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

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Abstract

In China and other parts of the world, hospital personnel adherence to evidence-based stroke care is limited.

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Most cited references 12

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Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative.

Gregg C. Fonarow, Xin Zhao, Eric E. Smith … (2016)

The benefits of intravenous tissue plasminogen activator (tPA) in patients with acute ischemic stroke (AIS) are time dependent and guidelines recommend a door-to-needle (DTN) time of 60 minutes or less. However, studies have found that less than 30% of US patients are treated within this time window. Stroke was designed as a national quality improvement initiative to improve DTN times for tPA administration in patients with AIS. To evaluate DTN times for tPA administration and the proportion of patients with times of 60 minutes or less before and after initiation of a quality improvement initiative and to determine whether potential improvements in DTN times were associated with improvements in clinical outcomes. The Stroke initiative disseminated 10 care strategies to achieve faster DTN times for tPA administration, provided clinical decision support tools, facilitated hospital participation, and encouraged sharing of best practices. This study included 71,169 patients with AIS treated with tPA (27,319 during the preintervention period from April 2003-December 2009 and 43,850 during the postintervention period from January 2010-September 2013) from 1030 Get With The Guidelines-Stroke participating hospitals (52.8% of total). The DTN times for tPA administration of 60 minutes or less and in-hospital risk-adjusted mortality, symptomatic intracranial hemorrhage, ambulatory status at discharge, and discharge destination. Median DTN time for tPA administration declined from 77 minutes (interquartile range [IQR], 60-98 minutes) during the preintervention period to 67 minutes (IQR, 51-87 minutes) during the postintervention period (P < .001). The DTN times for tPA administration of 60 minutes or less increased from 26.5% (95% CI, 26.0%-27.1%) of patients during the preintervention period to 41.3% (95% CI, 40.8%-41.7%) during the postintervention period (P < .001). The DTN times of 60 minutes or less increased from 29.6% (95% CI, 27.8%-31.5%) of patients in the quarter immediately before the intervention (fourth quarter of 2009) to 53.3% (95% CI, 51.5%-55.2%) in the final postintervention quarter (third quarter of 2013) (P < .001). The annual rate of improvement in DTN times of 60 minutes or less increased from 1.36% (95% CI, 1.04%-1.67%) per year preintervention to 6.20% (95% CI, 5.58%-6.78%) per year postintervention (P < .001). In-hospital all-cause mortality improved significantly from the preintervention to the postintervention period (9.93% vs 8.25%, respectively; adjusted odds ratio [OR], 0.89 [95% CI, 0.83-0.94], P < .001), symptomatic intracranial hemorrhage within 36 hours was less likely to occur (5.68% vs 4.68%; adjusted OR, 0.83 [95% CI, 0.76-0.91], P < .001), and discharge to home was more frequent (37.6% vs 42.7%; adjusted OR, 1.14 [95% CI, 1.09-1.19], P < .001). Implementation of a national quality improvement initiative was associated with improved timeliness of tPA administration following AIS on a national scale, and this improvement was associated with lower in-hospital mortality and intracranial hemorrhage, along with an increase in the percentage of patients discharged home.

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Get With the Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack.

Lee H. Schwamm, A Ellrodt, Kenneth LaBresh … (2009)

Adherence to evidence-based guidelines for treatment of stroke or transient ischemic attack is suboptimal. We sought to establish whether participation in Get With the Guidelines-Stroke was associated with improvements in adherence. This prospective, nonrandomized, national quality improvement program measured adherence to guideline recommendations in 322 847 hospitalized patients discharged with a diagnosis of ischemic stroke or transient ischemic attack. A volunteer sample of 790 US academic and community hospitals participated from 2003 through 2007. The main outcome measures were change in adherence over time to 7 prespecified performance measures and a composite measure (total number of interventions provided in eligible patients divided by total number of care opportunities among eligible patients). Generalized estimating equations were used to identify factors associated with improvement. Participation in Get With the Guidelines-Stroke was associated with improvements in the 7 individual and 1 composite measures from baseline to the fifth year: intravenous thrombolytics (42.09% versus 72.84%), early antithrombotics (91.46% versus 97.04%), deep vein thrombosis prophylaxis (73.79% versus 89.54%), discharge antithrombotics (95.68% versus 98.88%), anticoagulation for atrial fibrillation (95.03% versus 98.39%), lipid treatment for low-density lipoprotein >100 mg/dL (73.63% versus 88.29%), smoking cessation (65.21% versus 93.61%), and composite (83.52% versus 93.97%) (P<0.0001 for all comparisons). Multivariate analysis showed that time in Get With the Guidelines-Stroke was associated with a 1.18-fold yearly increase in the odds of fulfilling care opportunities that was independent of secular trends. Get With the Guidelines-Stroke participation was associated with increased adherence to all stroke performance measures. Markedly improved stroke care was seen in all hospitals regardless of size, geography, and teaching status.

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Characteristics, performance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in get with the guidelines-stroke.

J. Smith, Lee H. Schwamm, Ledia Hernandez … (2010)

Stroke results in substantial death and disability. To address this burden, Get With The Guideline (GWTG)-Stroke was developed to facilitate the measurement, tracking, and improvement in quality of care and outcomes for acute stroke and transient ischemic attack (TIA) patients in the United States. We analyzed the characteristics, performance measures, and in-hospital outcomes in the first 1 000 000 acute ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, and TIA admissions from 1392 hospitals that participated in the GWTG-Stroke Program 2003 to 2009. Patients were 53.5% women, 73.3% white, and with mean age of 70.1+/-14.9 years. There were 601 599 (60.2%) ischemic strokes, 108 671 (10.9%) intracerebral hemorrhages, 34 945 (3.5%) subarachnoid hemorrhages, 26 977 (2.7%) strokes not classified, and 227 788 (22.8%) TIAs. Performance measures showed small to moderate differences by cerebrovascular event type. In-hospital mortality rate was highest among intracerebral hemorrhage (25.0%) and subarachnoid hemorrhage (20.4%), and intermediate in ischemic stroke (5.5%) patients and lowest among TIA patients (0.3%). Significant improvements over time from 2003 to 2009 in quality of care were observed: all-or-none measure, 44.0% versus 84.3% (+40.3%, P<0.0001). After adjustment for patient and hospital variables, the cumulative adjusted odds ratio for the all-or-none measure over the 6 years was 9.4 (95% confidence interval, 8.3 to 10.6, P<0.0001). Temporal improvements in length of stay and risk-adjusted in-hospital mortality rate (for ischemic stroke and TIA) were also observed. With more than 1 million patients enrolled, GWTG-Stroke represents an integrated stroke and TIA registry that supports national surveillance, innovative research, and sustained quality improvement efforts facilitating evidence-based stroke/TIA care.

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Author and article information

Journal

Title: JAMA

Abbreviated Title: JAMA

Publisher: American Medical Association (AMA)

ISSN (Print): 0098-7484

Publication date Created: July 17 2018

Publication date (Print): July 17 2018

Volume: 320

Issue: 3

Page: 245

Affiliations

[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

Article

DOI: 10.1001/jama.2018.8802

PubMed ID: 29959443

SO-VID: a25ed5c0-67ff-49cd-91de-b89ee067efa1

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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

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Most cited references 12

Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative.

Get With the Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack.

Characteristics, performance measures, and in-hospital outcomes of the first one million stroke and transient ischemic attack admissions in get with the guidelines-stroke.

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