TENNESSEE STROKE REGISTRY QUARTERLY REPORT

Transcription

1 TENNESSEE STROKE REGISTRY QUARTERLY REPORT Volume 1, Issue 3 September 2018 This report is published quarterly using data from the Tennessee Stroke Registry. Inside this report Data on diagnosis, gender distributions, age distribution, arrival modes, insurance status, last known well to arrival, and medical history Data from January 2018 to March 2018 Contact information for the Tennessee Stroke Registry

2 Background The Tennessee Stroke Registry (TSR) was created in 2009 through the Tennessee Stroke Registry Act of In July 2017, the legislation was updated with Tennessee House Bill 123, requiring all certified comprehensive and primary stroke centers in Tennessee to share their data with the TSR in order to improve stroke care in the state. The bill requires data to be provided from hospitals on a quarterly basis. The data are uploaded to the American Heart/American Stroke Association s Get With the Guidelines (GWTG) data system, Quintiles. This report provides a summary of the TSR data for the third quarter of the fiscal year, January to March The data are aggregate data from the 30 hospitals currently reporting to Quintiles. In this report, illustrations are made on similarities and differences between Quarter 1, 2, and 3 data. Quarter 1 contains data from July to September 2017, and Quarter 2 contains data from October through December 2017.

3 Data and Distributions Diagnosis Stroke diagnosis Quarters 1, 2, and 3 Quarter 1 Quarter 2 Quarter 3 78% 70% 69.7% 8% 6% 7.0% 4% 5% 4.7% 14% 14% 13.9% Ischemic stroke Transient ischemic attack (<24 hours) Subarachnoid Hemorrhage Intracerebral Hemorrhage Overall, the patterns and distributions for the second quarter are similar to what was shown in past TSR reports. The total number of stroke cases for the quarter was 2,888. The most common cases were ischemic strokes at 69.7% of strokes reported to the registry. In Quarter 1, there was a greater proportion of ischemic strokes than in Quarters 2 and 3. The difference was significant between Quarter 1 and 2, with 77.9% ischemic strokes in Quarter 1, and Quarter 2 having 70% (z=7.068, p<.01). The difference was also significant between Quarter 1 and Quarter 3 (z=4.559, p <.01).

4 Gender Distributions There were similar percentages of male and female cases for ischemic strokes and intracerebral hemorrhages for the first, second, and third quarters. The proportion of female cases for transient ischemic attack (TIA) tend to be higher than male cases. The gender differences in strokes were more pronounced for subarachnoid hemorrhage (SAH) in the third and second quarters than in the first. In the second quarter, 60% of SAH cases were female compared to 57% in the first (z= , p=.04). The difference was not significant between the third and first quarters, but the difference between male and female SAH cases in Quarter 3 was significant (z=-2.954, p=.003). Ischemic Stroke Quarter 3 n = % 49% Subarachnoid Hemorrhage Quarter 3 n = % 40% TIA (<24 hours) Quarter 3 n = % 47% Intracerebral Hemorrhage Quarter 3 n = % 50% Gender distribution SAH Quarters 1, 2, and 3 Quarter 1 Quarter 2 Quarter 3 57% 60% 63% 43% 40% 37%

5 Ischemic Stroke Quarter 2 n = 2187 TIA (<24 hours) Quarter 2 n = % 51% 55% 45% Subarachnoid Hemorrhage Quarter 2 n = 165 Intracerebral Hemorrhage Quarter 2 n = % 37% 52% 48%

6 Age distributions Average Ages of Stroke Subtypes Quarter 2 and 3 +/- 1 Standard Deviation Quarter 2 Mean Quarter 3 Mean All stroke Ischemic TIA SAH ICH The most common age group experiencing strokes were those from ages 66-85, with 49% of all cases in this bracket. The prevalence of stroke overall increased by Age Distribution among SAH Patients Quarter 2 >85 2% % % 30% % Age Distribution among SAH Patients Quarter 3 >85 4% % % age, with only 8.2% of cases occurring from in those aged This pattern was similar for all stroke types except subarachnoid hemorrhage (SAH), where 47% of cases occurred in those ages There was an increase for SAH in the age group in the second quarter compared to the first quarter of In the third quarter, we saw the proportion of cases in the age bracket decrease to 19%, a significant decrease from Quarter 2 (z=2.077, p=.038).

