TENNESSEE STROKE REGISTRY QUARTERLY REPORT Volume 1, Issue 2 July 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 October 2017 to December 2017 Contact information for the Tennessee Stroke Registry EAST TENNESSEE STATE UNIVERSITY COLLEGE OF PUBLIC HEALTH DEPARTMENT OF BIOSTATISTICS AND EPIDEMIOLOGY
Background The Tennessee Stroke Registry (TSR) was created in 2009 through the Tennessee Stroke Registry act of 2008. 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 second quarter of the fiscal year, October through December 2017. The data are aggregate data from the 30 hospitals currently reporting to Quintiles. In this report, illustrations are made on similarities and differences between the first and second quarter of 2017, which contains data from July to September. After feedback from the Tennessee Stroke Alliance, measures of National Institutes of Health Stroke Scale/Score (NIHSS) reporting, time to intravenous thrombolytic therapy (IV t-pa), length of stay, and GWTG and Centers for Disease Control and Prevention Defect Free were added to the report. Also added into the report were patients Modified Rankin Scale at discharge, reasons for no IV tpa, reasons for delay of IV tpa beyond 60 minutes, complication types, and initial exam findings. 2
Data and distributions Diagnosis Overall, the patterns and distributions for the second quarter are similar to what was shown in past TSR reports. The 77.9% 70.0% Quarter 1 and Quarter 2 Strokes by Diagnosis Quarter 1 Quarter 2 total number of stroke 7.6% 6.2% 4.5% 5.3% 13.7% 13.7% cases for the quarter was 3,123. The most common Ischemic stroke Transient ischemic attack (<24 hours) Subarachnoid Hemorrhage Intracerebral Hemorrhage cases were ischemic strokes at 70% of strokes reported to the registry. There were less ischemic strokes in the second quarter than in the first, where 77.9% of cases were ischemic strokes (z=7.0682, p<.01). 3
Gender distributions There were similar percentages of male and female cases for ischemic strokes and intracerebral hemorrhages for the first and Gender Distribution Across Stroke Types for Quarter 1 Male 57% 57% 49% 51% 51% 48% 43% 43% Female second quarter. The proportion of female cases for transient ischemic attack (TIA) were higher in the second quarter Ischemic stroke Transient ischemic attack (<24 hours) Subarachnoid Hemorrhage Intracerebral Hemorrhage than in the first, with 57% in the first quarter versus 53%, Gender Distribution Across Stroke Types for Quarter 2 Male Female but not significantly so. The gender differences in strokes were more pronounced for 49% 51% 47% 53% 40% 60% 50% 50% subarachnoid hemorrhage, which was also seen in the first quarter of 2017, with 60% of subarachnoid hemorrhage Ischemic stroke Transient ischemic Subarachnoid Intracerebral attack (<24 hours) Hemorrhage Hemorrhage cases strokes female in the second quarter and 57% in the first (z=.558, p=.575). 4
Age distributions The most common age group experiencing strokes were those from ages 66-85, with 47% of all cases in this bracket. The prevalence of strokes overall increased by age, with only 8.2% of cases occurring from in those aged 18-45. This pattern was similar for all stroke types except subarachnoid hemorrhage (SAH), where 90 80 70 60 50 40 30 20 10 0 Average Ages of Stroke Subtypes +/- 1 Standard Deviation 67.4 67.4 67.9 67.8 68.4 70 60.4 58.1 65.4 67.2 All stroke Ischemic TIA SAH ICH Quarter 1 Mean Quarter 2 Mean 45% of cases occurred in those ages 46-65. There was an increase for SAH in the 18-45 age group from the first quarter of 2017. Only 10% of SAH were in this age group in the first quarter of 2017, versus 24% in the second quarter of 2017 (z = -2.919, p=.004). The age distribution in SAH for the second quarter is more similar to trends normally seen than Age Distribution of All Strokes in Tennessee in the first quarter. Aggregate data from all Quarter 2 cases in 2017 showed that 48% of SAH 18-45 occurred in the 46-65 age group, and 30% in the 66-85 age group. >85 10% 8% 66-85 47% 46-65 34% 5
Co-morbidities The top three co-morbidities among stroke Co-morbidities among Stroke Patients 75.2% patients were hypertension 34.2% 38.5% with 76.1%, dyslipidemia at 15.1% 23.3% 24.1% 22.3% 39.7%, and Atrial CAD/Prior MI Diabetes Dyslipidemia Hypertension Previous Smoker diabetes Fib/Flutter Mellitus Stroke mellitus at 34.7%. 6
Arrival mode Most patients arrived via EMS services, with 39% of patients in the second quarter using this method of transportation. Less people arrived via private transport in the second quarter than in the first, with proportions of 32% versus 28% (z=2.3419, p=.0193). Mode for All Stroke Types Quarter 1 Arrival Mode for All Stroke Types Quarter 2 7
