Effect of a Multifaceted Quality Improvement Intervention on Hospital Personnel Adherence to Performance Measures in Patients With Acute Ischemic Stroke in China
Authors: Yilong Wang, Zixiao Li, Xingquan Zhao, Chunjuan Wang, Xianwei Wang, David Wang, Li Liang, Liping Liu, Chunxue Wang, Hao Li, Haipeng Shen, Janet Bettger, Yuesong Pan, Yong Jiang, Xiaomeng Yang, Changqing Zhang, Xiujie Han, Xia Meng, Xin Yang, Hong Kang, Weiqiang Yuan, Gregg C. Fonarow, Eric D. Peterson, Lee H. Schwamm, Ying Xian, Yongjun Wang
Journal: JAMA (2018)

<h3>Importance</h3> In China and other parts of the world, hospital personnel adherence to evidence-based stroke care is limited. <h3>Objective</h3> 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. <h3>Design, Setting, and Participants</h3> 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. <h3>Interventions</h3> 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). <h3>Main Outcomes and Measures</h3> 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. <h3>Results</h3> 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%],<i>P</i> = .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%],<i>P</i> = .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%];<i>P</i> = .007), 6 months (6.3% vs 7.8%, respectively; difference, −2.18% [95% CI, −4.0% to −0.35%];<i>P</i> = .02) and 12 months (9.1% vs 11.8%, respectively; difference, −3.13% [95% CI, −5.28% to −0.97%];<i>P</i> = .005). <h3>Conclusions and Relevance</h3> 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. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT02212912