7 Co-morbidities Top 5 Co-morbidities among Stroke Patients Quarter 1 Quarter 2 Quarter 3 76% 75% 78% 40% 38% 39% 35% 34% 34% 24% 24% 24% 24% 23% 24% Hypertension Dyslipidemia Diabetes Mellitus Previous Stroke CAD/Prior MI The top three co-morbidities among stroke patients, as seen in past quarters data, were hypertension with 77.8% of cases, dyslipidemia at 39.1%, and diabetes mellitus at 34.2%. Arrival mode Most patients arrived via EMS services, with 39.7% of patients in the third quarter Arrival Mode for All Stroke Types Quarter 3 using this method of transportation. Transfer from other hospital 32.1% Private transport/taxi/ other from homes/scene 27.7% EMS from home/scene 39.7% Mobile Stroke Unit 0.4%

8 Transportation times Similar transport times for the various types of transportation were reported in the first and second quarter, with private transport experiencing longer transportation times on Time from Last Known Well to Arrival Quarter 2 and 3 Quarter 2 Quarter 3 11% 10% 11% 10% 9% 9% 7% 7% 64% 66% average from home/scene in comparison to Emergency Medical Services (EMS) transport. Most patients arrived at the hospital 0-60 min min min min. >300 Time from Last Known Well to Arrival Quarter 3 Private transport/taxi/other from home/scene EMS from home/scene 74% 51% in over 300 minutes via private transportation (74%) while only 51.1% 20% 14% 9% 9% 10% 5% 5% 7% of patients via EMS services arrived in that time frame (z=9.97, p<.001) min min min min. >300 Meanwhile, 14.2% of patients arrived to the hospital via EMS services in less than 60 minutes, compared to 9.5% in private transport (z=2.402, p=.016).

9 Insurance status The majority of stroke patients had Medicare (59.4%). This reflects that the most common age 58% Insurance Status of Stroke Patients Quarter 2 and Quarter 3 59% Quarter 2 Quarter 3 group experiencing strokes are those from ages % 34% 11% 11% 7% 7% Medicare Medicaid Private Self-pay NIHSS Reported The majority of patients with a diagnosis of ischemic stroke or stroke not otherwise specified, 94%, had a score reported for the National Institute of Health Stroke Scale (NIHSS). The Quarter 3 NIHSS Reported No 6% NIHSS is a 15-item examination used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor Yes 94% strength, ataxia, dysarthria, and sensory loss.

10 Time to Intravenous Thrombolytic Therapy IV t-pa was initiated within 60 minutes for most patients in Quarter 3, at 90.5%. 38% Time to Intravenous Thrombolytic Therapy Quarter 2 and 3 64% 51% 26% Quarter 2 Quarter 3 Compared to transport via EMS services, private transport experience slightly slower times with 6% 8% 3% 1% 1% 0% 0% 1% 0-30 min min min min min. >150 min. Time to Intravenous Thrombolytic Therapy Quarter 3 Private transport/taxi/other from home/scene EMS from home/scene 69% 63% 80% of patients receiving treatment in an hour versus 92.4% (z=-2.571, p=.01). 11% 29% 18% 6% 2% 0% 1% 0% 0% 0% 0-30 min min min min min. >150 min.

11 Reasons for no IV rt-pa 27% 23% 26% 24% Reasons for no IV rt-pa Initiation Quarter 2 and 3 20% 20% Quarter 2 Quarter 3 15% 14% 7% 8% 8% 7% 5% 5% 5% 5% 5% 3% The top five reasons for no IV rt-pa initiation in Quarter 3, in order of highest proportion of patients to lowest, were because IV or IA tpa was given outside the hospital, the stroke severity was too mild, the patient showed rapid improvement, acute bleeding diathesis, and recent IC or spinal surgery. In Quarter 2, we saw similar proportions for these reasons, except the top reason in Quarter 2 was that the stroke severity was too mild.

