这项试验的目的是评估质量改进协作在英国国家卫生服务(NHS)中实施大规模变更的有效性,特别是为了改善接受初治的患者的预后,选择性全髋关节或膝关节置换。
我们进行了双臂,整群随机对照试验比较两种术前途径的展开:甲氧西林敏感性金黄色葡萄球菌(MSSA)脱色(感染组)和贫血筛查和治疗(贫血组).NHS信托是在地理区域内提供医疗保健的公共部门组织。NHS信托(n=41)在英格兰提供主要,选择性全髋关节和膝关节置换,但没有术前贫血筛查或MSSA去哪儿化途径,被随机分配到两个平行的合作者之一。合作于2018年5月至2019年11月进行。27家信托基金完成了试验(11家贫血,16感染)。结果数据是为2018年11月至2019年11月期间执行的程序收集的。共同的主要结果是围手术期输血(手术后7天内)和由MSSA(手术后90天内)引起的深部手术部位感染(SSI),用于贫血和感染试验组。分别。次要结果是深层和浅层SSIs(任何生物),住院时间,重症监护入院和计划外再入院。过程措施包括接受每个术前倡议的合格患者比例。
结果中包括来自27个NHS信托的19,254个程序(来自贫血部门的11个信托的6324个程序,来自感染部门的16个信托基金的12,930个)。输血(贫血组183(2.9%);感染组302(2.3%)输血;调整比值比1.20,95%CI0.52-2.75,p=0.67)或MSSA深度SSI(贫血组8(0.13%);感染组18(0.14%);调整比值比1.01,95%CI0.42-2.46,p=0.98)未观察到改善。任何次要结果均无显著改善。尽管程序措施表明,在感染和贫血组中,有73.7%和61.1%的合格程序实施了术前途径,分别。
在本试验中,质量改善协作并未改善患者预后;然而,有一些证据可能支持在NHS中成功实施新的术前途径.
预计于2018年2月15日注册,ISRCTN11085475。
The aim of this
trial was to assess the effectiveness of quality improvement collaboratives to implement large-scale change in the National Health Service (NHS) in the UK, specifically for improving outcomes in patients undergoing primary, elective total hip or knee replacement.
We undertook a two-arm, cluster randomised controlled trial comparing the roll-out of two preoperative pathways: methicillin-sensitive Staphylococcus aureus (
MSSA) decolonisation (infection arm) and anaemia screening and treatment (anaemia arm). NHS Trusts are public sector organisations that provide healthcare within a geographical area. NHS Trusts (n = 41) in England providing primary, elective total hip and knee replacements, but that did not have a preoperative anaemia screening or
MSSA decolonisation pathway in place, were randomised to one of the two parallel collaboratives. Collaboratives took place from May 2018 to November 2019. Twenty-seven Trusts completed the
trial (11 anaemia, 16 infection). Outcome data were collected for procedures performed between November 2018 and November 2019. Co-primary outcomes were perioperative blood transfusion (within 7 days of surgery) and deep surgical site infection (SSI) caused by MSSA (within 90 days post-surgery) for the anaemia and infection
trial arms, respectively. Secondary outcomes were deep and superficial SSIs (any organism), length of hospital stay, critical care admissions and unplanned readmissions. Process measures included the proportion of eligible patients receiving each preoperative initiative.
There were 19,254 procedures from 27 NHS Trusts included in the results (6324 from 11 Trusts in the anaemia arm, 12,930 from 16 Trusts in the infection arm). There were no improvements observed for blood transfusion (anaemia arm 183 (2.9%); infection arm 302 (2.3%) transfusions; adjusted odds ratio 1.20, 95% CI 0.52-2.75, p = 0.67) or MSSA deep SSI (anaemia arm 8 (0.13%); infection arm 18 (0.14%); adjusted odds ratio 1.01, 95% CI 0.42-2.46, p = 0.98). There were no significant improvements in any secondary outcome. This is despite process measures showing the preoperative pathways were implemented for 73.7% and 61.1% of eligible procedures in the infection and anaemia arms, respectively.
Quality improvement collaboratives did not result in improved patient outcomes in this trial; however, there was some evidence they may support successful implementation of new preoperative pathways in the NHS.
Prospectively registered on 15 February 2018, ISRCTN11085475.