Quality Improvement Intervention for Reducing Acute Treatment Times in Ischemic Stroke
Authors: Hansen Daniël , den Hartog Sanne J. , van Leeuwen Nikki , Boiten Jelis , Dinkelaar Wouter , van Doormaal Pieter J. , Eijkenaar Frank , Emmer Bart J. , van Es Adriaan C. G. M. , Flach H. Zwenneke , Gons Rob , den Hertog M. Heleen , Imani Farshad , Janssen Paula M. , Kortman Hans , Kruyt Nyika D. , Kuhrij Laurien S. , van der Leij Christiaan , Lo T. H. Rob , van der Lugt Aad , Lycklama à Nijeholt Geert , Martens Jasper M. M. , Nederkoorn Paul J. , Piet Jurgen , Remmers Michel J. M. , Roos Yvo B. W. E. M. , Silvis Suzanne M. , Stolze Lotte J. , Stomp Wouter , van Tuijl Julia H. , Truijman Martine T. B. , Vermeer Sarah E. , van Walderveen Marianne A. A. , van den Wijngaard Ido R. , Van der Worp H. Bart , Yo Lonneke , Dippel Diederik W. J. , Lingsma Hester F. , Roozenbeek Bob ,   PERFEQTOS Investigators, Roozenbeek Bob , Hansen Daniël , den Hartog Sanne J. , Dippel Diederik W.J. , van der Lugt Aad , Lingsma Hester F. , van Leeuwen Nikki , Kuhrij Laurien S. , Stolze Lotte J. , Nederkoorn Paul J. , van Es Adriaan C.G.M. , van den Wijngaard Ido R. , Janssen Paula M. , van Doormaal Pieter-Jan , Roos Yvo B.W.E.M. , Emmer Bart J. , Silvis Suzanne M. , Dinkelaar Wouter , Remmers Michel J.M. , Imani Farshad , Gons Rob A.R. , Yo Lonneke S.F. , van Tuijl Julia H. , Kortman Hans , Boiten Jelis , Lycklama à Nijeholt Geert J. , Piet Jurgen R. , Stomp Wouter , den Hertog Heleen M. , Flach H. Zwenneke , Kruyt Nyika D. , van Walderveen Marianne A.A. , Truijman Martine T.B. , van der Leij Christiaan , Martens Jasper M. , Vermeer Sarah E. , van der Worp H. Bart , Lo Rob T.H. , Tonino Bart. A.R. , Wolsink Axel , de Jonge Jeroen , Mulder Maxim J.H.L. , Brenner Juliette , Engelkes Sophie , Miah Ishita , van Norden Anouk G.W. , Wassink Luc , van Zwam Wim , van Oostenbrugge Robert , van der Steen Laurine , van Westering Nelleke , Zitman Femke , de Meris Joke , Eilander Rieke , van der Slot Martine , Verheesen Sabrina , Hendrikx-Lodiers Miranda , van Doorne Noemi , Slotboom Annemarie , Smallegange Maylee , Vervoort Jocova , de Laat Karlijn F. , de Pont Lisa , Saniman-Lefeber Michelle , Verschoof Merelijne , Drabbe-Coops Yvonne , van Griensven Carlijn , Gemmink Heidi 
Published: December 2024

Importance

Efficient care processes are crucial to minimize treatment delays and improve outcome after endovascular thrombectomy (EVT) in patients with ischemic stroke. A potential means to improve care processes is performance feedback.

Objective

To evaluate the effect of performance feedback to hospitals on treatment times for EVT.

Design, Setting, and Participants

This cluster randomized clinical trial was conducted from January 1, 2020, to June 30, 2022. Participants were consecutive adult patients with ischemic stroke who underwent EVT in 13 Dutch hospitals. No patients were excluded. Data analysis took place from March to May 2023.

Intervention

The intervention consisted of feedback on hospital performance using structure, process, and outcome indicators. Indicator scores were based on data from a national quality registry and compared with a benchmark. Performance feedback was provided through a dashboard for local quality improvement teams who developed and implemented improvement plans based on the feedback. Every 6 months, 3 to 4 randomly selected hospitals switched to the intervention condition.

Main Outcome and Measures

The primary outcome was time from door to groin puncture for all patients treated with EVT. Secondary outcomes included door-to-needle time, National Institutes of Health Stroke Scale (NIHSS) score at day 2, expanded Treatment in Cerebral Infarction (eTICI) score, and modified Rankin Scale (mRS) score at 3 months. The effect of the intervention was estimated with multivariable linear mixed models.

Results

A total of 4747 patients were included (intervention: 2431; control: 2316). Their mean (SD) age was 72 (13) years; 2337 (49.2%) were female and 2410 (50.8%) were male. The median (IQR) baseline NIHSS score was 14 (8-19). Median (IQR) door-to–groin puncture time under the intervention condition was 47 (25-71) minutes, compared with 52 (29-75) minutes under the control condition. The adjusted absolute reduction was 5 minutes (β = −4.8; 95% CI, −9.5 to −0.1; P = .04), corresponding to a relative reduction of 9.2% (95% CI, −18.3% to −0.2%).

Conclusion and Relevance

This study found that performance feedback provided through a dashboard used by local quality improvement teams reduced door-to–groin puncture time for EVT. Implementation of performance feedback in hospitals providing EVT can improve the quality of care for ischemic stroke.

Trial Registration

The Netherlands Trial Register: NL9090