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A cluster-randomised quality improvement study to improve two inpatient stroke quality indicators
  1. Linda Williams1,2,3,
  2. Virginia Daggett1,4,
  3. James E Slaven5,
  4. Zhangsheng Yu5,
  5. Danielle Sager1,
  6. Jennifer Myers1,
  7. Laurie Plue1,
  8. Heather Woodward-Hagg1,4,
  9. Teresa M Damush1,3,6
  1. 1Roudebush VAMC, Indianapolis, Indiana, USA
  2. 2Department of Neurology, Indiana University School of Medicine, Indianapolis, Indiana, USA
  3. 3Regenstrief Institute, Inc., Indianapolis, Indiana, USA
  4. 4VA Center for Applied Systems Engineering, Indianapolis, Indiana, USA
  5. 5Department of Medicine/Biostatistics, Indiana University School of Medicine, Indianapolis, Indiana, USA
  6. 6Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
  1. Correspondence to Dr Linda Williams, Roudebush VAMC, Indianapolis, Indiana, USA; Linda.Williams6{at}


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.

Conclusion 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.

  • Healthcare quality improvement
  • Cluster trials
  • Audit and feedback
  • Six Sigma
  • Team training

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