Clinical impact of practice registers in Bourgogne and Rhône Alpes Dr Yannick Béjot The Dijon Stroke Registry EA4184, University Hospital and Medical School of Dijon, France Dr Carlos El KHOURY c.elkhoury@ch-vienne.fr Rhone Valley Emergency Network Paris Experience Days International Forum for Quality and Safety in Health Care Paris - 8 April 2014
An example of organisation of a dedicated stroke care network and its evaluation in Dijon, France Dr Yannick Béjot The Dijon Stroke Registry EA4184, University Hospital and Medical School of Dijon, France Paris Experience Days International Forum for Quality and Safety in Health Care Paris - 8 April 2014
Disclosures Paid speaker Boehringer-Ingelheim France, Novartis, BMS Consultant or member of a scientific council Boehringer-Ingelheim France, Novartis Manager of travel expenses, lodging, or conference/event registration Boehringer-Ingelheim France, Novartis, BMS, Bayer, GSK, Teva, Sanofi, MSD, Biogen, Lundbeck Other: none
Background Stroke 3rd leading cause of death 1st leading cause of handicap in adults Management of stroke patients in a dedicated stroke unit is associated with improved survival and functional outcome Need for implementation of dedicated stroke care networks Pre-hospital management Intra-hospital management
Stroke care organisation in Dijon Dijon: 151,000 inhabitants 1 University Hospital with the unique department of neurology
Stroke care organisation in Dijon BEFORE 2003 No specific management of stroke patients No stroke unit Patients with stroke/tia during weekdays managed by neurologists Patients with stroke/tia during weekends or bank holidays managed by emergency doctors and admitted to either the department of clinical neurology or to another medical department if no beds were available in this unit AFTER 2003 Implementation of a stroke unit at the University Hospital Organization of a dedicated specialized stroke network pre-hospital pathway with established procedures emergency medical services training program stroke prioritization, CT priority for stroke patients 24/7 availability of a stroke-trained neurologist and interventional neuroradiologist for patients admitted with stroke
Stroke care organisation in Dijon after 2003 Stroke onset Call 15 Transport Hospital admission Acute management Medical dispatcher Emegency doctors Neurologists Neuroradiologists Stroke unit
The «week end effect» in the literature
Our aim To assess the impact of setting up a dedicated stroke care network in our community on 30-day all-cause mortality of patients with stroke/tia during weekends or bank holidays as compared with those experiencing the event during weekdays
The Dijon Stroke Registry (1985 present) University Hospital Private hospitals (n=3) Death certificates Stroke and TIA Clinics University Hospital Private clinics Brain imaging Private and public centres Vascular imaging Private and public centres General practitioners
Results 5864 strokes/tias from 1985 to 2010 75 % 25 % 4399 : weekdays 1465 : weekends/bank holidays
Results Survival stratified by day of onset
Results Multivariable analysis
Conclusion The higher risk of 30-day all-cause mortality observed during the period 1985-2003 in patients suffering a stroke/tia during weekends or bank holidays totally disappeared during the period 2004-2010 The implementation of a dedicated specialized stroke network in our community may have contributed to improvements in acute stroke care during weekends and bank holidays Our findings provide strong support for the implementation of quality improvement initiatives in order to attenuate inequalities in the management of stroke patients.
Clinical impact of Practice Registers in Rhône Alpes Carlos El KHOURY c.elkhoury@ch-vienne.fr Rhone Valley Emergency Network Paris Experience Days International Forum for Quality and Safety in Health Care Paris - 8 April 2014
Disclosures Health Industry Interests relevant to Presentation CEK Patent holder/shareholder or member or employee of a government organization Consultant or member of a scientific council Paid speaker or author/editor of articles or documents Manager of travel expenses, lodging, or conference/event registration Principal Investigator of a research or clinical study Co-Investigator of a clinical study Yes No No No No No
How are optimal care pathways organised in Rhône-Alpes region for stroke management? tre
Stroke care organization before 2008 after 2008 No health policy for stroke 1 geographic network dedicated for stroke management : regional public information campaign written updated management protocol training of emergency doctors for stroke management registry recording and monitoring Clinical Practice Indicators with quality targets
How is quality measured since 2008? 2007 2008 2009 2010 2011 2012 Assessment Registry Identifying optimal pathways for stroke Establishment of a «neurovascular emergency network» Regional guidelines editing Training for stroke management Assessment Registry clinical practice indicators (HAS) Regional guidelines updating 2007 2008 2009 2010 2011 2012
Results before (in 2007) direct admission to SU : 8% refusal of admission in SU : 30% TL rate : < 5% % of TL performed in ED : 0.4% MRI : 34% Time from symptom to TL : 180 min after (in 2013) 15% 0% 9.1% 16% 73% 155 min
Conclusion Clinical Practice Indicators : a common language for assessing practices Recording and monitoring Clinical Practice Indicators help to achieve and maintain quality targets Their implementation in registries and networks requires public support Optimal results in recommended pathway A positive impact on improving practices Efforts to make thrombolysis available to as many patients as possible should be continued