The Stroke Practice Improvement Network: a quasiexperimental trial of a multifaceted intervention to improve quality.
OBJECTIVE
The aim of this project was to determine whether a tailored multifaceted intervention aimed at site-specific barriers is more effective than audit feedback alone for improving adherence to inhospital stroke performance measures (PMs): door to needle time of less than 1 hour for tissue plasminogen activator, dysphagia screening, deep venous thrombosis prophylaxis, and warfarin treatment for atrial fibrillation.


METHODS
Hospitals were paired on baseline adherence to dysphagia screening and quality improvement infrastructure and randomized to receive audit feedback alone (n=7) versus audit feedback plus site-specific interventions (n=6). Data were collected on all admitted patients with stroke seen in the neurology department before and after a 6-month implementation period. The primary end point was the difference in postintervention adherence rates for each PM, except tissue plasminogen activator because of low sample size.


RESULTS
Data were collected on 2071 preintervention patients and 1240 postintervention patients. Targeted site-specific interventions, such as standing orders and standardized dysphagia screens, were imperfectly implemented during the 6-month intervention period. For atrial fibrillation, the intervention group had an 11% higher postintervention adherence rate beyond that of the control group (98% v 87%, P < .005). No other statistically significant changes in PM adherence were observed.


CONCLUSIONS
Implementation of site-specific interventions for quality improvement of specific measures in stroke was difficult to achieve in a 6-month time frame and led to improved adherence for only one of 3 PMs. Studies with a longer intervention period and more sites are required to determine whether tailored interventions can enhance stroke improvement.
Hinchey
Judith A
JA
Institute of Clinical Care Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts 02135, USA. judith.hinchey@caritaschristi.org
Shephard
Timothy
T
Tonn
Sarah T
ST
Ruthazer
Robin
R
Hermann
Richard C
RC
Selker
Harry P
HP
Kent
David M
DM
D000368:Aged; D000925:Anticoagulants / Q000627:therapeutic use; D001281:Atrial Fibrillation / Q000150:complications / Q000188:drug therapy / Q000517:prevention & control; D003131:Combined Modality Therapy / Q000592:standards; D003133:Commission on Professional and Hospital Activities; D003680:Deglutition Disorders / Q000175:diagnosis / Q000209:etiology; D004632:Emergency Medical Services / Q000379:methods / Q000592:standards*; D004636:Emergency Service, Hospital / Q000592:standards; D005246:Feedback; D005260:Female; D019983:Guideline Adherence / Q000592:standards* / Q000639:trends; D006801:Humans; D007362:Intensive Care Units / Q000592:standards; D008297:Male; D008403:Mass Screening; D011785:Quality Assurance, Health Care / Q000379:methods*; D011787:Quality of Health Care; D020521:Stroke / Q000150:complications / Q000175:diagnosis / Q000628:therapy*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D020246:Venous Thrombosis / Q000188:drug therapy / Q000209:etiology / Q000517:prevention & control; D014859:Warfarin / Q000008:administration & dosage
D000925:Anticoagulants; D014859:Warfarin; D010959:Tissue Plasminogen Activator