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Sustained increase in annual transcranial Doppler screening rates in children with sickle cell disease: A quality
Jeffrey G Edwards1, Adam P Yan2,3, Ramy Yim1
1Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA.
Insights
Quality improvement initiatives increased transcranial Doppler (TCD) screening adherence for sickle cell disease (SCD) patients. This study demonstrated a sustained adherence rate of 92%, significantly improving stroke risk assessment for children with SCD.
Area of Science:
- Pediatric Neurology
- Hematology
- Quality Improvement Science
Background:
- Annual transcranial Doppler (TCD) screening is crucial for stroke risk assessment in children with sickle cell disease (SCD), aged 2-16.
- Despite its importance in reducing morbidity, TCD screening adherence rates remain suboptimal nationwide.
Purpose of the Study:
- To implement and evaluate a quality improvement (QI) initiative to sustainably increase TCD screening adherence.
- To achieve and maintain TCD screening adherence above 95% within 15 months for eligible SCD patients.
Main Methods:
- Utilized three iterative plan-do-study-act (PDSA) cycles over an 8-year period.
- Employed interrupted time series (ITS) analysis to assess the impact of QI interventions on TCD adherence rates.
Main Results:
- Mean TCD adherence increased from a baseline of 67% to 92% by the third PDSA cycle.
- ITS analysis revealed a significant increase in adherence, with QI interventions contributing an estimated 17.9% rise.
Conclusions:
- This QI project is the first to demonstrate sustained improvement in TCD screening adherence over an extended period (8 years).
- The findings support the effectiveness of multi-cycle PDSA interventions in enhancing adherence to critical stroke prevention protocols for SCD patients.
Introduction:
Individuals with sickle cell disease (SCD) at increased risk for stroke should undergo annual stroke risk assessment using transcranial Doppler (TCD) screening between the ages of 2 and 16. Though this screening can significantly reduce morbidity associated with SCD, screening rates at Boston Children's Hospital (and nationwide) remain below the recommended 100% screening adherence rates.
Methods:
Three plan-do-study-act (PDSA) cycles were designed and implemented. The Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) aim of our quality improvement (QI) initiative was to sustainably increase the proportion of eligible patients receiving a TCD within 15 months of their last TCD to greater than 95%. An interrupted time series (ITS) analysis was performed, comparing TCD adherence rates from PDSA Cycle 1 to those from PDSA Cycles 2 and 3.
Results:
Mean TCD adherence increased across all three PDSA cycles, from a baseline of 67% in the first cycle (January 2015 to September 2020) to 92% in the third cycle (May 2021 to March 2023). In the ITS analysis of TCD adherence rates, there was a significant difference in the final TCD adherence rate achieved compared to the rate predicted, with a total estimated increase in adherence of 17.9% being attributable to the interventions from PDSA Cycles 2 and 3.
Discussion:
Although other QI initiatives had demonstrated ability to increase adherence to TCD screening for patients with SCD, this is the first QI project to collect data over such a prolonged period of time to demonstrate a sustained increase in screening rates throughout the intervention (an 8-year period).
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