STAR- - Stroke Treatment Alliance of Rochester

Transcription

1 STAR- - Stroke Treatment Alliance of Rochester Curtis Benesch, M.D., M.P.H. Medical Director, URMC Comprehensive Stroke Center March 30, 2017

2 Background of the STAR Consortium What we learned from STAR Future directions: STAR-NY

3 Stroke in Greater Rochester Area Nearly 3000 admissions to Rochester hospitals each year Four hospitals: Strong Memorial, Rochester General Hospital, Highland Hospital, Unity Hospital All 4 hospitals are designated Primary Stroke Centers by the New York State Department of Health As of 2014, Strong Memorial Hospital became a designated Comprehensive Stroke Center (Joint Commission)

4 Stroke Costs - Rochester $149 million for direct costs $79 million for indirect costs from lost productivity Annual es7mates (2013) from NY- SPARCS (NY Statewide Planning and Research Coopera7ve System)

5 City- wide Stroke Consor7um Began meeting in 2007 to develop a city-wide program Vascular neurologists/neurosurgeons/stroke coordinators from all 4 hospitals Modeled after successful program in Neurosurgery To improve the care of pa7ents with stroke in the Rochester community

6 Grant Funding : Greater Rochester Health Foundation Specific Goals: Increase rate of acute stroke treatment from 10% to 15% of patients Increase adherence rates to secondary prevention measures by 15% (absolute) To improve the delivery of 7mely, comprehensive, and standardized care in pa7ents with stroke

7 STAR Processes Abstraction of data from all patients discharged from 4 hospitals with cerebrovascular diagnosis Identified by GWTG entry Additional health information combined with GWTG Data sharing, comparison of best practices, and open discussion occurring every 3 months during grant period Each site had opportunity to review data prior to Quarterly Meetings

8 STAR Initial Steps Gather baseline data (6 months) Review each site s acute stroke treatment process Disseminate site protocols and order sets across all 4 sites Review longitudinal follow-up procedures at each site Begin Quality Improvement analyses (GRHF-funded QI consultant)

9 STAR Data Collection Abstraction of all patients discharged from all 4 hospitals with cerebrovascular diagnosis (AIS, TIA, ICH, SAH) Identified by GWTG entry, pooled using SuperUser agreement Additional clinical information abstracted (two study abstractors, on site and EMR) Each patient assigned unique STAR ID Out-patient follow-up care appointments reviewed

10 Total Enrollment (4 years): N = 8,743 patients Total Episodes of Care - Citywide Percent Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Stroke Type AIS TIA SAH ICH

11 85 Demographics: Age - By Site AIS ONLY Median Age Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Site Hospital 1 Hospital 2 Hospital 3 Hospital 4

12 Admission NIHSS Distribution: AIS - Citywide 12 Percent Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 NIHSS: >20 Excludes: TIA, SAH, ICH, and Other Patients / In- Patient Strokes / IV tpa Received at Outside Hospital

13 Admission NIHSS Distribution: AIS - By Site 13 Percent Hospital HH-B1 Hospital HH-Q12 1 Hospital RGH-B 2 RGH-Q12 Hospital 2 Hospital SMH-B3 SMH-Q12 Hospital 3 Hospital UH-B 4 Hospital UH-Q12 4 B Q12 B Q12 B Q12 B Q12 NIHSS: 0 Excludes: TIA, SAH, ICH, and Other Patients / In-Patient Strokes / IV tpa Received at Outside Hospital >20

14 Onset to Arrival: AIS & TIA - Citywide 14 Percent Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Arrival: 0-3 Hours Hours Hours 6-8 Hours 8-12 Hours 12+ Hours Unknown Excludes: Missing Arrival Date- Time and- or Last Well Known Date- Time / SAH, ICH, and Other Patients / In- Patient Strokes

15 60 Time to Arrival 4.5 Hours: AIS / TIA - By Site Percent Hospital HH 1 Hospital RGH 2 Hospital SMH 3 Hospital UH 4 Site Period Baseline Excludes: Missing Arrival/Last Well Known Date/Time / SAH, ICH, and Other Patients / In-Patient Strokes Q12 Q13

16 IV tpa Eligible Distribu1on - Citywide Period Baseline Q Q Q Q Q Q Q Q Percent Contraindica7ons: Absolute & Rela7ve Absolute Only Rela7ve Only No Contraindica7ons IVtPA Given Excludes: SAH, ICH, and Other Pa7ents In- Pa7ent Strokes IV tpa Received at Outside Hospital NIHSS=0 Symptoms to Door > 4 Hours

17 IV tpa eligible distribu7on Citywide 17

18 Citywide Rela7ve Contraindica7ons Relative Contraindications - Citywide 0-3 Hour Window Hour Window 18 MI in Previous 3 Months NIHSS > 22 Stroke Severity Too Mild Rapid Improvement Pregnancy Severe Comorbidity Left Heart Thrombus Increased Risk of Bleeding Glucose < 50 or > 400 Advanced Age Seizure at Onset Quarter: Baseline Excludes: SAH, ICH, and Other Patients / In- Patient Strokes / IV tpa Received at Outside Hospital / NIHSS=0 / Symptoms to Door > 4 Hours Q Q13