Transportation times Similar transport times for the various types of transportation were reported in the first and second quarter, with private from Last Known Well to Arrival by Mode of Transportation Quarter 1 I Quarter 2 65.74% 59.44% transport experiencing longer transportation times on average from home/scene in comparison to Emergency Medical Services (EMS) transport. Most patients arrived at the hospital in over 300 minutes via private transportation (72%) while only 50.4% of patients via EMS 15.26% 12.03% I 12.53% 13.55% I 6.51% 6.93% 6.10% 6.83% 0-60 min. 61-120 min. 121-180 min. 181-300 min. >300 Time from Last Known Well to Arrival by Mode of Transportation for Quarter 2 Private trans po rt/ taxi/other from home/scene EMS from ho me/scene 72.0% 50.9% 50.4% services arrived in that time frame. Meanwhile, 17.8% of 11.7% patients arrived to the hospital <=60 min. <=120 mi n. <=180 min. <=300 min >300 via EMS services in less than 60 minutes. Transportation times overall were faster in the second quarter, with only 59.4% of patients having transportation times over 300 minutes versus 65.4% of patients in the first quarter (z= -4.182, p<.001). 8
Insurance status The majority of stroke patients had Medicare (57.7%). This reflects that the most common 70% 60% 50% Insurance Status of Stroke Patients Quarter 1 and Quarter 2 54.4% 57.7% age group experiencing strokes are those from ages 66-85. 40% 30% 20% 10% 9.2% 10.6% 30.1% 34.6% 5.9% 7.2% 0% Medicare Medicaid Private Self-pay Quarter 1 Quarter 2 9
National Institute of Health Stroke Scale (NIHSS) Reported The majority of patients with a diagnosis of ischemic stroke or stroke not otherwise specified, 94%, had a score reported for the Quarter 2 NIHSS Reported No 6% NIHSS. Yes 94% Time to Intravenous Thrombolytic Therapy IV t-pa was initiated within 60 minutes for most patients, at 89.6%. 38.1% Quarter 2 Time to Intravenous Thrombolytic Therapy 51.5% I 5.9% I 2.6% 1.5% 0.4% 0-30 min. 31-60 min. 61-90 min. 91-120 min. 121-150 min. >150 min. 10
Reasons for no intravenous recombinant tissue plasminogen activator (IV rt-pa) Quarter 2 Reasons for no IV rt-pa Initiation 27.2% 24.3% 19.8% 14.8% 7.0% 5.3% 5.3% 5.3% 4.5% 2.9% The top five reasons for no IV rt-pa initiation were because the stroke severity was too mild, IV or IA tpa given at outside hospital, the patient showed rapid improvement, acute bleeding diathesis, and anticoagulant use prior to admission. 11
Reasons for delay, IV rt-pa beyond 60 minutes The most common reason for delay in IV rt- 53.7% Quarter 2 Reasons for no IV rt-pa Initiation Beyond 60 mins PA beyond 60 minutes was that care-team was 22.4% unable to 11.9% determine 9.0% 4.5% eligibility of Care-team Hypertension Refusal Further diagnostic Management of patient, composting 53.7% of cases. eligibility evaluation concomitant emergent conditions 12
Modified Rankin Scale at discharge Quarter 2 Modified Rankin Scale at Discharge 73.2% 26.8% 10.2% 11.0% 9.6% 9.9% 17.2% 4.7% 10.6% 0 1 2 3 4 5 6 ND/Missing Documented mrs at discharge 73.2% of patients had their Modified Ranking Scale at discharge documented. 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 13
Complication types The most common type of complication for thrombolytic Quarter 2 Complication Types 59.3% 40.7% therapy was intraarterial and symptomatic intracranial hemorrhage at 59.3%. 11.1% 11.1% I l I IV t-pa & Intra-arterial & IV t-pa & Life- Intra-arterial & Life- Symptomatic Symptomatic threatening, serious threatening Intracranial Intracranial systemic hem Hemorrhage Hemorrhage Initial exam findings The most common findings in initial exam of patients was weakness/paresis (63.5%), language Quarter 2 Initial Exam Findings 63.5% 45.1% 39.2% 24.1% disturbance (39.2%), and other neurological 3.5% 0.3% 7.0% symptoms (45.1%). 14
Length of stay (LOS) The type of stroke with the longest length of hospital stay was SAH at an average of 12 days, and the type of stroke with the shortest LOS was TIA at about 2.4 days. 14 12 10 8 6 4 2 5.87 5.26 Average Length of Stay Quarter 2 2.36 12.18 0 ~" ~e e ~ f}<, ~ ~ ~4. ~e,;:. 0 "-'Ii '!(:-'Ii '!(:-'Ii,4-~,::.0 0 c., I,.'- '$::, q_'li ~ 1,.<.. ~,;:..t::-.,._c., ~'l>~ ~c., ~o ~o ~o -x:-e e~ X'q; X'q; e~ l> e,;:.,::.g "" '-"c; o' -o ~ e~,c; 1!-.~ ~~ o" :Q<..._e 11:: ~ 'X:-,;:. /..q; 0 ~e -o',;:. ~f 'l>c; c.,e ~e ~,:- ~ -,,j.'li 0._o 1,.0,._'I> c., ~ ~,-:- ~o cl s.e " & q; 8 4.81 5.5 1.81 GWTG/PAA Defect Free 93% of patients received appropriate intervention and care based on their stroke diagnosis according to GWTG standards. Quarter 2 Percentage GWTG/PAA Defect Free Not Defect Free 7% Defect Free 93% 15
CDC/COV Defect Free 84% of patients received appropriate intervention and care based on their stroke diagnosis, according to the Centers for Disease Control and Prevention (CDC) standards. Quarter 2 Percentage CDC/COV Defect Free Not Defect Free 16% Defect Free 84% 16
Discharge Destination 47.0% Quarter 2 Discharge Destination 18.0% 14.9% 9.2% 4.4% 2.8% 1.2% The top three discharge destinations were the patient s home, inpatient rehabilitation facility, and a skilled nursing facility. Of all cases, 9.2% of patients expired/died. 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. Email (preferred): strokeregistry@etsu.edu or stanleyn1@etsu.edu Phone: (423) 439-4427 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. 17