Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana.
Veterans Affairs Health Services Research and Development, Center for Health Information and Communication, Richard L. Roudebush VA Medical Center, Indianapolis, Indiana.
JAMA Netw Open. 2020 Sep 1;3(9):e2015920. doi: 10.1001/jamanetworkopen.2020.15920.
Patients with transient ischemic attack (TIA) are at high risk of recurrent vascular events. Timely management can reduce that risk by 70%; however, gaps in TIA quality of care exist.
To assess the performance of the Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms (PREVENT) intervention to improve TIA quality of care.
DESIGN, SETTING, AND PARTICIPANTS: This nonrandomized cluster trial with matched controls evaluated a multicomponent intervention to improve TIA quality of care at 6 diverse medical centers in 6 geographically diverse states in the US and assessed change over time in quality of care among 36 matched control sites (6 control sites matched to each PREVENT site on TIA patient volume, facility complexity, and quality of care). The study period (defined as the data period) started on August 21, 2015, and extended to May 12, 2019, including 1-year baseline and active implementation periods for each site. The intervention targeted clinical teams caring for patients with TIA.
The quality improvement (QI) intervention included the following 5 components: clinical programs, data feedback, professional education, electronic health record tools, and QI support.
The primary outcome was the without-fail rate, which was calculated as the proportion of veterans with TIA at a specific facility who received all 7 guideline-recommended processes of care for which they were eligible (ie, anticoagulation for atrial fibrillation, antithrombotic use, brain imaging, carotid artery imaging, high- or moderate-potency statin therapy, hypertension control, and neurological consultation). Generalized mixed-effects models with multilevel hierarchical random effects were constructed to evaluate the intervention associations with the change in the mean without-fail rate from the 1-year baseline period to the 1-year intervention period.
Six facilities implemented the PREVENT QI intervention, and 36 facilities were identified as matched control sites. The mean (SD) age of patients at baseline was 69.85 (11.19) years at PREVENT sites and 71.66 (11.29) years at matched control sites. Most patients were male (95.1% [154 of 162] at PREVENT sites and 94.6% [920 of 973] at matched control sites at baseline). Among the PREVENT sites, the mean without-fail rate improved substantially from 36.7% (58 of 158 patients) at baseline to 54.0% (95 of 176 patients) during a 1-year implementation period (adjusted odds ratio, 2.10; 95% CI, 1.27-3.48; P = .004). Comparing the change in quality at the PREVENT sites with the matched control sites, the improvement in the mean without-fail rate was greater at the PREVENT sites than at the matched control sites (36.7% [58 of 158 patients] to 54.0% [95 of 176 patients] [17.3% absolute improvement] vs 38.6% [345 of 893 patients] to 41.8% [363 of 869 patients] [3.2% absolute improvement], respectively; absolute difference, 14%; P = .008).
The implementation of this multifaceted program was associated with improved TIA quality of care across the participating sites. The PREVENT QI program is an example of a health care system using QI strategies to improve performance, and may serve as a model for other health systems seeking to provide better care.
ClinicalTrials.gov Identifier: NCT02769338.
短暂性脑缺血发作（TIA）患者发生血管再发事件的风险很高。及时的管理可以将这种风险降低 70%；然而，TIA 护理质量仍存在差距。
评估 Protocol-Guided Rapid Evaluation of Veterans Experiencing New Transient Neurological Symptoms（PREVENT）干预措施对改善 TIA 护理质量的效果。
设计、地点和参与者：这是一项非随机的多中心对照试验，评估了一项多成分干预措施，以改善美国 6 个地理位置不同的州的 6 个不同医疗中心的 TIA 护理质量，并评估了 36 个匹配的对照组中 TIA 患者数量、设施复杂性和护理质量等方面的质量改善情况。研究期间（定义为数据期）从 2015 年 8 月 21 日开始，一直持续到 2019 年 5 月 12 日，包括每个站点的 1 年基线期和积极实施期。该干预措施针对的是治疗 TIA 患者的临床团队。
质量改进（QI）干预措施包括以下 5 个部分：临床方案、数据反馈、专业教育、电子健康记录工具和 QI 支持。
主要结果是无失败率，定义为特定医疗机构内 TIA 患者接受所有 7 项符合条件的护理流程的比例（即，心房颤动的抗凝治疗、抗血栓药物使用、脑成像、颈动脉成像、高或中效他汀类药物治疗、高血压控制和神经科咨询）。使用具有多层次分层随机效应的广义混合效应模型来评估干预措施与从 1 年基线期到 1 年干预期的平均无失败率变化之间的关联。
有 6 家机构实施了 PREVENT QI 干预措施，有 36 家机构被确定为匹配的对照组。基线时患者的平均（SD）年龄为 PREVENT 组的 69.85（11.19）岁，匹配对照组的 71.66（11.29）岁。大多数患者为男性（PREVENT 组为 95.1%[154/162]，匹配对照组为 94.6%[920/973]）。在 PREVENT 组中，无失败率从基线时的 36.7%（158 例患者中的 58 例）显著提高到 1 年实施期间的 54.0%（176 例患者中的 95 例）（调整后的优势比，2.10；95%置信区间，1.27-3.48；P = .004）。将 PREVENT 组与匹配对照组的质量变化进行比较，PREVENT 组的无失败率改善幅度大于匹配对照组（36.7%[158 例患者中的 58 例]至 54.0%[176 例患者中的 95 例]，改善 17.3%；38.6%[893 例患者中的 345 例]至 41.8%[869 例患者中的 363 例]，改善 3.2%；绝对差异，14%；P = .008）。
该多方面计划的实施与参与机构的 TIA 护理质量提高有关。PREVENT QI 计划是医疗保健系统使用 QI 策略来提高绩效的一个例子，可能成为其他寻求提供更好护理的医疗系统的典范。
ClinicalTrials.gov 标识符：NCT02769338。
