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International Journal of Stroke 18(3)
98.82% for antiplatelet therapy. The overall HPCP across
three dimensions was 62.99%, and the median HPCP of
hospitals was 76.78% (interquartile range (IQR),
71.80-81.95%).
Characteristics of hospitals and patients
Two groups were selected based on GBM and the optimal
trajectory was shown in Figure 1(a), and the posterior probabilities
of the hospital assigned to each group were shown
in Figure 2 and Supplementary Table III. Hospitals in
Group 1 were identified as likely to have lower-HPCP with
46 hospitals and 51,509 patients, and Group 2 had 63 hospitals
and 71,750 patients with higher-HPCP. The characteristics
of hospitals in both groups were presented in
Supplementary Table IV. Among the 109 hospitals, tertiary
first-class hospitals accounted for nearing 90%. The number
of nurses in Group 2 hospitals was lower than that in
Group 1, while the nurse bed ratio was superior, but the
difference was not statistically significant. The percentage
of urban hospitals was lower in Group 2 than in Group 1
(p = 0.042).
The characteristics of the patients were summarized in
Supplementary Table V. The proportion of patients with
long lengths of stay (⩾ 10 days) was higher in Group 2 than
Group 1, and the patients in Group 2 had a higher independence
rate than Group 1. Table 2 displays the impact of hospital
subgroups on outcomes. After adjusting for patient
age, medical insurance, comorbidities, patterns of admission,
and National Institutes of Health Stroke Scale
(NIHSS)-scores, patients in the high-HPCP group presented
higher rate of independence and longer length of
stay compared to the low-HPCP group.
Disparity indicators based on multi-level
model
We fitted multi-level model for QIs and took into account
the impact of subgroups-time interactions on QIs adherence.
When the interaction was statistically significant, we
did not focus on the individual effects of the group and time.
We found that the QIs of the treatment dimension had
similar compliance in both groups, while the adherence in
the QIs related to emergency examination and function
evaluation which tended to have more significant variation
between groups. Figure 1(b-i), Table 3, and Supplementary
Table VI showed that eight indicators were statistically significant.
Specifically, access to emergency services within
15 min of arrival at the hospital, neuroimaging examination
of the head, and NIHSS assessment of first neurologic deficit
in emergency admission with a larger variation between
the two groups, electrocardiograph (ECG) diagnosis in the
emergency department performed in the Group 2 was higher
than the Group 1, but had a downward trend in recent years,
followed by blood lipid evaluation and dysphagia
International Journal of Stroke, 18(3)
evaluation, and compliance of treatment with statins and
aspirin or clopidogrel treatment within 48 h of admission
fluctuated slightly over time but maintained a relatively
high level of use. The difference in adherence for the remaining
indicators was not statistically significant, but the doorto-needle
(DTN) usage rate was the weakest of the 12
indicators.
Sensitive analysis
The results with adjustment for length of stay were similar
to the above analysis. The significant effect of length of
stay on independence was also observed, and the results are
presented in the Supplementary Table VII.
Discussion
In the current study, despite the fact that, in principle, the
clinical pathway for stroke is standardized, it has actually
fluctuated over time among hospitals. Quality-of-care evaluation
comparisons between hospital subgroups based on
the GBM can identify different trajectories of performance
over time and determine the QIs that guide this gap, to provide
a reference for long-term medical service distribution.
Since 2009, China has made substantial investments in
healthcare and has issued several policy documents highlighting
the importance of care quality. Examples include
the Measures for the Management of Medical Quality
Control Centers (Trial) issued in June 2009 and the
Measures for the Management of Medical Quality formulated
in 2016.13 Besides, an increasing number of hospitals
in China have implemented " clinical pathway management, "
with the goal of optimal sequencing and timing of
interventions by physicians, nurses, and other staff for a
particular diagnosis or procedure.14 However, the interpretation
and implementation of policy documents among hospitals
exists in variability. For example, some hospitals
have established specialized quality management departments
responsible for improving the quality of patient care;
such hospital-level covariates are unavailable to us.15 These
may contribute to the time trends of adherence to QIs
between hospitals. Care processes are complex and their
patterns of variation may be attributable to many causal
factors. In fact, we were unable to identify these causal factors,
but some hypotheses may develop for future research
on more effective organization of medical care.
Any quality improvement project or technique must be
conducted in a relatively reasonable and cost-effective
manner. It is usually impractical and time-consuming to
conduct randomized trials to identify priorities for care performance
improvement. QIs of process-based care represent
an important part in the evaluation of quality of care,
and these indicators are relatively accessible for modification
that has the potential to supply providers with definitive
targets for improvement. However, identifying quality
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