1. In this cluster-randomized clinical trial, quality improvement interventions led to slightly greater adherence of evidence-based, performance measures compared to care as usual for acute ischemic stroke management in China.
2. Quality improvement interventions were associated with fewer vascular events and less stroke disability over one year of follow up.
Evidence Rating Level: 1 (Excellent)
Study Rundown: Evidence-based guidelines for acute ischemic stroke management, such as timely tPA treatment and antiplatelet therapy for atrial fibrillation patients, have been shown to improve outcomes for patients. However, adherence to these performance measures is suboptimal in some developing countries, such as China. In this cluster-randomized clinical trial, multifaceted quality improvement interventions to increase adherence to nine performance measures were enforced in multiple public hospitals in China and compared to care as usual for patients with acute ischemic stroke. As a composite, the intervention group had better adherence to the performance measures but did not have better “all-or-nothing” adherence, defined as complete adherence to all nine performance measures. In particular, adherence to two out of the nine measures were statistically increased in the intervention group: DVT prophylaxis and antidiabetic medication. In addition, quality improvement interventions were associated with fewer vascular events and less stroke disability over one year of follow up.
Though this study suggests that quality improvement interventions are likely to lead to greater adherence to performance measures for stroke and better overall clinical outcomes, it should be noted that this study resulted in a smaller change in adherence than predicted by its power analysis. In addition, it is not clear if the results in this study will be generalizable to other developing countries. Still, this study adds to a growing body of literature suggesting that quality improvement initiatives can make significant changes in patient outcomes.
In-Depth [randomized controlled trial]: In the Intervention to Bridge the Evidence-based Gap in Stroke Care Quality (GOLDEN BRIDGE-AIS) Trial, 40 hospitals from 18 Chinese provinces recruited 2400 acute ischemic stroke patients per group (intervention vs care as usual) in a clustered randomized manner and followed them for 3, 6, and 12 months (83.5% and 82.4% follow rates for the intervention and control groups, respectively). The quality care intervention consisted of evidence-based clinical pathways, written care protocols for implementation of performance measures, a full-time quality coordinator, and a monitoring and feedback system. The nine performance measures that have been shown to improve outcomes for stroke patients were formulated from evidence-based recommendations created by a panel of stroke experts and according to peer-reviewed literature.
For the composite measure of adherence, defined as the total number of performance measures performed divided by the total number of total performance measures, the intervention group had a slight but significant increase in adherence (88.2% intervention group vs 84.8% control group; absolute difference 3.54%; CI95 0.68 to 6.40%). For “all-or-nothing” adherence, defined as the proportion of patients who received all of the performance measures, there was no significant difference between groups (absolute difference 6.69%; CI95 -0.41 to 13.79%). In particular, adherence to two out of the nine measures were statistically increased in the intervention group: DVT prophylaxis and antidiabetic medication (p < 0.05). New clinical vascular events were reduced in the intervention group at 3 months (hazard ratio 0.65; CI95 0.49 to 0.86), 6 months (HR 0.72; CI95 0.57 to 0.90), and 12 months (HR 0.72; CI95 0.60 to 0.87). Stroke-related disability was reduced in the intervention group at 3 months (odds ratio 0.76; CI95 0.63 to 0.91), 6 months (OR 0.74; CI95 0.61 to 0.89), and 12 months (OR 0.74; CI95 0.59 to 0.93).
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