title: A cluster-randomized trial to improve stroke care in hospitals.
abstract: OBJECTIVE
  We evaluated the effect of performance feedback on acute ischemic stroke care quality in Minnesota hospitals.
  
  
  METHODS
  A cluster-randomized controlled trial design with hospital as the unit of randomization was used. Care quality was defined as adherence to 10 performance measures grouped into acute, in-hospital, and discharge care. Following preintervention data collection, all hospitals received a report on baseline care quality. Additionally, in experimental hospitals, clinical opinion leaders delivered customized feedback to care providers and study personnel worked with hospital administrators to implement changes targeting identified barriers to stroke care. Multilevel models examined experimental vs control, preintervention and postintervention performance changes and secular trends in performance.
  
  
  RESULTS
  Nineteen hospitals were randomized with a total of 1,211 acute ischemic stroke cases preintervention and 1,094 cases postintervention. Secular trends were significant with improvement in both experimental and control hospitals for acute (odds ratio = 2.7, p = 0.007) and in-hospital (odds ratio = 1.5, p < 0.0001) care but not discharge care. There was no significant intervention effect for acute, in-hospital, or discharge care.
  
  
  CONCLUSIONS
  There was no definite intervention effect: both experimental and control hospitals showed significant secular trends with performance improvement. Our results illustrate the potential fallacy of using historical controls for evaluating quality improvement interventions.
  
  
  METHODS
  This study provides Class II evidence that informing hospital leaders of compliance with ischemic stroke quality indicators followed by a structured quality improvement intervention did not significantly improve compliance more than informing hospital leaders of compliance with stroke quality indicators without a quality improvement intervention.
authors.affiliation: Department of Neurology, School of Medicine, University of Minnesota, Minneapolis, MN 55455, USA. laksh004@umn.edu
authors.forename: K
authors.initials: K
authors.lastname: Lakshminarayan
authors.forename: C
authors.initials: C
authors.lastname: Borbas
authors.forename: B
authors.initials: B
authors.lastname: McLaughlin
authors.forename: N E
authors.initials: NE
authors.lastname: Morris
authors.forename: G
authors.initials: G
authors.lastname: Vazquez
authors.forename: R V
authors.initials: RV
authors.lastname: Luepker
authors.forename: D C
authors.initials: DC
authors.lastname: Anderson
mesh_terms: D016009:Chi-Square Distribution; D019983:Guideline Adherence / Q000592:standards*; D019538:Health Care Surveys; D006761:Hospitals / Q000592:standards*; D006801:Humans; D057194:Intention to Treat Analysis; D016017:Odds Ratio; D011787:Quality of Health Care / Q000592:standards*; D020521:Stroke / Q000628:therapy*; D017749:Total Quality Management / Q000592:standards*; D014481:United States