title: A cluster-randomised quality improvement study to improve two inpatient stroke quality indicators.
abstract: BACKGROUND
  Quality indicator collection and feedback improves stroke care. We sought to determine whether quality improvement training plus indicator feedback was more effective than indicator feedback alone in improving inpatient stroke indicators.
  
  
  METHODS
  We conducted a cluster-randomised quality improvement trial, randomising hospitals to quality improvement training plus indicator feedback versus indicator feedback alone to improve deep vein thrombosis (DVT) prophylaxis and dysphagia screening. Intervention sites received collaborative-based quality improvement training, external facilitation and indicator feedback. Control sites received only indicator feedback. We compared indicators pre-implementation (pre-I) to active implementation (active-I) and post-implementation (post-I) periods. We constructed mixed-effect logistic models of the two indicators with a random intercept for hospital effect, adjusting for patient, time, intervention and hospital variables.
  
  
  RESULTS
  Patients at intervention sites (1147 admissions), had similar race, gender and National Institutes of Health Stroke Scale scores to control sites (1017 admissions). DVT prophylaxis improved more in intervention sites during active-I period (ratio of ORs 4.90, p<0.001), but did not differ in post-I period. Dysphagia screening improved similarly in both groups during active-I, but control sites improved more in post-I period (ratio of ORs 0.67, p=0.04). In logistic models, the intervention was independently positively associated with DVT performance during active-I period, and negatively associated with dysphagia performance post-I period.
  
  
  CONCLUSIONS
  Quality improvement training was associated with early DVT improvement, but the effect was not sustained over time and was not seen with dysphagia screening. External quality improvement programmes may quickly boost performance but their effect may vary by indicator and may not sustain over time.
authors: Roudebush VAMC, Indianapolis, Indiana, USA Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA Regenstrief Institute, Inc., Indianapolis, Indiana, USA.
authors: Linda
authors: L
authors: Williams
authors: Roudebush VAMC, Indianapolis, Indiana, USA VA Center for Applied Systems Engineering, Indianapolis, Indiana, USA.
authors: Virginia
authors: V
authors: Daggett
authors: Department of Medicine/Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.
authors: James E
authors: JE
authors: Slaven
authors: Department of Medicine/Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA.
authors: Zhangsheng
authors: Z
authors: Yu
authors: Roudebush VAMC, Indianapolis, Indiana, USA.
authors: Danielle
authors: D
authors: Sager
authors: Roudebush VAMC, Indianapolis, Indiana, USA.
authors: Jennifer
authors: J
authors: Myers
authors: Roudebush VAMC, Indianapolis, Indiana, USA.
authors: Laurie
authors: L
authors: Plue
authors: Roudebush VAMC, Indianapolis, Indiana, USA VA Center for Applied Systems Engineering, Indianapolis, Indiana, USA.
authors: Heather
authors: H
authors: Woodward-Hagg
authors: Roudebush VAMC, Indianapolis, Indiana, USA Regenstrief Institute, Inc., Indianapolis, Indiana, USA Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA.
authors: Teresa M
authors: TM
authors: Damush
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D016000:Cluster Analysis; D005246:Feedback; D006761:Hospitals / Q000592:standards; D006801:Humans; D007297:Inpatients / Q000706:statistics & numerical data; D008875:Middle Aged; D015999:Multivariate Analysis; D058996:Quality Improvement; D019984:Quality Indicators, Health Care / Q000592:standards*; D018570:Risk Assessment; D012737:Sex Factors; D020521:Stroke / Q000175:diagnosis / Q000628:therapy*; D016896:Treatment Outcome; D014481:United States; D020246:Venous Thrombosis / Q000517:prevention & control*
keywords: Audit and feedback; Cluster trials; Healthcare quality improvement; Six Sigma; Team training