Are EMS bypass policies effective implementation strategies for intravenous alteplase for stroke?
Are EMS bypass policies effective implementation strategies for intravenous alteplase for stroke?
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DOI：
10.1186/s43058-020-00041-5
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发表时间：
2020-06-05
影响因子：
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通讯作者：
Govindarajan, Prasanthi
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文献类型：
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作者：
Harris, Alex H. S.;Barreto, Nicolas B.;Govindarajan, Prasanthi
背景：在美国，中风是导致残疾的主要原因，也是第五大死亡原因。静脉注射阿替普酶是一种高效的溶栓中风治疗方法，必须在医院环境中的时间敏感窗口内进行。为了增加中风患者静脉阿替普酶的使用，美国许多县制定了政策，要求紧急医疗服务 (EMS) 护理人员绕过当地急诊室，直接将患者送往配备特殊设备的中风中心。这项混合方法研究的目的是评估政策制定作为实施策略的有效性，政策结构和流程的差异如何影响有效性，并探讨县、医院和政策因素如何解释实施和临床结果的变化。本文详细描述了医疗质量与研究机构 (AHRQ) 资助的协议，包括在定性设计中使用实施研究综合框架 (CFIR)。方法/设计：我们将构建有史以来最大的国家医疗保险参保者中风数据库（相当于 150 万中风患者），代表 896 个政策县和 1792 个非政策县，然后整合来自八个不同数据源的患者、医院、县和州级协变量。我们将使用双重差异分析来估计政策制定对静脉阿替普酶使用（实施结果）以及关键患者结果的总体影响。我们还将定量研究环境（城乡状况）的变化和政策特征的变化是否会影响结果。最后，将采用基于 CFIR 的多案例研究设计来采访 24 个县的 72 个利益相关者，以识别和验证影响政策效果的因素。讨论：政策可以是有效的实施策略。然而，EMS 旁路政策对增加静脉阿替普酶使用的效果尚未经过严格评估。通过了解背景和政策结构如何影响阿替普酶的实施，以及负责政策制定的利益相关者所经历的障碍和促进因素，本研究的结果将为有关是否以及如何将 EMS 绕行政策推广到非政策县的决策提供信息，并在有指示的情况下创建“最佳实践”工具包。
Background: Stroke is a leading cause of disability and the fifth leading cause of death in the USA. Intravenous alteplase is a highly effective clot-dissolving stroke treatment that must be given in a hospital setting within a time-sensitive window. To increase the use of intravenous alteplase in stroke patients, many US counties enacted policies mandating emergency medical service (EMS) paramedics to bypass local emergency departments and instead directly transport patients to specially equipped stroke centers. The objective of this mixed-methods study is to evaluate the effectiveness of policy enactment as an implementation strategy, how differences in policy structures and processes impact effectiveness, and to explore how the county, hospital, and policy factors explain variation in implementation and clinical outcomes. This paper provides a detailed description of an Agency for Healthcare Quality and Research (AHRQ)-funded protocol, including the use of the Consolidated Framework for Implementation Research (CFIR) in the qualitative design. Methods/design: We will construct the largest-ever national stroke database of Medicare enrollees (similar to 1.5 million stroke patients) representing 896 policy counties paired with 1792 non-policy counties, then integrate patient-, hospital-, county-, and state-level covariates from eight different data sources. We will use a difference-in-differences analysis to estimate the overall effect of the policy enactment on intravenous alteplase use (implementation outcome) as well as key patient outcomes. We will also quantitatively examine if variation in the context (urban/rural status) and variation in policy features affect outcomes. Finally, a CFIR-informed multiple case study design will be used to interview informants in 72 stakeholders in 24 counties to identify and validate factors that enable policy effects. Discussion: Policies can be potent implementation strategies. However, the effects of EMS bypass policies to increase intravenous alteplase use have not been rigorously evaluated. By learning how context and policy structures impact alteplase implementation, as well as the barriers and facilitators experienced by stakeholders responsible for policy enactment, the results of this study will inform decisions regarding if and how EMS bypass policies should spread to non-policy counties, and if indicated, creation of a "best practices" toolkit.