Get With The Guidelines - Stroke and Trends in New Jersey

Transcription

1 The Road to Recovery: Get With The Guidelines - Stroke and Trends in New Jersey Zainab Magdon-Ismail, DrPH Vice President, Quality & Systems Improvement Founders Affiliate (NJ-ME) American Heart Association (AHA) 1

2 The Road to Recovery: Get With The Guidelines - Stroke and Trends in New Jersey TODAY S FOCUS AREAS 1. How far have we come? NJ Stroke Care Trends Stroke Treatment Guidelines Get With The Guidelines Stroke (GWTG-Stroke) Data 3. Decision Making for Post-acute Care 2

3 3 I. STROKE CARE TRENDS

4 National Stroke Statistics 1 Stroke is the No. 5 cause of death in the U.S., killing more than 140,000 people in That s 1 in every 19 deaths. Stroke is a leading cause of serious long-term disability. Projections show that by 2030, an additional 3.4 million U.S. adults will have had a stroke a 20.5% increase in prevalence from

5 National Stroke Statistics Disparities in Stroke Impact More women than men have strokes each year, in part because women live longer. o Certain stroke risk factors tend to be stronger or more common in women than men, for example high blood pressure, migraine with aura, atrial fibrillation, diabetes, depression and emotional stress. 2 Non-Hispanic black people have nearly twice the risk for a first-ever stroke as whites, and a much higher death rate from stroke. 1 African-American and Hispanic stroke survivors are more likely to become disabled and have difficulty with activities of daily living than non-hispanic white people. 1 5

6 New Jersey Stroke Statistics ~2.8% of NJ adults have had a Stroke 3 In NJ patients aged 35 to 39 years, the rate of stroke more than doubled : 9.5 strokes per 100,000 people : 23.6 strokes per 100,000 people Stroke was the No. 4 leading cause of death in NJ in 2016, with an age-adjusted death rate lower than that of the nation 30.4 deaths per 100,000 in NJ, compared to 37.3 nationally 4 1 6

7 Then and Now, Nationally: Stroke Death Rates Between 2007 and 2014, stroke death rates decreased 5 : o 16.1% in non-hispanic whites o 17.3% in Hispanics o 19.6% in non-hispanic Asian and Pacific Islanders; 20.2% in non-hispanic blacks o 22.5% in non-hispanic American Indian or Alaska Natives 7

8 Then and Now, New Jersey: Stroke Death Rates NJ s 2013/2015 age-adjusted stroke death rate was the 8 th lowest among all states. 1 8 State Rank Stroke Death Rate New York Rhode Island Connecticut New Hampshire Massachusetts Arizona Puerto Rico New Jersey Wyoming New Mexico Maine Minnesota Vermont Colorado Florida % Change, to

9 New Jersey: Healthcare Access & Outcomes NJ Healthcare Facilities: o71 acute care hospitals 53 designated by the State of NJ as Primary Stroke Center 14 designated by the State of NJ as Comprehensive Stroke Center ~10.7% of NJ adults have no health coverage, according to the 2016 New Jersey Behavioral Risk Factor Survey 6 Life expectancy in NJ is slowly increasing among all racial and ethnic groups as well as among both males and females. o As of 2014, the average life expectancy among residents was 80.9 years, compared to 77.6 years in

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13 13 2. Stroke Treatment Guidelines Get With The Guidelines Stroke (GWTG-Stroke) Data

14 14 Clinical Treatment Guidelines

15 Knowledge-Treatment Gap Physician Awareness of National Cholesterol Education Provider Guidelines Patient Treated to Goal Provider awareness does not equal successful implementation 15 Pearson Arch Intern Med Pearson 2000;160: Arch Intern Med 2000;160:459-67

16 BRIDGING THE GAP BETWEEN EFFICACY AND EFFECTIVENESS EFFICACY Outcomes associated with an intervention under ideal circumstances Clinical trial reported in literature Guidelines SYSTEMS EFFECTIVENESS Outcomes associated with an intervention in the real world Hospital Outpatient Across Continuum 16 Systems to Translate Efficacy Effectiveness

17 17 GWTG-Stroke In-Hospital Data Collection 17

18 GWTG-Stroke: Transitions of Care 18 GWTG-Stroke 30-Day Post-Discharge Follow-Up Measures 30-Day Follow-Up, Process Measures 30 Day Antithrombotic Therapy 30 Day Anticoagulation Therapy for Atrial Fibrillation 30 Day Lipid Lowering Therapy for LDL > 100 or ND 30 Day Antihypertensive Therapy 30 Day Antihypertensive Therapy Meds 30 Day Hypertension Control 30 Day Diabetes Therapy 30 Day Assessment for Rehabilitation 30 Day Smoking Cessation Counseling 30 Day Smoking Cessation 30 Day Functional Status 30 Day Follow-Up, Outcome Measures 30 Day Mortality 30 Day Mortality Post Discharge 30 Day Mortality by Location 30 Day Re-hospitalization Number of 30 Day Re-hospitalizations 30 Day Re-hospitalization for DVT/PE 30 Day Re-hospitalization for Pneumonia 30 Day Re-hospitalization for AMI 30 Day Re-hospitalization for Recurrent Stroke/TIA

19 GWTG-Stroke Data: Evidence-Based Care at Discharge % Discharged on Statin Medication % Discharged on Intensive Statin Therapy % Smoking Cessation Advice or Counseling % Given Stroke Education 19

20 GWTG-Stroke Data: Rehab Considered : NJ 94.0% Nation 94.2% 2018: NJ 98.0% Nation 97.9% % Assessed for Rehabilitation Services 20

21 GWTG-Stroke Data: mrs at Discharge 2018 Modified Rankin Scale at Discharge 2018, mrs Documented: NJ 72.3% Nation 56.5% mrs Missing or ND mrs Documented

22 Mission: MISSION: Lifeline LIFELINE Stroke STROKE The RIGHT treatment for the RIGHT patient in the RIGHT amount of time Primary Stroke Center Onset of Stroke symptoms EMS dispatch EMS on-scene LKW Time Stroke Screen LVO Screening Tool EMS Triage Plan Stroke Alert Protocol Comprehensive or Thrombectomy Capable Center Total Ischemic Time 22 * Using patient selection criteria consistent with 2018 AHA/ASA AIS Guidelines.

