title: Did a quality improvement collaborative make stroke care better? A cluster randomized trial.
abstract: BACKGROUND
  Stroke can result in death and long-term disability. Fast and high-quality care can reduce the impact of stroke, but UK national audit data has demonstrated variability in compliance with recommended processes of care. Though quality improvement collaboratives (QICs) are widely used, whether a QIC could improve reliability of stroke care was unknown.
  
  
  METHODS
  Twenty-four NHS hospitals in the Northwest of England were randomly allocated to participate either in Stroke 90:10, a QIC based on the Breakthrough Series (BTS) model, or to a control group giving normal care. The QIC focused on nine processes of quality care for stroke already used in the national stroke audit. The nine processes were grouped into two distinct care bundles: one relating to early hours care and one relating to rehabilitation following stroke. Using an interrupted time series design and difference-in-difference analysis, we aimed to determine whether hospitals participating in the QIC improved more than the control group on bundle compliance.
  
  
  RESULTS
  Data were available from nine interventions (3,533 patients) and nine control hospitals (3,059 patients). Hospitals in the QIC showed a modest improvement from baseline in the odds of average compliance equivalent to a relative improvement of 10.9% (95% CI 1.3%, 20.6%) in the Early Hours Bundle and 11.2% (95% CI 1.4%, 21.5%) in the Rehabilitation Bundle. Secondary analysis suggested that some specific processes were more sensitive to an intervention effect.
  
  
  CONCLUSIONS
  Some aspects of stroke care improved during the QIC, but the effects of the QIC were modest and further improvement is needed. The extent to which a BTS QIC can improve quality of stroke care remains uncertain. Some aspects of care may respond better to collaboratives than others.
  
  
  BACKGROUND
  ISRCTN13893902.
authors.affiliation: Director of Innovation and Improvement Science, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, England. maxine.power@nhs.net.
authors.forename: Maxine
authors.initials: M
authors.lastname: Power
authors.forename: Pippa J
authors.initials: PJ
authors.lastname: Tyrrell
authors.forename: Anthony G
authors.initials: AG
authors.lastname: Rudd
authors.forename: Mary P
authors.initials: MP
authors.lastname: Tully
authors.forename: David
authors.initials: D
authors.lastname: Dalton
authors.forename: Martin
authors.initials: M
authors.lastname: Marshall
authors.forename: Ian
authors.initials: I
authors.lastname: Chappell
authors.forename: Delphine
authors.initials: D
authors.lastname: Corgié
authors.forename: Don
authors.initials: D
authors.lastname: Goldmann
authors.forename: Dale
authors.initials: D
authors.lastname: Webb
authors.forename: Mary
authors.initials: M
authors.lastname: Dixon-Woods
authors.forename: Gareth
authors.initials: G
authors.lastname: Parry
mesh_terms: D003299:Cooperative Behavior; D004739:England; D005260:Female; D006801:Humans; D008297:Male; D058996:Quality Improvement / Q000592:standards*; D011787:Quality of Health Care / Q000592:standards*; D015203:Reproducibility of Results; D012307:Risk Factors; D020521:Stroke / Q000175:diagnosis / Q000628:therapy*; D000071939:Stroke Rehabilitation; D013997:Time Factors; D016896:Treatment Outcome