Performance feedback on the quality of care in hospitals performing thrombectomy for ischemic stroke (PERFEQTOS): protocol of a stepped wedge cluster randomized trial
Authors: Amini Marzyeh , den Hartog Sanne J. , van Leeuwen Nikki , Eijkenaar Frank , Kuhrij Laurien S. , Stolze Lotte J. , Nederkoorn Paul J. , Lingsma Hester F. , van Es Adriaan C. G. M. , van den Wijngaard Ido R. , van der Lugt Aad , Dippel Diederik W. J. , Roozenbeek Bob ,   on behalf of the PERFEQTOS Investigators, Roozenbeek Bob , 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. , Vos Douwe L. D. , 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. , van Zwam Wim H. , van Oostenbrugge Robert J. , Martens Jasper M. , Hofmeijer Jeannette , van der Worp H. Bart , Lo Rob T. H. 
Published: December 2021

Abstract
Background
Although the provision of performance feedback to healthcare professionals based on data from quality registries is common practice in many fields of medicine, observational studies of its effect on the quality of care have shown mixed results. The objective of this study is to evaluate the effect of performance feedback on the quality of care for acute ischemic stroke.

Methods
PERFEQTOS is a stepped wedge cluster randomized trial in 13 hospitals in the Netherlands providing endovascular thrombectomy for ischemic stroke. The primary outcome is the hospital’s door-to-groin time. The study starts with a 6-month period in which none of the hospitals receives the performance feedback intervention. Subsequently, every 6 months, three or four hospitals are randomized to cross over from the control to the intervention conditions, until all hospitals receive the feedback intervention. The feedback intervention consists of a dashboard with quarterly reports on patient characteristics, structure, process, and outcome indicators related to patients with ischemic stroke treated with endovascular thrombectomy. Hospitals can compare their present performance with their own performance in the past and with other hospitals. The performance feedback is provided to local quality improvement teams in each hospital, who define their own targets on specific indicators and develop performance improvement plans. The impact of the performance feedback and improvement plans will be evaluated by comparing the primary outcome before and after the intervention.

Discussion
This study will provide evidence on the effectiveness of performance feedback to healthcare providers. The results will be actively disseminated through peer-reviewed journals, conference presentations, and various stakeholder engagement activities.

Trial registration
Netherlands Trial Register NL9090. Registered on December 3, 2020