提高加拿大四个省份急性缺血性中风治疗的可及性和效率：一项阶梯楔形试验。
Improving access and efficiency of acute ischemic stroke treatment across four Canadian provinces: a stepped-wedge trial.
作者信息
Kamal Noreen, Cora Elena A, Alim Simone, Goldstein Judah, Volders David, Aljendi Shadi, Williams Heather, Fok Patrick T, van der Linde Etienne, Helm-Neima Trish, Cashin Renee, Metcalfe Brian, Savoie Julie, Simpkin Wendy, Chisholm Cassie, Hill Michael D, Menon Bijoy K, Phillips Stephen
机构信息
Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada.
Department of Community Health and Epidemiology, Faculty of Medicine, Dalhousie University, Halifax, NS, Canada.
出版信息
Front Neurol. 2025 Aug 18;16:1610307. doi: 10.3389/fneur.2025.1610307. eCollection 2025.
BACKGROUND
The translation of standard-of-care in acute ischemic stroke reperfusion interventions into practice is well established, but multifactorial obstacles exist in complete adoption, which has led to inequities in access and delivery of services. The objective of this study was to improve access and efficiency of ischemic stroke treatment across four Atlantic Canadian Provinces.
METHODS
A stepped-wedge cluster trial was conducted over 30 months with 3 clusters covering 34 sites. The trial was conducted across all 4 Atlantic Canadian provinces: Nova Scotia (NS), New Brunswick (NB), Prince Edward Island (PE), and Newfoundland and Labrador (NL). The design was quasi-randomized, with each cluster associated with one or more provinces: cluster 1-NS; cluster 2-NB and PE; and cluster 3-NL. The patient population was all ischemic stroke patients across all 4 provinces. The intervention was a 6-month modified Quality Improvement Collaborative (mQIC), which was modified from the Breakthrough Series Collaborative to be half of the 1-year period and conducted virtually. The intervention consisted of assembling an interdisciplinary improvement team, 2 full-day workshops, webinars, and virtual site visits. Suggested changes included 6 process improvement strategies.
RESULTS
Over the trial period, 8,594 ischemic stroke patients were included, out of which 1,599 patients received acute reperfusion treatment. The proportion of patients that received treatment did not increase significantly with the intervention [0.4% increase for patients that received thrombolysis and/or EVT ( = 0.68)]. Median door-to-needle time was reduced by 9.8 min with the intervention ( = 0.006). Cluster 3 saw the greatest improvements in both access and efficiency.
CONCLUSION
A mQIC intervention resulted in improvement of process measures like door-to-needle time. Quality improvement initiatives may need to be longer to allow full implementation and tailored for each health system to ensure that each system sees improvement. In-person activities might be critical to ensure fidelity of the intervention.
CLINICAL TRIAL REGISTRATION
ISRCTN11109800, https://www.isrctn.com/ISRCTN11109800.
背景
急性缺血性中风再灌注干预的标准治疗方法已在实践中得到确立，但在全面采用过程中存在多方面障碍，这导致了服务获取和提供方面的不平等。本研究的目的是提高加拿大大西洋沿岸四个省份缺血性中风治疗的可及性和效率。
方法
在30个月内进行了一项阶梯式楔形整群试验，3个整群涵盖34个地点。该试验在加拿大大西洋沿岸的所有4个省份进行：新斯科舍省（NS）、新不伦瑞克省（NB）、爱德华王子岛省（PE）和纽芬兰与拉布拉多省（NL）。设计为准随机化，每个整群与一个或多个省份相关联：整群1 - NS；整群2 - NB和PE；整群3 - NL。患者群体为所有4个省份的缺血性中风患者。干预措施是为期6个月的改良质量改进协作项目（mQIC），该项目由突破系列协作项目修改而来，为期1年的一半时间，并以虚拟方式进行。干预措施包括组建一个跨学科改进团队、举办2次全天工作坊、开展网络研讨会以及进行虚拟实地考察。建议的改进措施包括6项流程改进策略。
结果
在试验期间，纳入了8594例缺血性中风患者，其中1599例患者接受了急性再灌注治疗。接受治疗的患者比例在干预后没有显著增加[接受溶栓和/或血管内治疗的患者增加了0.4%（P = 0.68）]。干预后，中位门到针时间缩短了9.8分钟（P = 0.006）。整群3在可及性和效率方面的改善最为显著。
结论
mQIC干预措施使门到针时间等流程指标得到了改善。质量改进举措可能需要更长时间才能全面实施，并且需要针对每个卫生系统进行调整，以确保每个系统都能有所改善。面对面活动对于确保干预措施的保真度可能至关重要。
临床试验注册
ISRCTN11109800，https://www.isrctn.com/ISRCTN11109800 。
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