Objectives: Epilepsy care in China has expanded considerably in the last decade but still remains largely unknown; we developed an easy-to-use tool to assess its quality. Methods: We adapted the Epilepsy Update Quality Measurement, produced by the American Academy of Neurology (AAN) for use in China: The Quality Indicator for Epilepsy Treatment-China National Action (QUIETCHINA). This tool incorporates a standardized case report form initially for logging quality indicators for people with epilepsy during in-patient stays. Nine quality indicators covered seizures, drugs, diagnostics, screening for co-morbid conditions, counseling for woman of child bearing age, and a composite indicator was further proposed by total number of interventions performed divided by the total number of people eligible in each indicator. The tool also has an electronic reporting and data feedback system. 96 epilepsy centers in 31 jurisdictions in mainland China have been piloted since 2017. Results: Data from 11,600 individuals with epilepsy in the first 3-year study period were analyzed. The median age was 31; 60% were male. The composite indicators were 74%. Seizure freedom rate was less than 25% in all epilepsy types and post-surgical seizure freedom rate was 21%. 90% had seizure type and frequency, antiepileptic drugs recorded, while only 70% with active epilepsy were on regular antiepileptic drugs treatment. Investigations for diagnosis and etiology were performed in around 90% but screening for co-morbid conditions and counseling for women of childbearing potential was 38% and 15% respectively. Severe side effect happened in 2% individuals during the treatment. Conclusion: The preliminary results of the national action provided some baseline information. Except for an overall improvement, a significant treatment gap still exists, and psychiatric co-morbidities or issues affecting women are not seen as a priority. QUIET-CHINA will be expanded to more and other levels of hospitals, to help narrow the treatment gap and equalize the comprehensive epilepsy care on the national level.

Objective From the perspective of two main tasks of constructing China’s medical quality management system and a new system of high-quality development of public hospitals, this paper studied the mechanism of national medical quality control center in the two systems, aiming to serve the efficient allocation of medical quality management resources. Methods The mechanism design theory was used to analyze the functional mechanism of national quality control center in the construction of those two systems, as well as the collaboration mechanism between national quality control center and other quality control organizations. Results The establishment of national quality control center is an institutional arrangement of medical quality management with Chinese characteristics, which meets the participatory constraints and incentive compatibility constraints from the perspective of mechanism design theory, and is an effective institutional arrangement. Conclusion In the construction of medical quality management system, national quality control center has played an important role as participating entities. In the construction of a new system of high-quality development of public hospitals, national quality control centers should develop in coordination with other centers, such as national medical centers and national clinical research centers, which will have a positive impact on the efficient allocation and balanced distribution of medical quality resources.

目的 了解我国三级公立医院神经重症住院患者医疗质量现状.方法 采用病案首页主要诊断和其他诊断的疾病编码,提取医院质量监测系统中2013年1月1日-2017年12月31日诊断为神经系统疾病的神经重症患者信息.采用SPSS 21.0统计软件对相关指标数据进行分析.结果 全国506家三级公立医院共计220027例神经重症患者纳入研究,其中,男性患者居多,占住院总人次的58.61％,年龄中位数(四分位数)为58(27,72)岁.患者住院死亡率和平均住院天数呈逐年下降趋势,出院人数逐年增加,机械通气时间逐年缩短,31天重返ICU率在小范围内波动.神经重症患者付费方式以城镇职工基本医疗保险为主,新型农村合作医疗保险次之.结论 我国神经重症医疗质量逐年上升,救治水平在逐步提高,未来仍需继续关注结构、过程、结局指标,以持续改进.

