Department of Neurology Erasmus MCUniversity Medical Center Rotterdam the Netherlands.
Department of Radiology and Nuclear Medicine Erasmus MCUniversity Medical Center Rotterdam the Netherlands.
J Am Heart Assoc. 2022 Jan 4;11(1):e022192. doi: 10.1161/JAHA.121.022192. Epub 2021 Dec 20.
Background Time to reperfusion in patients with ischemic stroke is strongly associated with functional outcome and may differ between hospitals and between patients within hospitals. Improvement in time to reperfusion can be guided by between-hospital and within-hospital comparisons and requires insight in specific targets for improvement. We aimed to quantify the variation in door-to-reperfusion time between and within Dutch intervention hospitals and to assess the contribution of different time intervals to this variation. Methods and Results We used data from the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. The door-to-reperfusion time was subdivided into time intervals, separately for direct patients (door-to-computed tomography, computed tomography-to-computed tomography angiography [CTA], CTA-to-groin, and groin-to-reperfusion times) and for transferred patients (door-to-groin and groin-to-reperfusion times). We used linear mixed models to distinguish the variation in door-to-reperfusion time between hospitals and between patients. The proportional change in variance was used to estimate the amount of variance explained by each time interval. We included 2855 patients of 17 hospitals providing endovascular treatment. Of these patients, 44% arrived directly at an endovascular treatment hospital. The between-hospital variation in door-to-reperfusion time was 9%, and the within-hospital variation was 91%. The contribution of case-mix variables on the variation in door-to-reperfusion time was marginal (2%-7%). Of the between-hospital variation, CTA-to-groin time explained 83%, whereas groin-to-reperfusion time explained 15%. Within-hospital variation was mostly explained by CTA-to-groin time (33%) and groin-to-reperfusion time (42%). Similar results were found for transferred patients. Conclusions Door-to-reperfusion time varies between, but even more within, hospitals providing endovascular treatment for ischemic stroke. Quality of stroke care improvements should not only be guided by between-hospital comparisons, but also aim to reduce variation between patients within a hospital, and should specifically focus on CTA-to-groin time and groin-to-reperfusion time.
背景
缺血性脑卒中患者的再灌注时间与功能结局密切相关，且可能因医院和医院内患者的不同而有所差异。通过医院间和医院内的比较，可以对再灌注时间的改善进行指导，这需要对具体的改进目标有深入的了解。本研究旨在量化荷兰介入医院间及医院内的门到再灌注时间的差异，并评估不同时间段对这种差异的贡献。
方法和结果
我们使用 MR CLEAN（荷兰多中心急性缺血性脑卒中血管内治疗随机临床试验）登记处的数据。门到再灌注时间被细分为时间间隔，分别针对直接患者（门到计算机断层扫描、计算机断层扫描到计算机断层扫描血管造影[CTA]、CTA 到腹股沟、腹股沟到再灌注时间）和转院患者（门到腹股沟和腹股沟到再灌注时间）。我们使用线性混合模型来区分医院间和医院内门到再灌注时间的差异。比例变化方差用于估计每个时间段解释的方差量。我们纳入了 17 家提供血管内治疗的医院的 2855 名患者。其中，44%的患者直接到达血管内治疗医院。门到再灌注时间的医院间差异为 9%，医院内差异为 91%。病例组合变量对门到再灌注时间差异的影响很小（2%-7%）。医院间差异中，CTA 到腹股沟时间解释了 83%，而腹股沟到再灌注时间解释了 15%。医院内差异主要由 CTA 到腹股沟时间（33%）和腹股沟到再灌注时间（42%）解释。转院患者也有类似的结果。
结论
为缺血性脑卒中提供血管内治疗的医院间及医院内的再灌注时间存在差异。改善卒中护理质量不仅应通过医院间的比较进行指导，还应旨在减少医院内患者间的差异，具体应侧重于 CTA 到腹股沟时间和腹股沟到再灌注时间。
