Effect of the Shanghai Stroke Service System (4S) on the quality of stroke care and outcomes: A prospective quality improvement project

Jiawen Xu, Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.
Yanan Xie, Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.
Kun Fang, Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.
Xin Wang, Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, China.
Shengdi Chen, Department of Neurology, Ruijin Hospital affiliated to Shanghai Jiaotong University, Shanghai, China.
Xueyuan Liu, Department of Neurology, The Tenth Peoples Hospital affiliated to Shanghai Jiaotong University, Shanghai, China.
Yuwu Zhao, Department of Neurology, The Sixth Peoples Hospital affiliated to Shanghai Jiaotong University, Shanghai, China.
Yangtai Guan, Department of Neurology, RenJi Hospital affiliated to Shanghai Jiaotong University, Shanghai, China.
Dingfang Cai, Department of Neurology, ShuGuang Hospital Affiliated to University of Chinese Medicine, Shanghai, China.
Gang Li, Department of Neurology, Shanghai East Hospital, Shanghai, China.
Jianmin Liu, Department of Neurology, Changhai Hospital of Shanghai, Shanghai, China.
JianRen Liu, Department of Neurology, Shanghai Ninth People's Hospital, Shanghai, China.
Jianhua Zhuang, Department of Neurology, Shanghai Changzheng Hospital, Shanghai, China.
Ying Xian, Duke Clinical Research Institute, Duke University, Durham, NC, USA.
Haipeng Shen, Faculty of Business and Economics, University of Hong Kong, Pokfulam, Hongkong.
Hao Li, China National Clinical Research Center for Neurological Diseases, Beijing, China.
David Z. Wang, Neurovascular Division, Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA.Follow
Bruce Cv Campbell, Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia.
Mark W. Parsons, Department of Neurology, Liverpool Hospital, South Western Sydney Clinical School, University of New South Wales, Liverpool, NSW, Australia.
Yi Dong, Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.
Qiang Dong, Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China.

Document Type

Article

Abstract

BACKGROUND: In China, disparities in the quality of stroke care still exist and implementing quality improvement is still a challenge. AIM: The aim of the study was to determine whether the intervention by Shanghai Stroke Service System (4S) has helped improve adherence to stroke care guidelines and patient outcome. METHODS: The 4S is a regional stroke network with real-time data extraction among its 61 stroke centers in Shanghai. A total of 11 key performance indicators (KPIs) were evaluated. The primary outcomes were a composite measure and an all-or-none measure of adherence to 11 KPIs. The secondary outcomes were length of hospital stay and in-hospital mortality. RESULTS: The study enrolled 92,395 patients (mean age 69.0 ± 12.5 years, 65.2% men) with acute ischemic stroke hospitalized within 7 days of onset in Shanghai from January 2015 to December 2020. More patients received guideline recommended care between 2018 and 2020 than those between 2015 and 2017 (composite measure 87.1% vs 83.6%; absolute difference 2.9%, 95% confidence interval (CI) = [2.7%, 3.2%], p < 0.001; all-or-none measure 49.2% vs 44.8% patients; absolute difference 3.5%, 95% CI = [2.7%, 4.2%], p < 0.001). Further analysis of individual KPIs showed an absolute increase in six KPIs ranging from 3.4% to 8.9% (p < 0.001 for all comparisons). Compared with 2015-2017, hospital length of stay was shorter (10.95 vs 11.90 days; absolute difference -1.08, 95% CI = [-1.18, -0.99], p < 0.001), and in-hospital mortality was significantly reduced (risk ratio (RR) = 0.88, 95% CI = [0.79, 0.98], p = 0.01) in 2018-2020. CONCLUSION: The 4S intervention was associated with increased adherence to the stroke care guidelines, which further translated to improved clinical outcomes. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02735226.

Medical Subject Headings

Aged; Aged, 80 and over; Female; Humans; Male; Middle Aged; China (epidemiology); Ischemic Stroke; Prospective Studies; Quality Improvement; Stroke (epidemiology, therapy)

Publication Date

6-1-2023

Publication Title

International journal of stroke : official journal of the International Stroke Society

E-ISSN

1747-4949

Volume

18

Issue

5

First Page

599

Last Page

606

PubMed ID

36082948

Digital Object Identifier (DOI)

10.1177/17474930221125993

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