23 23 DECISION-MAKING FOR POST- ACUTE CARE

24 24 Pilot Study Published:

25 Follow-up Published: Age -NIHSS on Admission -Ambulation on Discharge 25

26 26 Further Query Published:

27 27 TYPICAL LEVEL OF INFLUENCE AT HOSPITAL 27 Case Manager/Social Worker/Discharge Planner Patient/family Physical Therapist Occupational Therapist Speech/Language Therapist Hospitalist/Internist Neurologist Nurse Physiatrist (Rehab Physician) Other Physician Neurosurgeon 1=Lowest 10=Highest

28 28 IMPORTANCE OF FACTORS THAT INFLUENCE THE SELECTION OF A POST ACUTE CARE FACILITY 1=Lowest 10=Highest 28 Quality of post-acute facility Insurance Prognosis for functional improvement Stroke severity Likelihood of ultimate return to the community Location of post-acute facility Patient motivation Cognitive/Communication impairments Pre-stroke functional status Medical comorbidities/complexity Mobility (e.g. ability to walk, transfer) Ability to perform ADL s ADLs Patient age Affiliation of post-acute facility with my hospital/health system Immigration Status (i.e. illegal immigrant)

29 29 THE NEED FOR SPEED IS THERE PRESSURE TO DISCHARGE PATIENTS QUICKLY? 29

30 30 How frequently does the speed with which you are able to discharge a stroke patient impact his or her final destination? 7.2% 4.3% 13.0% Always Very Frequently Frequently 39.1% Rarely Never 36.2% 30

31 31 BARRIERS TO REFERRING PATIENTS TO APPROPRIATE LEVEL OF CARE/FACILITY Insurance was identified by 48% as the single greatest barrier in referring stroke patients to the most appropriate level of post acute care. The most significant barriers to referring patients to the most appropriate specific facility for post-acute care, were insurance (27%), bed availability (18%), and facility location (8%). 31

32 32 New Study Focus on discharge planners and physical therapists to assess real world situations 20 cases per hospital 7 questions per patient 3-5 mins per patient for data collection Each participant will also answer 5 short case vignettes Study duration: 20 cases; no longer than 3 months Data will be linked to GWTG-Stroke 32

33 33 Which Healthcare Professional Had the Greatest Influence in Determining Discharge Location for the Patient?

34 34 What Situations/Circumstances Had Greatest Influence in Determining Discharge Location? Ranked as #1 Reason

35 35 F. Most Significant Factor (if any) That Prevented Patient From Being Discharged to 1 st Choice of Most Clinically Appropriate Level of Care?

36 36 G. Did Speed with Which You Were Required to Discharge Patient Impact Discharge Destination?

37 37 H. WAS PATIENT'S DISCHARGE DELAYED DUE TO POST-ACUTE CARE BED AVAILABILITY? Answers (Discharge Planners Only) # of Responses % of Response Yes % No % Total % 37

38 SUMMARY OF FINDINGS Demographics 45% of the patients were female Mean age was Primary insurance was Medicare (50.8%), Medicaid (4.9%), Managed Care/Commercial (21.5%) or other/uninsured (3.3%) Findings DPs and PTs agreed regarding preferred discharge destination in 355 (83.1%) of cases The actual discharge destination matched the preferred discharge destination in 92.5% of these cases There were 23 cases (6.5%) where the patient was discharged to a less intensive setting than preferred by both respondents In 8 (2.3%) insurance barriers were cited by at least one respondent as the reason for the discrepancy in discharge destination. In most of the remaining cases the discrepancy was accounted for by patient/family preference 38

39 DELPHI STUDY LINK: 39

40 DELPHI STUDY Which Road to Recovery? Factors Influencing Post-Acute Discharge Destinations A Delphi Study PHASE I: Our primary objective is to conduct a study using the Delphi method to identify key factors influencing the selection of post-acute level of care. Phase II: Development of a Decision Support Tool Phase III: Follow-up Testing to Establish Validity of the Tool Phase IV: a Cost-Effectiveness analysis 40

41 References 1 Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics 2018 update: A report from the American Heart Association. Circulation. 2018; 137: e67-e Bushnell C, McCullough LD, Awad IA, et al. Guidelines for the prevention of stroke in women: A statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2014; 45: New Jersey Behavioral Risk Factor Survey (NJBRFS). New Jersey Department of Health, Center for Health Statistics, New Jersey State Health Assessment Data (NJSHAD) [online]. Accessed at on [Oct 17, 2018] at [19:48 EDT]. 4 Centers for Disease Control and Prevention, National Center for Health Statistics. (2018, April 10). Stats of the State of New Jersey. Retrieved from 5 Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics 2017 update: A report from the American Heart Association. Circulation. 2017; 135: e146-e New Jersey Behavioral Risk Factor Survey (NJBRFS). New Jersey Department of Health, Center for Health Statistics, New Jersey State Health Assessment Data (NJSHAD) [online]. Accessed at on [Oct 18, 2018] at [08:19 EDT]. 7 Health Indicator Report. New Jersey Department of Health, Center for Health Statistics, New Jersey State Health Assessment Data (NJSHAD) [online]. Accessed at on [Oct 18, 2018] at [08:45 EDT]. 41