目的 描述全国三级公立医院卒中住院患者医疗质量现状.方法 采用病案首页主要诊断和其他诊断的疾病编码,提取医院质量监测系统中2013年1月1日至2018年12月31日脑梗死(I63)和脑出血(I61)两种类型卒中住院患者信息.并描述卒中患者人口学信息、住院费用及其付费方式、危险因素诊断及出院时情况.结果 全国506家三级公立医院共计8 426 489例卒中患者中,脑梗死、脑出血和蛛网膜下腔出血患者分别为7 558 404和868 085例,男性患者居多,中位年龄分别为69.0(60.0～77.0)和61.0(51.0～70.0)岁.卒中患者付费方式以社会基本医疗保险为主,全自费方式的比例呈逐渐下降趋势(从14.1％降至9.7％).卒中危险因素较高的疾病为高血压病(61.6％～67.7％)、糖尿病(11.1％～25.3％)、冠心病/心肌梗死(6.9％～24.1％)、血脂异常(5.3％～13.6％)、心律失常(4.9％～11-9％)、心衰(2.8％～10.0％)和心房颤动(2.3％～5.3％).卒中患者住院死亡率呈逐年下降趋势(从1.9％降至1.2％)、非医嘱离院444 419例(5.3％).结论 基于病案首页信息可以描述我国的卒中医疗质量信息,为我国卒中持续质量改进提供宝贵数据.

目的 基于医院质量监测系统中的住院患者病案首页信息,对全国三级公立医院癫痫住院患者医疗服务现状进行描述.方法 提取2015年--2017年医院质量监测系统采集全国三级公立医院主要出院诊断为癫痫(国际疾病分类第10次修订本编码为G40)住院患者的信息,描述患者的人口学信息、住院费用及付费信息、出院情况;并分年度统计计算患者年龄、性别构成比例、住院费用、付费方式构成比例、平均住院时间及住院期间死亡率,进行相关横断面研究.结果 纳入来自全国31个省市585家三级公立医院的329 241例癫痫患者,患者的平均年龄为31.74岁,男性患者占比60.00％.支付方式以国家基本医疗保险(包括城镇职工基本医疗保险、城镇居民基本医疗保险和新型农村合作医疗保险)为主,占比50.15％,其中2015年、2016年、2017年分别为49.03％、49.79％、51.80％;全自费患者占比30.40％.患者平均住院时间为6.65 d,平均住院费用为7 985.53元,其中平均自付费用为3 979.62元.离院患者中,医嘱离院占比88.02％,医嘱转院占比0.40％,非医嘱离院占比6.59％;住院期间死亡患者占比0.16％,2015年、2016年、2017年分别为0.19％、0.16％、0.12％.结论 基于病案首页信息的研究显示2015年-2017年间全国三级公立医院癫痫住院患者住院期间死亡率逐年下降,国家基本医疗保险覆盖率逐年升高,且仍有进一步提升的空间.

PURPOSE:We attempted to determine the nationwide in-hospital mortality rate in people with status epilepticus (SE) in China. METHODS:Using the database of the Chinese Hospital Quality Monitoring System (HQMS), we identified people hospitalised from 2013 to 2017 with an ICD-10 code G41 for SE as the primary diagnosis. HQMS was developed by the National Health Commission of the People's Republic of China. Demographics, outcomes at discharge, and financial information were extracted automatically from the medical records. RESULTS:We identified 29,031 cases with SE as the primary diagnosis from 585 tertiary centres during the five-year period. Among those included, there was a preponderance of men (61 %), and the mean age was 40.4 ± 25.2 years (range: 0-98). The in-hospital mortality rate was 1.46 % over the whole time period, while the overall mortality ranged from 1.80 % in 2013 to 1.20 % in 2017. The mean cost of treatment was 14517.81 RMB ($ 2147.92) per individual, and the mean duration of hospital stay was 9.25 days. CONCLUSION:We provide an overview of mortality related to SE in China as the HQMS database covers a large number of cases of SE in China, making it one of the most efficient tools for mortality investigation. The use of electronic medical records in China creates several challenges and here we discuss lessons learned. The methodology will be improved and will be used in future studies.

