上海脑卒中服务体系（4S）对脑卒中医疗质量和结局的影响：一项前瞻性质量改进项目。

Effect of the Shanghai Stroke Service System (4S) on the quality of stroke care and outcomes: A prospective quality improvement project.

机构信息

Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.

Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China.

出版信息

Int J Stroke. 2023 Jun;18(5):599-606. doi: 10.1177/17474930221125993. Epub 2022 Oct 15.

DOI:10.1177/17474930221125993

PMID:36082948

Abstract

BACKGROUND

In China, disparities in the quality of stroke care still exist and implementing quality improvement is still a challenge.

AIM

The aim of the study was to determine whether the intervention by Shanghai Stroke Service System (4S) has helped improve adherence to stroke care guidelines and patient outcome.

METHODS

The 4S is a regional stroke network with real-time data extraction among its 61 stroke centers in Shanghai. A total of 11 key performance indicators (KPIs) were evaluated. The primary outcomes were a composite measure and an all-or-none measure of adherence to 11 KPIs. The secondary outcomes were length of hospital stay and in-hospital mortality.

RESULTS

The study enrolled 92,395 patients (mean age 69.0 ± 12.5 years, 65.2% men) with acute ischemic stroke hospitalized within 7 days of onset in Shanghai from January 2015 to December 2020. More patients received guideline recommended care between 2018 and 2020 than those between 2015 and 2017 (composite measure 87.1% vs 83.6%; absolute difference 2.9%, 95% confidence interval (CI) = [2.7%, 3.2%], p < 0.001; all-or-none measure 49.2% vs 44.8% patients; absolute difference 3.5%, 95% CI = [2.7%, 4.2%], p < 0.001). Further analysis of individual KPIs showed an absolute increase in six KPIs ranging from 3.4% to 8.9% (p < 0.001 for all comparisons). Compared with 2015-2017, hospital length of stay was shorter (10.95 vs 11.90 days; absolute difference -1.08, 95% CI = [-1.18, -0.99], p < 0.001), and in-hospital mortality was significantly reduced (risk ratio (RR) = 0.88, 95% CI = [0.79, 0.98], p = 0.01) in 2018-2020.

CONCLUSION

The 4S intervention was associated with increased adherence to the stroke care guidelines, which further translated to improved clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02735226.

摘要

背景

在中国，脑卒中治疗质量仍存在差异，实施质量改进仍然是一项挑战。

目的

本研究旨在确定上海脑卒中服务体系（4S）的干预措施是否有助于提高脑卒中治疗指南的依从性和患者结局。

方法

4S 是一个区域脑卒中网络，其 61 家脑卒中中心实时提取数据。共评估了 11 项关键绩效指标（KPI）。主要结局为 11 项 KPI 综合措施和全部或无措施的依从性。次要结局为住院时间和院内死亡率。

结果

本研究纳入了 2015 年 1 月至 2020 年 12 月期间上海发病后 7 天内住院的 92395 例急性缺血性脑卒中患者（平均年龄 69.0±12.5 岁，65.2%为男性）。与 2015 年至 2017 年相比，2018 年至 2020 年接受指南推荐治疗的患者比例更高（综合措施 87.1% vs 83.6%；绝对差异 2.9%，95%置信区间（CI）为[2.7%，3.2%]，p<0.001；全部或无措施 49.2% vs 44.8%患者；绝对差异 3.5%，95%CI=[2.7%，4.2%]，p<0.001）。对个别 KPI 的进一步分析显示，6 项 KPI 的绝对增加幅度在 3.4%至 8.9%之间（所有比较均 p<0.001）。与 2015-2017 年相比，住院时间缩短（10.95 天 vs 11.90 天；绝对差异-1.08，95%CI=[-1.18，-0.99]，p<0.001），2018-2020 年院内死亡率显著降低（风险比（RR）=0.88，95%CI=[0.79，0.98]，p=0.01）。