , 2017, Circulation.

[6]  E. Peterson,et al.  Substantial Progress Yet Significant Opportunity for Improvement in Stroke Care in China , 2016, Stroke.

[7]  Alan D. Lopez,et al.  Cause-specific mortality for 240 causes in China during 1990–2013: a systematic subnational analysis for the Global Burden of Disease Study 2013 , 2016, The Lancet.

[8]  Sidney C. Smith,et al.  Rationale and design of a cluster-randomized multifaceted intervention trial to improve stroke care quality in China: The GOLDEN BRIDGE-Acute Ischemic Stroke. , 2015, American heart journal.

[9]  S. Barber,et al.  The hospital of the future in China: China's reform of public hospitals and trends from industrialized countries. , 2014, Health policy and planning.

[10]  Eric E. Smith,et al.  Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. , 2014, JAMA.

[11]  V. Feigin,et al.  Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study 2010 , 2014, The Lancet.

[12]  V. Chair,et al.  Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. , 2014, Stroke.

[13]  M. Wintermark,et al.  Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association , 2013, Stroke.

[14]  Zhenzhen Xu,et al.  A multilevel intervention to increase community hospital use of alteplase for acute stroke (INSTINCT): a cluster-randomised controlled trial , 2013, The Lancet Neurology.

[15]  Xingquan Zhao,et al.  Clinical Characteristics, Management, and Functional Outcomes in Chinese Patients Within the First Year After Intracerebral Hemorrhage: Analysis from China National Stroke Registry , 2012, CNS neuroscience & therapeutics.

[16]  Kris Vanhaecht,et al.  A cluster randomized trial to assess the effect of clinical pathways for patients with stroke: results of the clinical pathways for effective and appropriate care study , 2012, BMC Medicine.

[17]  G. Donnan,et al.  Clinical practice. Secondary prevention after ischemic stroke or transient ischemic attack. , 2012, The New England journal of medicine.

[18]  E. Peterson,et al.  Effect of a multifaceted intervention on use of evidence-based therapies in patients with acute coronary syndromes in Brazil: the BRIDGE-ACS randomized trial. , 2012, JAMA.

[19]  G. Piaggio,et al.  Consort 2010 statement: extension to cluster randomised trials , 2012, BMJ : British Medical Journal.

[20]  Liping Liu,et al.  Stroke and stroke care in China: huge burden, significant workload, and a national priority. , 2011, Stroke.

[21]  J. Grimshaw,et al.  Implementation of evidence-based treatment protocols to manage fever, hyperglycaemia, and swallowing dysfunction in acute stroke (QASC) :a cluster randomised controlled trial , 2015 .

[22]  J. Jeng,et al.  Get With The Guidelines-Stroke Performance Indicators: Surveillance of Stroke Care in the Taiwan Stroke Registry: Get With The Guidelines-Stroke in Taiwan , 2010, Circulation.

[23]  David C. Anderson,et al.  A cluster-randomized trial to improve stroke care in hospitals , 2010, Neurology.

[24]  Gregory W Albers,et al.  Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials , 2010, The Lancet.

[25]  S. Sidney,et al.  Standardized discharge orders after stroke: Results of the quality improvement in stroke prevention (QUISP) cluster randomized trial , 2010, Annals of neurology.

[26]  Sean M. O'Brien,et al.  ACCF/AHA 2010 Position Statement on Composite Measures for Healthcare Performance Assessment: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Performance Measures (Writing Committee to develop a position statement on composite measures). , 2010, Circulation.

[27]  中华医学会神经病学分会脑血管病学组急性缺血性脑卒中诊治指南撰写组.  中国急性缺血性脑卒中诊治指南2010 , 2010 .

[28]  A. Rabinstein.  Characteristics, Performance Measures, and In-Hospital Outcomes of the First One Million Stroke and Transient Ischemic Attack Admissions in Get With The Guidelines-Stroke , 2010 .

[29]  K. Lee.  Get With the Guidelines–Stroke Is Associated With Sustained Improvement in Care for Patients Hospitalized With Acute Stroke or Transient Ischemic Attack , 2010 .

[30]  P. Sandercock,et al.  Effectiveness of thigh-length graduated compression stockings to reduce the risk of deep vein thrombosis after stroke (CLOTS trial 1): a multicentre, randomised controlled trial , 2009, The Lancet.

[31]  M. Ferri,et al.  An emergency clinical pathway for stroke patients – results of a cluster randomised trial (isrctn41456865) , 2009, BMC health services research.

[32]  Li Liang,et al.  Get With the Guidelines–Stroke Is Associated With Sustained Improvement in Care for Patients Hospitalized With Acute Stroke or Transient Ischemic Attack , 2009, Circulation.

[33]  Tihomir Asparouhov,et al.  Intention‐to‐treat analysis in cluster randomized trials with noncompliance , 2008, Statistics in medicine.

[34]  S. Iliffe,et al.  Bmc Medical Research Methodology Open Access the Hawthorne Effect: a Randomised, Controlled Trial , 2022 .

[35]  C. Kase,et al.  The efficacy and safety of enoxaparin versus unfractionated heparin for the prevention of venous thromboembolism after acute ischaemic stroke (PREVAIL Study): an open-label randomised comparison , 2007, The Lancet.

[36]  William J Taylor,et al.  Effectiveness of a clinical pathway for acute stroke care in a district general hospital: an audit , 2006, BMC Health Services Research.

[37]  D. Torgerson,et al.  Cluster randomized controlled trials. , 2005, Journal of evaluation in clinical practice.

[38]  D. Torgerson,et al.  Evidence for risk of bias in cluster randomised trials: review of recent trials published in three general medical journals , 2003, BMJ : British Medical Journal.

[39]  Lalit Kalra,et al.  Early Assessments of Dysphagia and Aspiration Risk in Acute Stroke Patients , 2003, Stroke.

[40]  Jeremy M. Grimshaw,et al.  Changing Provider Behavior: An Overview of Systematic Reviews of Interventions , 2001, Medical care.

[41]  M. Cabana,et al.  Why don't physicians follow clinical practice guidelines? A framework for improvement. , 1999, JAMA.

[42]  Koroshetz Wj,et al.  Tissue plasminogen activator for acute ischemic stroke. , 1996, The New England journal of medicine.

[43]  Joseph P. Broderick,et al.  Tissue plasminogen activator for acute ischemic stroke. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. , 1995 .