Objectives: To determine the association of preceding therapeutic anticoagulation with stroke severity and in-hospital complications. Method: All acute ischemic stroke patients with known history of AF, who were included into CSCA, were divided into five groups: not receiving any antithrombotic therapy, only antiplatelet therapy, receiving subtherapeutic warfarin (international normalized ratio [INR] <2), receiving therapeutic warfarin (INR≥2) and receiving non-vitamin K antagonist oral anticoagulants (NOACs). Stroke severity was measured by the National Institutes of Health Stroke Scale (NIHSS, a score ≥16 indicating moderate or severe stroke), and in-hospital complications included pneumonia, deep vein thrombosis, pulmonary embolism, seizures, hydrocephalus, urinary tract infections, hemorrhoids, depression, myocardial infarction and gastrointestinal bleeding. Results: Of 25 475 patients (mean [SD] age, 73.7 [10.6] years; 51.1% male), none were receiving NOACs, 438 (1.7%) were receiving therapeutic warfarin, 2 520 (9.9%) were receiving subtherapeutic warfarin, 5 847 (23.0%) were receiving antiplatelet therapy only, and 16 670 (65.4%) were not receiving any antithrombotic treatment before onset of stroke. Among 22 113 high-risk patients (prestroke CHA2DS2-VASc score ≥2), 19 546 (88.4%) were neither receiving warfarin nor NOACs before stroke. After adjusting for potential confounders, compared with no antithrombotic treatment, preceding use of therapeutic warfarin, untheraputic warfarin, or antiplatelet therapy only was associated with lower odds of moderate or severe stroke (adjusted odds ratio [95% CI], 0.71 [0.53-0.93], 0.88 [0.78-0.99], and 0.87 [0.80-0.96], respectively) and in-hospital complications (adjusted odds ratio [95% CI], 0.79 [0.62-1.00], 0.88 [0.79-0.98], and 0.99 [0.91-1.07], respectively). Conclusions: Among Chinese patients with acute ischemic stroke and known history of atrial fibrillation, therapeutic anticoagulation was associated not only with lower odds of moderate or severe stroke but also with lower odds of in-hospital complications.

Background and Purpose— Emergency medical services (EMSs) are critical for early treatment of patients with ischemic stroke, yet data on EMS utilization and its association with timely treatment in China are still limited. Methods— We examined data from the Chinese Stroke Center Alliance for patients with ischemic stroke from June 2015 to June 2018. Absolute standardized difference was used for covariates’ balance assessments. We used multivariable logistic models with the generalized estimating equations to account for intrahospital clustering in identifying demographic and clinical factors associated with EMS use as well as in evaluating the association of EMS use with timely treatment. Results— Of the 560 447 patients with ischemic stroke analyzed, only 69 841 (12.5%) were transported by EMS. Multivariable-adjusted results indicated that those with younger age, lower levels of education, less insurance coverage, lower income, lower stroke severity, hypertension, diabetes mellitus, and peripheral vascular disease were less likely to use EMS. However, a history of cardiovascular diseases was associated with increased EMS usage. Compared with self-transport, EMS transport was associated with significantly shorter onset-to-door time, door-to-needle time (if prenotification was sent), earlier arrival (adjusted odds ratio [95% CIs] were 2.07 [1.95–2.20] for onset-to-door time ⩽2 hours, 2.32 [2.18–2.47] for onset-to-door time ⩽3.5 hours), and more rapid treatment (2.96 [2.88–3.05] for IV-tPA [intravenous recombinant tissue-type plasminogen activator] in eligible patients, 1.70 [1.62–1.77] for treatment with IV-tPA by 3 hours if onset-to-door time ⩽2 hours, and 1.76 [1.70–1.83] for treatment with IV-tPA by 4.5 hours if onset-to-door time ⩽3.5 hours). Conclusions— Although EMS transportation is associated with substantial reductions in prehospital delay and improved likelihood of early arrival and timely treatment, rate of utilization is currently low among Chinese patients with ischemic stroke. Developing an efficient EMS system and promoting culture-adapted education efforts are necessary for improving EMS activation.

