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