一项提高急性脑卒中管理中循证实践依从性的阶梯式整群随机试验。

A Stepped-Wedge Cluster-Randomized Trial to Improve Adherence to Evidence-Based Practices for Acute Stroke Management.

出版信息

Jt Comm J Qual Patient Saf. 2022 Dec;48(12):653-664. doi: 10.1016/j.jcjq.2022.09.003. Epub 2022 Sep 28.

DOI:10.1016/j.jcjq.2022.09.003

Abstract

BACKGROUND

There is limited evidence regarding the optimal design and composition of multifaceted quality improvement programs to improve acute stroke care. The researchers aimed to test the effectiveness of a co-designed multifaceted intervention (STELAR: Shared Team Efforts Leading to Adherence Results) directed at hospital clinicians for improving acute stroke care tailored to the local context using feedback of national registry indicator data.

METHODS

STELAR was a stepped-wedge cluster trial (partial randomization) using routinely collected Australian Stroke Clinical Registry data from Victorian hospitals segmented in two-month blocks. Each hospital (cluster) contributed control data from May 2017 and data for the intervention phase from July 2017 until September 2018. The intervention was multifaceted, delivered predominantly in two educational outreach workshops by experienced, external improvement facilitators, consisting of (1) feedback of registry data to identify practice gaps and (2) interprofessional education, barrier assessment, and documentation of an agreed action plan initiated by local clinical leaders appointed as change champions for prioritized clinical indicators. The researchers provided additional outreach support by e-mail/telephone for two months. Multilevel, multivariable regression models were used to assess change in a composite outcome of indicators selected for actions plans (primary outcome) and individual indicators (secondary outcome). Patient survival and disability 90-180 days after stroke were also compared.

RESULTS

Nine hospitals (clusters) participated, and 144 clinicians attended 18 intervention workshops. The control phase included 1,001 patients (median age 76.7 years; 47.4% female, 64.7% ischemic stroke), and the intervention phase 2,146 patients (median age 74.9 years; 44.2% female, 73.8% ischemic stroke). Compared to the control phase, the median score for the composite outcome for the intervention phase was 17% greater for the indicators included in the hospitals' action plans (range 3% to 30%, p = 0.016) and overall for the 10 indicators 6% greater (range 3% to 10%, p < 0.001). Compared to the control phase, patients in the intervention phase more often received stroke unit care (odds ratio [OR] 1.39, 95% confidence interval [CI] 1.05-1.84), were discharged on antithrombotic medications (OR 1.87, 95% CI 1.50-2.33), and received a discharge care plan (OR 1.27, 95% CI 1.05-1.53). Patient outcomes were unchanged.

CONCLUSION

External quality improvement facilitation using workshops and remote support, aligned with routine monitoring via registries, can improve acute stroke care.

摘要

背景

关于提高急性脑卒中护理质量的多方面质量改进方案的最佳设计和组成，证据有限。研究人员旨在测试一种针对医院临床医生的联合设计的多方面干预措施（STELAR：共同努力导致结果的一致性）的有效性，该措施针对特定地区的急性脑卒中护理进行了调整，并使用全国登记指标数据的反馈。

方法

STELAR 是一项采用分步楔形群试验（部分随机化），使用维多利亚州医院常规收集的澳大利亚脑卒中临床登记数据，以两个月为一个分段。每个医院（群集）在 2017 年 5 月提供对照数据，并在 2017 年 7 月至 2018 年 9 月期间提供干预阶段的数据。干预措施是多方面的，主要由经验丰富的外部改进促进者通过两次教育推广研讨会来提供，包括（1）登记数据反馈以确定实践差距，以及（2）专业间教育、障碍评估和由当地临床领导者启动的商定行动计划的文件，这些临床领导者被任命为优先临床指标的变革推动者。研究人员通过电子邮件/电话提供了两个月的额外推广支持。使用多水平、多变量回归模型评估选定行动计划的指标的综合结果（主要结果）和个别指标（次要结果）的变化。还比较了脑卒中后 90-180 天的患者生存和残疾情况。

结果

9 家医院（群集）参与，144 名临床医生参加了 18 次干预研讨会。对照阶段包括 1001 名患者（中位年龄 76.7 岁；47.4%为女性，64.7%为缺血性脑卒中），干预阶段包括 2146 名患者（中位年龄 74.9 岁；44.2%为女性，73.8%为缺血性脑卒中）。与对照阶段相比，干预阶段包含在医院行动计划中的指标的综合结果中位数增加了 17%（范围为 3%至 30%，p=0.016），10 个指标的整体中位数增加了 6%（范围为 3%至 10%，p<0.001）。与对照阶段相比，干预阶段的患者更常接受脑卒中单元护理（优势比[OR]1.39，95%置信区间[CI]1.05-1.84），出院时更常接受抗血栓药物治疗（OR 1.87，95%CI 1.50-2.33），并获得出院护理计划（OR 1.27，95%CI 1.05-1.53）。患者结局未发生变化。