Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Wright Street, Clayton, Victoria 3168, Australia.
Stroke Division, The Florey Institute of Neuroscience and Mental Health, Melbourne Brain Centre, University of Melbourne, Burgundy Street, Heidelberg, Victoria 3084, Australia.
Int J Qual Health Care. 2023 Feb 17;35(1). doi: 10.1093/intqhc/mzad003.
Variation in the delivery of evidence-based care affects outcomes for patients with stroke. A range of hospital (organizational), patient, and clinical factors can affect care delivery. Clinical registries are widely used to monitor stroke care and guide quality improvement efforts within hospitals. However, hospital features are rarely collected. We aimed to explore the influence of hospital resources for stroke, in metropolitan and regional/rural hospitals, on the provision of evidence-based patient care and outcomes. The 2017 National Audit organizational survey (Australia) was linked to patient-level data from the Australian Stroke Clinical Registry (2016-2017 admissions). Regression models were used to assess the associations between hospital resources (based on the 2015 Australian National Acute Stroke Services Framework) and patient care (reflective of national guideline recommendations), as well as 90-180-day readmissions and health-related quality of life. Models were adjusted for patient factors, including the severity of stroke. Fifty-two out of 127 hospitals with organizational survey data were merged with 22 832 Australian Stroke Clinical Registry patients with an admission for a first-ever stroke or transient ischaemic attack (median age 75 years, 55% male, and 66% ischaemic). In metropolitan hospitals (n = 42, 20 977 patients, 1701 thrombolyzed, and 2395 readmitted between 90 and 180 days post stroke), a faster median door-to-needle time for thrombolysis was associated with ≥500 annual stroke admissions [-15.9 minutes, 95% confidence interval (CI) -27.2, -4.7], annual thrombolysis >20 patients (-20.2 minutes, 95% CI -32.0, -8.3), and having specialist stroke staff (dedicated medical lead and stroke coordinator; -12.7 minutes, 95% CI -25.0, -0.4). A reduced likelihood of all-cause readmissions between 90 and 180 days was evident in metropolitan hospitals using care pathways for stroke management (odds ratio 0.82, 95% CI 0.67-0.99). In regional/rural hospitals (n = 10, 1855 patients), being discharged with a care plan was also associated with the use of stroke clinical pathways (odds ratio 3.58, 95% CI 1.45-8.82). No specific hospital resources influenced 90-180-day health-related quality of life. Relevant to all international registries, integrating information about hospital resources with clinical registry data provides greater insights into factors that influence evidence-based care.
证据为基础的护理提供情况的变化会影响到中风患者的治疗结果。一系列医院（组织）、患者和临床因素会影响护理的提供。临床登记册被广泛用于监测中风护理并指导医院内的质量改进工作。然而，很少收集医院的特点。我们的目的是探讨大都市和城乡/农村医院中风的医院资源对提供基于证据的患者护理和治疗结果的影响。2017 年全国审计组织调查（澳大利亚）与澳大利亚中风临床登记册（2016-2017 年入院）的患者水平数据相关联。回归模型用于评估医院资源（基于 2015 年澳大利亚国家急性中风服务框架）与患者护理（反映国家指南建议）之间的关联，以及 90-180 天再入院和健康相关生活质量。模型调整了患者因素，包括中风的严重程度。52 家有组织调查数据的医院与 22832 名澳大利亚中风临床登记册的患者合并（中位年龄 75 岁，55%为男性，66%为缺血性），首次发生中风或短暂性缺血性发作的患者。在大都市医院（n=42，20977 例患者，1701 例溶栓，90-180 天内 2395 例再入院），溶栓的中位门到针时间较快与每年 500 例以上的中风入院有关[-15.9 分钟，95%置信区间（CI）-27.2，-4.7]，每年溶栓治疗患者>20 例[-20.2 分钟，95%CI-32.0，-8.3]，以及有专业中风工作人员（专职医疗负责人和中风协调员）[-12.7 分钟，95%CI-25.0，-0.4]。在大都市医院使用中风管理护理途径，90-180 天内全因再入院的可能性降低（比值比 0.82，95%CI 0.67-0.99）。在城乡/农村医院（n=10，1855 例患者），出院时制定护理计划也与使用中风临床途径有关（比值比 3.58，95%CI 1.45-8.82）。没有特定的医院资源影响 90-180 天的健康相关生活质量。与所有国际登记册一样，将医院资源信息与临床登记册数据相结合，可以更深入地了解影响循证护理的因素。
