From the Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia (D.A.C., R.G., M.F.K., N.E.A., A.G.T.).
Stroke Division, Florey Institute of Neuroscience and Mental Health, The University of Melbourne Heidelberg, Victoria, Australia (D.A.C., M.F.K., B.G., G.A.D.).
Stroke. 2019 Jun;50(6):1525-1530. doi: 10.1161/STROKEAHA.118.023075. Epub 2019 May 14.
Background and Purpose- Hospital uptake of evidence-based stroke care is variable. We aimed to determine the impact of a multicomponent program involving financial incentives and quality improvement interventions, on stroke care processes. Methods- A prospective study of interventions to improve clinical care quality indicators at 19 hospitals in Queensland, Australia, during 2010 to 2015, compared with historical controls and 23 other Australian hospitals. After baseline routine audit and feedback (control phase, 30 months), interventions involving financial incentives (21 months) and then addition of externally facilitated quality improvement workshops with action plan development (9 months) were implemented. Postintervention phase was 13 months. Data were obtained for the analysis from a previous continuous audit in Queensland and subsequently the Australian Stroke Clinical Registry. Primary outcome: change in median composite score for adherence to ≤8 indicators. Secondary outcomes: change in adherence to self-selected indicators addressed in action plans and 4 national indicators compared with other Australian hospitals. Multivariable analyses with adjustment for clustered data. Results- There were 17 502 patients from the intervention sites (median age, 74 years; 46% women) and 20 484 patients from other Australian hospitals. Patient characteristics were similar between groups. There was an 18% improvement in the primary outcome across the study periods (95% CI, 12%-24%). The largest improvement was following introduction of financial incentives (14%; 95% CI, 8%-20%), while indicators addressed in action plans provided an 8% improvement (95% CI, 1%-17%). The national score (4 indicators) improved by 17% (95% CI, 13%-20%) versus 0% change in other Australian hospitals (95% CI, -0.03 to 0.03). Access to stroke units improved more in Queensland than in other Australian hospitals ( P<0.001). Conclusions- The quality improvement interventions significantly improved clinical practice. The findings were primarily driven by financial incentives, but were also contributed to by the externally facilitated, quality improvement workshops. Assessment in other regions is warranted.
背景与目的-医院对循证卒中治疗的采用情况存在差异。本研究旨在确定涉及经济激励和质量改进干预的多组分方案对卒中治疗过程的影响。
方法-对澳大利亚昆士兰州 19 家医院 2010 年至 2015 年期间改善临床护理质量指标的干预措施进行前瞻性研究，将其与历史对照和其他 23 家澳大利亚医院进行比较。在基线常规审核和反馈（对照阶段，30 个月）后，实施了涉及经济激励的干预措施（21 个月），然后加入了外部促进的质量改进研讨会，并制定行动计划（9 个月）。干预后阶段持续 13 个月。分析数据来自昆士兰州之前的连续审核，随后来自澳大利亚卒中临床登记处。主要结局：≤8 个指标的依从性中位数综合评分的变化。次要结局：与其他澳大利亚医院相比，行动计划中涉及的自我选择指标和 4 个国家指标的依从性变化。考虑到聚类数据进行多变量分析。
结果-干预组有 17502 名患者（中位年龄 74 岁，46%为女性），其他澳大利亚医院有 20484 名患者。两组患者特征相似。研究期间，主要结局改善了 18%（95%CI，12%-24%）。最大的改善是在引入经济激励措施后（14%，95%CI，8%-20%），而行动计划中涉及的指标提供了 8%的改善（95%CI，1%-17%）。国家评分（4 个指标）改善了 17%（95%CI，13%-20%），而其他澳大利亚医院的变化为 0%（95%CI，-0.03 至 0.03）。昆士兰州的卒中单元的可及性改善程度大于其他澳大利亚医院（P<0.001）。
结论-质量改进干预措施显著改善了临床实践。这一发现主要是由经济激励驱动的，但外部促进的质量改进研讨会也做出了贡献。在其他地区进行评估是有必要的。