19 AIM 1: Acute Intervention Rate, IV tpa & IA - Citywide Percent Baseline Q1 Q2 Intervention to Date Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q13 Q12 Q11 Q10 Excludes: SAH, ICH, and Other Patients / In- Patient Strokes / IV tpa Received at Outside Hospital / NIHSS=0

20 120 Door to IVtPA Time - By Site Median Minutes Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Site: Hospital SMH1 Hospital UH 2 RGH Hospital 3 HH Hospital 4 Excludes: Missing Arrival/IVtPA Date/Time / SAH, ICH, and Other Patients / In-Patient Strokes / IV tpa Received at Outside Hospital

21 100 Percentage having a follow-up visit w/in 105 days Citywide Time to First Follow- Up Visit - Citywide Percent of FU Q1 Baseline Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Stroke Type AIS TIA SAH ICH

22 Median Time to 1 st follow-up visit Citywide Time to First Follow-Up Visit - Citywide Median Days to 1st FU Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Stroke Type AIS TIA SAH ICH

23 100 Medication Persistence/Compliance Citywide AIS Medication Persistence: AIS - Citywide Percent Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Medication AP or AC Anti-HTN Anti-Lipid Anti-Diabetic Percent=# patients on medication from discharge to fu / total # patients on medication at discharge

24 STAR Outcomes 4 years later About 35% of the 2800 episodes of stroke care/year arrive to the hospital within 4.5 hours of onset of symptoms Increased community-wide acute intervention rates for ischemic stroke (65% of all strokes) patients to ~13-14% Identified that 53% of ischemic stroke patients and 30% of hemorrhagic stroke patients are discharged home after their acute episode in our community Demonstrated 30% improvement of patients following up with a neurologist or neurosurgeon after their stroke

25 STAR A Model for the Future Initiated and led by providers (rather than hospitals/systems) Sharing resources and ideas Learning from each other s practices Collaborative rather than competitive 25

26 Establishing a Regional STAR Program Improve stroke care throughout the region by providing a framework for collaboration, communication and care Developing best practices through communication and data-sharing Utilizing measures of effectiveness to improve quality Providing resources for education (meeting CME needs) Enhancing clinical care with telestroke Extending resources across all sites

27 Clinical STAR-NY 24/7 phone consultation through the Transfer Center Acute telestroke capabilities for sites wishing to enhance level of urgent consultations Formal contract, credentialing, call coverage Commitment to maintaining connectivity, software, A-V needs Streamlined process for transfer of patients as appropriate or assisting in local care

28 STAR-NY Education Ready access to URMC CSC faculty for quarterly CME presentations, selected from a pool of topics by the participating sites Acute stroke treatment, evaluation of patients with TIA, ICU management, Inpatient management, secondary prevention, unusual cases, vascular malformations/aneurysms Materials such as treatment algorithms, NIHSS cards, dysphagia screens, order sets Selected lectures/presentations for raising community awareness

29 Programmatic STAR-NY Periodic program reviews by CSC Director and/or CSC coordinator to assist with maintaining/obtaining Primary Stroke Center status In-service training for ED/hospital staff in stroke care

30 STAR-NY Quality Improvement On-going participation in performance reviews and improvement Development of Stroke Care Dashboard (similar to data abstracted in STAR program) Time to treatment, reason for tpa exclusion, discharge location, GWTG performance measures, etc Quarterly review meetings to compare local vs aggregate data, share best practices, optimize resources

31 What can STAR-NY tell us? How many patients with stroke are we seeing? When are they arriving at the hospital? Pre-arrival notification? Of those eligible for tpa, when are they arriving? Of those eligible for tpa, who is being treated? For those not receiving tpa, why not? What is the overall rate in the community for acute stroke treatment?

32 Sample Data Elements 2016 Four regional hospitals (blinded) One large academic hospital Two medium-sized community hospitals One small community hospital

33 Percent all pa1ents arriving via EMS with pre- arrival no1fica1on Hospital 1 Hospital 2 Hospital 3 Hospital 4

34 Pre- arrival no1fica1on content includes pre- hospital stroke scale and last known well Hospital 1 Hospital 2 Hospital 3 Hospital 4

35 18 % ischemic strokes receiving IV tpa at hospital Hospital 1 Hospital 2 Hospital 3 Hospital 4

36 % DTN 60 min Hospital 1 Hospital 2 Hospital 3 Hospital 4

37 Median Door To Needle Time Hospital 1 Hospital 2 Hospital 3 Hospital 4

38 Percent ischemic stroke Hospital 1 Hospital 2 Hospital 3 Hospital 4

39 70 Stroke Diagnosis by Hospital % isch stroke % TIA % SAH % ICH Stroke not No stroke diagnosis otherwise specified Hospital 1 Hospital 2 Hospital 3 Hospital 4

40 Data Summary Wide variations Pre-hospital notification rates and content Thrombolytic utilization rates Time to treatment Diagnostic coding Disparities often provide a road map for quality improvement

41 STAR-NY Steps for joining pilot STAR-NY program Gather GWTG data Join SuperUser Agreement with URMC Institutional sign-off on quality improvement project Participate in quarterly meetings Share best-practices Avail your organization to CME, in-service, enhanced tele-stroke care