12 Reasons for delay, IV rt-pa beyond 60 minutes 54% 45% Reasons for no IV rt-pa Initiation Beyond 60 mins Quarter 2 and 3 Quarter 2 Quarter 3 22% 30% 12% 4% 9% 15% 4% 11% Care-team unable to determine patient eligibility Hypertension Refusal Further diagnostic evaluation Management of concomitant emergent conditions The most common reason for delay in IV rt-pa beyond 60 minutes was that care-team was unable to determine eligibility of patient, composing 44.7% of cases. The difference between Quarter 2 and Quarter 3 was not significant.

13 Modified Rankin Scale at discharge Modified Rankin Scale at Discharge Quarter 2 and Quarter 3 Quarter 2 Quarter 3 73% 72% 27% 28% 10% 10% 11% 10% 10% 10% 10% 9% 17% 19% 5% 5% 11% 10% ND/Missing Documented mrs at discharge 72% of patients had their Modified Rankin Scale at discharge documented in Quarter 3. The Modified Rankin Scale ranges from 0-6, with the following designations for values: 0 - No symptoms at all 1 - No significant disability despite symptoms: Able to carry out all usual activities 2 - Slight disability 3 - Moderate disability: Requiring some help but able to walk without assistance 4 - Moderate to severe disability: Unable to walk without assistance and unable to attend to own bodily needs without assistance 5 - Severe disability: Bedridden, incontinent and requiring constant nursing care and attention 6 - Death

14 Complication types Co-morbidities among Stroke Patients 73% 59% Quarter 2 Quarter 3 41% 46% 11% 11% 12% 0% IV t-pa & Symptomatic Intracranial Hemorrhage Intra-arterial & Symptomatic Intracranial Hemorrhage IV t-pa & Life-threatening, serious systemic hem Intra-arterial & Lifethreatening The most common type of complication for thrombolytic therapy in Quarter 3 was Intra-arterial and Symptomatic Intracranial Hemorrhage at 73.1%. This was an increase from Quarter 2, but the difference was not significant, with a sample size in Quarter 2 of 27 and a sample size in Quarter 3 of 26.

15 Initial exam findings 63% 66% Quarter 2 and Quarter 3 Initial Exam Findings Quarter 2 Quarter 3 39% 44% 45% 47% 24% 24% 4% 3% 0% 0% 7% 6% The most common findings in initial exam of patients were weakness/paresis (65.5%), language disturbance (43.6%), and other neurological symptoms (45.1%).

16 Length of stay (LOS) Average Length of Stay Quarter 2 and 3 Quarter 2 Average Quarter 3 Average All Patients Ischemic Stroke Transient Ischemic Attack Subarachnoid Hemorrhage Intracerebral Hemorrhage Stroke of Uncertain Type No stroke related diagnosis Elective Carotid Intervention only The type of stroke with the longest length of hospital stay was SAH at about 11 days, and the type of stroke with the shortest LOS was TIA at about 3 days. GWTG/PAA Defect Free 93% of patients received defect free care according to GWTG standards. Quarter 3 Percentage GWTG/PAA Defect Free n = 2421 Not Defect Free 7% Defect Free 93%

17 CDC/COV Defect Free 84% of patients received defect free care according to the Center for Disease Control (CDC) standards. Not Defect Free 16% Quarter 3 Percentage CDC/COV Defect Free n = 2531 Defect Free 84% Contact Information For more information about the Tennessee Stroke Registry and how to participate, contact: Megan Quinn, TSR manager, or Natalie Stanley, TSR graduate assistant. (preferred): strokeregistry@etsu.edu or stanleyn1@etsu.edu Phone: (423) Local GWTG Representative: Angel Paylings Director, Quality & Systems Improvement, Tennessee Angel.Paylings@heart.org We look forward to working with you to improve stroke care in Tennessee.