Improving access and efficiency of acute ischemic stroke treatment across four Canadian provinces: a stepped-wedge trial

Background: The translation of standard-of-care in acute ischemic stroke reperfusion interventions into practice is well established, but multifactorial obstacles exist in complete adoption, which has led to inequities in access and delivery of services. The objective of this study was to improve access and efficiency of ischemic stroke treatment across four Atlantic Canadian Provinces. Methods: A stepped-wedge cluster trial was conducted over 30 months with 3 clusters covering 34 sites. The trial was conducted across all 4 Atlantic Canadian provinces: Nova Scotia (NS), New Brunswick (NB), Prince Edward Island (PE), and Newfoundland and Labrador (NL). The design was quasi-randomized, with each cluster associated with one or more provinces: cluster 1—NS; cluster 2—NB and PE; and cluster 3—NL. The patient population was all ischemic stroke patients across all 4 provinces. The intervention was a 6-month modified Quality Improvement Collaborative (mQIC), which was modified from the Breakthrough Series Collaborative to be half of the 1-year period and conducted virtually. The intervention consisted of assembling an interdisciplinary improvement team, 2 full-day workshops, webinars, and virtual site visits. Suggested changes included 6 process improvement strategies. Results: Over the trial period, 8,594 ischemic stroke patients were included, out of which 1,599 patients received acute reperfusion treatment. The proportion of patients that received treatment did not increase significantly with the intervention [0.4% increase for patients that received thrombolysis and/or EVT (p = 0.68)]. Median door-to-needle time was reduced by 9.8 min with the intervention (p = 0.006). Cluster 3 saw the greatest improvements in both access and efficiency. Conclusion: A mQIC intervention resulted in improvement of process measures like door-to-needle time. Quality improvement initiatives may need to be longer to allow full implementation and tailored for each health system to ensure that each system sees improvement. In-person activities might be critical to ensure fidelity of the intervention. Clinical trial registration: ISRCTN11109800, https://www.isrctn.com/ISRCTN11109800.