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International Journal of Stroke 18(5)
lacked long-term follow-up. LOS and in-hospital mortality
are poor surrogate markers for patient-level outcomes.
Third, our study lacked a comparison group. It is hard to
determine whether the small but significant improvement
of KPIs was completely attributable to 4S intervention, or
simply stroke care advances over the same time period.
Conclusion
Among 61 hospitals participating in 4S, there were significant
improvement in adherence to stroke care guidelines
and clinical outcomes of patients. Our study demonstrated
that quality improvement of stroke care can be achieved by
a regional management intervention. 4S may be a good
model for other regions within China and internationally.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support
for the research, authorship, and/or publication of this article: This
study was supported by Young Elite Scientist Sponsorship
Program by Chinese Association of Science and Technology
(YESS20170270) and Special Project of Clinical Research in
Health Industry of Shanghai Municipal Health Commission
(201940377). Hong Kong CRF C7162-20G, and University of
Hong Kong BRC Grant.
Research ethics and patient consent
The study was approved by Huashan Institutional Review Board
with waiver of consent as no identifying information was collected.
ORCID iDs
Jiawen Xu
https://orcid.org/0000-0002-8787-5592
Bruce CV Campbell
https://orcid.org/0000-0003-3632-9433
Data availability statement
Data are available based on reasonable request via Prof. Qiang
Dong, dong_qiang@fudan.edu.cn.
Supplemental material
Supplemental material for this article is available online.
References
1. Wang YJ, Li ZX, Gu HQ, et al. China stroke statistics 2019:
a report from the National Center for Healthcare Quality
Management in Neurological Diseases, China National
Clinical Research Center for Neurological Diseases, the
Chinese Stroke Association, National Center for Chronic and
Non-communicable Disease Control and Prevention, Chinese
Center for Disease Control and Prevention and Institute for
Global Neuroscience and Stroke Collaborations. Stroke Vasc
Neurol 2020; 5: 211-239.
International Journal of Stroke, 18(5)
2. Zhou M, Wang H, Zeng X, et al. Mortality, morbidity, and risk
factors in China and its provinces, 1990-2017: a systematic
analysis for the Global Burden of Disease Study 2017. Lancet
2019; 394: 1145-1158.
3. Meretoja A, Weir L, Ugalde M, et al. Helsinki model cut
stroke thrombolysis delays to 25 minutes in Melbourne in
only 4 months. Neurology 2013; 81: 1071-1076.
4. Ormseth CH, Sheth KN, Saver JL, Fonarow GC and
Schwamm LH. The American Heart Association's Get With
the Guidelines (GWTG)-Stroke development and impact on
stroke care. Stroke Vasc Neurol 2017; 2: 94-105.
5. Schwamm LH, Fonarow GC, Reeves MJ, et al. Get With the
Guidelines-Stroke is associated with sustained improvement
in care for patients hospitalized with acute stroke or transient
ischemic attack. Circulation 2009; 119: 107-115.
6. Wang Y, Li Z, Zhao X, et al. Effect of a multifaceted quality
improvement intervention on hospital personnel adherence to
performance measures in patients with acute ischemic stroke in
China: a randomized clinical trial. JAMA 2018; 320: 245-254.
7. Wang Y, Li Z, Xian Y, et al. Rationale and design of a clusterrandomized
multifaceted intervention trial to improve stroke
care quality in China: the GOLDEN BRIDGE-Acute Ischemic
Stroke. Am Heart J 2015; 169: 767-774.
8. Dong Y, Fang K, Wang X, et al. The network of Shanghai
Stroke Service System (4S): a public health-care web-based
database using automatic extraction of electronic medical
records. Int J Stroke 2018; 13: 539-544.
9. Nogueira RG, Abdalkader M, Qureshi MM, et al. Global
impact of COVID-19 on stroke care. Int J Stroke 2021; 16:
573-584.
10. Nogueira RG, Qureshi MM, Abdalkader M, et al. Global
impact of COVID-19 on stroke care and IV thrombolysis.
Neurology 2021; 96: e2824-e2838.
11. Chen Y, Gong X, Zhong W, et al. Evaluation of a multilevel program
to improve clinician adherence to management guidelines
for acute ischemic stroke. JAMA Netw Open 2022; 5: e2210596.
12. Howard G, Schwamm LH, Donnelly JP, et al. Participation in
Get With The Guidelines-Stroke and its association with quality
of care for stroke. JAMA Neurol 2018; 75: 1331-1337.
13. Overwyk KJ, Yin X, Tong X, et al. Defect-free care trends
in the Paul Coverdell National Acute Stroke Program, 2008-
2018. Am Heart J 2021; 232: 177-184.
14. Labarthe DR, Biggers A, LaPier T, George MG and Paul
Coverdell National Acute Stroke Registry. The Paul Coverdell
National Acute Stroke Registry (PCNASR): a public health
initiative. Am J Prev Med 2006; 31: S192-S195.
15. Wilson AM, Benish SM, Mccarthy L, et al. Quality of neurologic
care in the United States: initial report from the Axon
Registry. Neurology 2021; 97: e651-e659.
16. The Sentinel Stroke National Audit Program. https://www.
strokeaudit.org/ (accessed 29 June 2022).
17. Australian Stroke Coalition. https://australianstrokecoalition.
org.au/ (accessed 29 June 2022).
18. Marquina C, Ademi Z, Zomer E, Ofori-Asenso R, Tate R and
Liew D. Cost burden and cost-effective analysis of the nationwide
implementation of the quality in acute stroke care protocol
in Australia. J Stroke Cerebrovasc Dis 2021; 30: 105931.
19. McCarney R, Warner J, Iliffe S, et al. The Hawthorne Effect:
a randomised, controlled trial. BMC Med Res Methodol 2007;
7: 30.
https://www.orcid.org/0000-0002-8787-5592 https://www.orcid.org/0000-0003-3632-9433 https://www.strokeaudit.org/ https://www.strokeaudit.org/ https://australianstrokecoalition.org.au/ https://australianstrokecoalition.org.au/
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