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

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 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 outcomewas 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 Among4800patients with AIS enrolled from40hospitals 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 groupwere 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%to6.40%],P =.02). Theall-or-nonemeasuredidnotsignificantly 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). Newclinical vascular eventswere 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),6months (6.3%vs7.8%, respectively; difference,-2.18%[95%CI,-4.0%to-0.35%];P =.02)and12months (9.1%vs 11.8%, respectively; difference, -3.13%[95%CI, -5.28%to -0.97%]; P =.005). CONCLUSIONSANDRELEVANCE Among40hospitals in China, amultifaceted qualityimprovement 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.