(III) How evidence-based stroke treatments are implemented

The overall implementation strategy is based on a ‘detecting-understanding-reducing disparities’ conceptual framework.¹⁷ This framework focuses on evaluating and improving healthcare systems, as opposed to frameworks focused on community or societal determinants as part of a public health perspective.^17,18 Consistent with the framework, we considered the primary barrier to improving the uptake of evidence-based treatments to be the lack of knowledge of the current level of quality of stroke care. If gaps are not systematically monitored, including their severity, a lack of understanding of the underlying mechanisms will make it impossible to design effective (e.g. country and hospital specific) quality improvement interventions. Monitoring the quality of stroke care also allows for the establishment of an ‘audit and feedback’ mechanism as the initial motivation strategy for healthcare professionals, both to improve stroke care and provide data.¹⁵ ‘Audit and feedback’ requires reporting of results back to hospitals, therefore provision of reports must be integrated into the project at an early stage. The logical model of implementation is described in Figure 1. Recognition of champion stroke centres through awards based on performance is used as another motivation tool through the ANGELS Initiative.¹⁶

Logical model. The logical model describes how improvement in stroke care will be achieved. As mentioned above, ‘audit and feedback’ is the primary mechanism of intervention. Once gaps in stroke care are identified, additional interventions are planned.

Obtaining knowledge about the quality of stroke care has three components: (A) Stroke quality registry, (B) stroke management infrastructure which organises and performs the acquisition of quality metrics to implement programs for stroke care improvement, and (C) education and training.

Brief information on these three components is provided below, and more information is in the Supplement.

A stroke quality registry (A) requires: (A.1) selection from recognised quality metrics based on previously published data,^8,13 development of definitions and of the data collection form and (A.2) a software solution including development of a web-based platform.

Creation of effective stroke management infrastructure (B) is a complex task in countries where there are no organised professional societies or where societies do not have effective power to implement systematic changes in stroke care. There are four components necessary for building an effective project management structure: (B.1) human infrastructure, (B.2) leadership, (B.3) communication and (B.4) planning, including progress measurement. Project management infrastructure effectiveness is measured by: the number of hospitals recruited for a quality improvement program, the number of cases enrolled into the quality registry database, and in the future by the improvement in stroke care quality as evidenced by results at different time points.

Several types of education and training (C) were identified as pivotal (and complementary to existing education, e.g. ESO summer or winter schools). Research skills (C.1), which are not part of medical education in Eastern Europe, are important for e.g. data analysis or interpreting results from registries.

Additional educational activities were added, addressing two specific needs in improving uptake of evidence-based treatments: (C.2) improving stroke team members’ skills in intravenous thrombolysis treatment using simulations and (C.3) nurse skills. All activities from sections (A), (B), and (C) here, as well as phases and timelines of ESO EAST are detailed in the Supplement.