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Randomized Controlled Trial
. 2025 Feb 1;82(2):160-167.
doi: 10.1001/jamaneurol.2024.4304.

Quality Improvement Intervention for Reducing Acute Treatment Times in Ischemic Stroke: A Cluster Randomized Clinical Trial

Daniël Hansen  1   2 , Sanne J den Hartog  1   2   3 , Nikki van Leeuwen  1 , Jelis Boiten  4 , Wouter Dinkelaar  5 , Pieter J van Doormaal  3 , Frank Eijkenaar  6 , Bart J Emmer  7 , Adriaan C G M van Es  8 , H Zwenneke Flach  9 , Rob Gons  10 , M Heleen den Hertog  11 , Farshad Imani  12 , Paula M Janssen  2 , Hans Kortman  13 , Nyika D Kruyt  14 , Laurien S Kuhrij  15   16 , Christiaan van der Leij  17 , T H Rob Lo  18 , Aad van der Lugt  3 , Geert Lycklama À Nijeholt  19 , Jasper M M Martens  20 , Paul J Nederkoorn  15 , Jurgen Piet  21 , Michel J M Remmers  22 , Yvo B W E M Roos  15 , Suzanne M Silvis  23 , Lotte J Stolze  15   16 , Wouter Stomp  24 , Julia H van Tuijl  25 , Martine T B Truijman  26 , Sarah E Vermeer  27 , Marianne A A van Walderveen  8 , Ido R van den Wijngaard  4   19 , H Bart Van der Worp  28 , Lonneke Yo  29 , Diederik W J Dippel  2 , Hester F Lingsma  1 , Bob Roozenbeek  2 ; PERFEQTOS Investigators
Collaborators, Affiliations
Randomized Controlled Trial

Quality Improvement Intervention for Reducing Acute Treatment Times in Ischemic Stroke: A Cluster Randomized Clinical Trial

Daniël Hansen et al. JAMA Neurol. .

Abstract

Importance: Efficient care processes are crucial to minimize treatment delays and improve outcome after endovascular thrombectomy (EVT) in patients with ischemic stroke. A potential means to improve care processes is performance feedback.

Objective: To evaluate the effect of performance feedback to hospitals on treatment times for EVT.

Design, setting, and participants: This cluster randomized clinical trial was conducted from January 1, 2020, to June 30, 2022. Participants were consecutive adult patients with ischemic stroke who underwent EVT in 13 Dutch hospitals. No patients were excluded. Data analysis took place from March to May 2023.

Intervention: The intervention consisted of feedback on hospital performance using structure, process, and outcome indicators. Indicator scores were based on data from a national quality registry and compared with a benchmark. Performance feedback was provided through a dashboard for local quality improvement teams who developed and implemented improvement plans based on the feedback. Every 6 months, 3 to 4 randomly selected hospitals switched to the intervention condition.

Main outcome and measures: The primary outcome was time from door to groin puncture for all patients treated with EVT. Secondary outcomes included door-to-needle time, National Institutes of Health Stroke Scale (NIHSS) score at day 2, expanded Treatment in Cerebral Infarction (eTICI) score, and modified Rankin Scale (mRS) score at 3 months. The effect of the intervention was estimated with multivariable linear mixed models.

Results: A total of 4747 patients were included (intervention: 2431; control: 2316). Their mean (SD) age was 72 (13) years; 2337 (49.2%) were female and 2410 (50.8%) were male. The median (IQR) baseline NIHSS score was 14 (8-19). Median (IQR) door-to-groin puncture time under the intervention condition was 47 (25-71) minutes, compared with 52 (29-75) minutes under the control condition. The adjusted absolute reduction was 5 minutes (β = -4.8; 95% CI, -9.5 to -0.1; P = .04), corresponding to a relative reduction of 9.2% (95% CI, -18.3% to -0.2%).

Conclusion and relevance: This study found that performance feedback provided through a dashboard used by local quality improvement teams reduced door-to-groin puncture time for EVT. Implementation of performance feedback in hospitals providing EVT can improve the quality of care for ischemic stroke.

Trial registration: The Netherlands Trial Register: NL9090.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Nederkoorn reported being chair of the Dutch Acute Stroke Audit (DASA) from 2015 until 2023. Dr Van der Worp reported funding paid to their institution from the European Union, Dutch Heart Foundation, and Stryker and consultancy fees paid to their institution from Bayer and TargED. Dr Dippel reported funding paid to their institution from the Dutch Heart Foundation, Brain Foundation Netherlands, Netherlands Organisation for Health Research and Development, Health Holland Top Sector Life Sciences & Health and unrestricted grants paid to their institution from Penumbra, Stryker, Medtronic, Thrombolytic Science, and Cerenovus for research. Dr Roozenbeek reported funding paid to their institution from the Dutch Heart Foundation and Netherlands Organisation for Health Research and Development. No other disclosures were reported.

References

    1. Fransen PS, Berkhemer OA, Lingsma HF, et al. ; Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands Investigators . Time to reperfusion and treatment effect for acute ischemic stroke: a randomized clinical trial. JAMA Neurol. 2016;73(2):190-196. doi:10.1001/jamaneurol.2015.3886 - DOI - PubMed
    1. Saver JL, Goyal M, van der Lugt A, et al. ; HERMES Collaborators . Time to treatment with endovascular thrombectomy and outcomes from ischemic stroke: a meta-analysis. JAMA. 2016;316(12):1279-1288. doi:10.1001/jama.2016.13647 - DOI - PubMed
    1. Goyal M, Almekhlafi MA, Fan L, et al. . Evaluation of interval times from onset to reperfusion in patients undergoing endovascular therapy in the Interventional Management of Stroke III trial. Circulation. 2014;130(3):265-272. doi:10.1161/CIRCULATIONAHA.113.007826 - DOI - PMC - PubMed
    1. Menon BK, Almekhlafi MA, Pereira VM, et al. ; STAR Study Investigators . Optimal workflow and process-based performance measures for endovascular therapy in acute ischemic stroke: analysis of the Solitaire FR thrombectomy for acute revascularization study. Stroke. 2014;45(7):2024-2029. doi:10.1161/STROKEAHA.114.005050 - DOI - PubMed
    1. Demchuk AM, Goyal M, Menon BK, et al. ; ESCAPE Trial Investigators . Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial: methodology. Int J Stroke. 2015;10(3):429-438. doi:10.1111/ijs.12424 - DOI - PubMed

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