Abstract: Objective  To evaluate the improvement effect of early and late clinical pathway quality interventions on key performance indicators of medical service quality for ischemic stroke.
Methods  This prospective randomized control register study included consecutive ischemic stroke patients from 202 national hospitals from April 2016 to June 2017. The enrolled hospitals were matched according to the principle of geographical location, hospital level, teaching hospital, and were divided into early clinical pathway medical quality intervention group (as “early intervention group”) and “late intervention group”. The study time was divided into 5 phases, with every 3 months as one phase. The early intervention group started intervention from phase 1, and the late intervention group started from phase 3. Baseline characteristics and key performance indicators of medical service quality for ischemic stroke in the two groups were compared to assess the impact of early and late clinical pathway quality intervention on medical quality.
Results  There were 91 hospitals in the early intervention group and 111 hospitals in the late intervention group. A total of 15 167 patients were enrolled. In the 10 key performance indicators of medical service quality for ischemic stroke, the rate of antithrombotic therapy at discharge was higher in the early intervention group than that in the late intervention group in the first stage (95.6% vs. 92.7%, P=0.01). In the second stage, the rate of antithrombotic therapy (94.9% vs. 92.4%, P=0.01) and antihypertensives therapy (68.3% vs. 63.7%, P=0.02) in patients with hypertension were higher in the early intervention group. In the third stage, the rate of antithrombotic therapy (94.2% vs. 90.8%, P=0.01) and statin therapy (92.7% vs. 87.6%, P=0.01) at discharge were higher in the early intervention group. In the fourth stage, the early intervention group had higher rates of DVT prophylaxis (54.7% vs. 41.6%, P=0.01), antithrombotic therapy (94.7% vs. 91.1%, P=0.01) and statin therapy (93.6% vs. 88.5%, P=0.01) at discharge than the late intervention group. In the fifth stage, the early intervention group had a higher rate of rt-PA intravenous thrombolysis than the late intervention group (40.5% vs. 29.5%, P=0.04).
Conclusions  Early clinical pathway medical quality intervention is helpful to improve the key performance indicators of medical service quality for ischemic stroke in China.

Key words: Ischemic stroke; Medical quality; Clinical pathway

摘要： 目的 通过比较早期与晚期缺血性卒中临床路径医疗质量干预，评价2种临床路径质量干预方法对缺血性卒中医疗服务质量关键绩效指标的改进作用。
方法 前瞻性连续纳入全国202所医院2016年4月-2017年6月的缺血性卒中住院患者。入组医院按照地理位置、医院级别、是否教学医院进行匹配，分为早期临床路径医疗质量干预（早期干预）组和晚期临床路径医疗质量干预（晚期干预）组。研究根据时间顺序分为5个阶段，每3个月为1个阶段。早期干预组自第1阶段即开始进行临床路径干预，晚期干预组则在第3阶段开始进行临床路径干预。比较2组患者的基线特征及缺血性卒中医疗服务质量关键绩效指标，评估早期与晚期临床路径质量干预对医疗质量的影响。
结果 本研究中有91所医院随机进入早期干预组，111所医院随机进入晚期干预组，共纳入患者15 167例。在10个预设的缺血性卒中医疗服务质量关键绩效指标的执行率效果评价中，第1阶段，早期干预组患者出院时给予抗栓治疗的比例较晚期干预组高（95.6% vs. 92.7%，P=0.01）。第2阶段，早期干预组患者出院时给予抗栓治疗（94.9% vs. 92.4%，P=0.01）、出院时合并高血压的患者降压治疗的比例较晚期干预组高（68.3% vs. 63.7%，P=0.02）。第3阶段中，早期干预组患者较晚期干预组患者出院时给予抗栓治疗（94.2% vs. 90.8%，P=0.01）、出院时给予他汀类药物治疗的比例高（92.7% vs. 87.6%，P=0.01）。第4阶段中，早期干预组较晚期干预组入院48 h内患者不能行走进行深静脉血栓预防（54.7% vs. 41.6%，P=0.01）、出院时给予抗栓治疗（94.7% vs. 91.1%，P=0.01）、出院时给予他汀类药物治疗的比例高（93.6% vs. 88.5%，P=0.01）。第5阶段中，早期干预组患者较晚期干预组患者时间窗内rt-PA静脉溶栓率高（40.5% vs. 29.5%，P=0.04）。
结论 早期临床路径医疗质量干预有助于改善我国缺血性卒中患者的医疗服务质量关键绩效指标。

关键词: 缺血性卒中; 医疗质量; 临床路径