Introduction: A key element in modern stroke care is dedicated stroke units. However, it is unclear whether processes of acute ischemic stroke (AIS) care and outcomes are different between hospitals with and without stroke units in China. Methods: We analyzed the China National Stroke Registry II data from June 2012 to January 2013. Processes of care were examined by 13 individual national guideline-recommended indicators and composite score. Patients’ outcomes included all caused death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12month after discharge. Propensity score matching was used to balance the baseline characteristics. We used cox model with shared frailty model and logistic regression with generalized estimating equation to analysis the relationship between stroke units and clinical outcomes. Results: Among 19 604 AIS patients, there were 11050 (56.4%) patients in 121 hospitals with stroke units, and 8554 (43.6%) patients in 96 hospitals without stroke units. After matching, 8125 pairs of patients were analyzed. Totally, the composite score of processes was higher in hospitals with stroke units than that without(77% versus 74%, p<0.05). Hospitals with stroke units were more likely to conduct anticoagulation for atrial fibrillation, early antithrombotic treatment, smoking cessation, and stroke education (Figure 1). However, there are no differences between patients in hospitals with and without stroke units in clinical outcomes(Table 1). Conclusions: Our study showed that processes of care of AIS were better in patients in hospitals with stroke units. However, patients in hospitals with stroke units didn’t performance differences in clinical outcomes after discharge.

Introduction: Although urban and rural differences in care or outcomes are pervasive in many areas of medicine, little is known whether processes of acute ischemic stroke (AIS) care or outcomes are different between urban and rural patients in China. Methods: We analyzed China National Stroke Registry II data from June 2012 to January 2013. Urban and rural patients were classified by insurance types of urban basic medical insurance schemes and new rural cooperative medical schemes. Processes of care were examined by 13 individual national guideline-recommended indicators and composite score. Patients’ outcomes included all-cause death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12 month after discharge. Propensity score matching was used to balance the baseline characteristics. Cox model with shared frailty model and logistic regression with generalized estimating equation were employed to analyze the outcomes. Results: Among 19 604 AIS patients, there were 7747 (39.5%) rural and 10 021 (51.1%) urban patients. After matching, 5231 pairs of rural and urban subjects were analyzed. Totally, urban and rural patients had similar processes of care composite score (0.76±0.18 versus 0.77±0.18) (Figure 1). However, comparing to urban patients, rural patients had higher hazard of stroke recurrence and death at 3, 6 and 12 months, and higher odds of disability at 3 months (Table 1). Conclusions: Processes of care were similar between urban and rural patients with AIS. However, rural AIS patients had worse unfavorable clinical outcomes after discharge. Difference of stroke care after discharge should be further explored among rural and urban AIS patients.

Background: Guideline-concordant processes of care improve longitudinal outcomes in patients with acute stroke. Little is known whether there are different processes of acute ischemic stroke (AIS) care or outcomes between secondary and tertiary hospitals. Methods: We analyzed 19 604 AIS patients across 219 hospitals in China National Stroke Registry II from June 2012 to January 2013. The primary outcome was guideline-concordant care, defined as compliance with 13 guideline-recommended performance metrics and composite score. Propensity score matching was used to balance the baseline characteristics. We used cox model and logistic regression with generalized estimating equation to compare the relationship between secondary and tertiary hospitals on quality measures and all caused death, stroke recurrence, and disability (modified Rankin Score ≥3) at 3, 6 and 12month after discharge. Results: Among 19 604 AIS patients, 6 038 (30.8%) and 13 566 (69.2%) were admitted to 66 (30.1%) secondary and 153 (69.9%) tertiary hospitals separately. After matching, 5959 pairs of patients in secondary and tertiary were analyzed. The composite score was higher at tertiary hospitals than secondary hospitals (77% versus 74%, P<0.001). Tertiary hospitals were more likely to perform early antithrombotic, carotid imaging, anticoagulation for atrial fibrillation, antihypertensive therapy, hypoglycemic medications, and rehabilitation (Figure 1). Furthermore, comparing to AIS patients among tertiary hospitals, those admitted to secondary hospitals had higher hazard of disability at 3 months (19.3% versus 21.5%) and 1-year stroke recurrence (4.4% versus 5.4%) after matching. Conclusions: In China, tertiary hospitals have better processes of AIS care and more favorable clinical outcomes than secondary hospitals. The quality of process of AIS care should be further increased to improve the patients’ clinical outcomes especially among secondary hospitals.