STAR- - Stroke Treatment Alliance of Rochester Curtis Benesch, M.D., M.P.H. Medical Director, URMC Comprehensive Stroke Center March 30, 2017
Background of the STAR Consortium What we learned from STAR Future directions: STAR-NY
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)
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)
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
Grant Funding 2011-2015 : 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
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
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)
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
Total Enrollment (4 years): N = 8,743 patients 10 80 Total Episodes of Care - Citywide 70 60 50 Percent 40 30 20 10 0 Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Stroke Type AIS TIA SAH ICH
85 Demographics: Age - By Site AIS ONLY 11 80 Median Age 75 70 65 Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Site Hospital 1 Hospital 2 Hospital 3 Hospital 4
100 90 80 70 60 Admission NIHSS Distribution: AIS - Citywide 12 Percent 50 40 30 20 10 0 Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 NIHSS: 0 1-5 6-10 11-15 16-20 >20 Excludes: TIA, SAH, ICH, and Other Patients / In- Patient Strokes / IV tpa Received at Outside Hospital
100 90 80 70 Admission NIHSS Distribution: AIS - By Site 13 Percent 60 50 40 30 20 10 0 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 1-5 6-10 11-15 16-20 >20
100 90 80 70 60 Onset to Arrival: AIS & TIA - Citywide 14 Percent 50 40 30 20 10 0 Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Arrival: 0-3 Hours 3-4.5 Hours 4.5-6 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
60 Time to Arrival 4.5 Hours: AIS / TIA - By Site 15 50 42.6 Percent 40 30 39.3 39.1 34.4 32.7 36.5 30.0 29.1 32.6 30.6 20 19.3 20.8 10 0 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
IV tpa Eligible Distribu1on - Citywide Period Baseline Q1 18.7 7.1 31.3 8.8 34.1 16 23.4 8.6 35.2 4.7 28.1 Q2 24.8 8.3 22.3 6.6 38.0 Q3 24.8 11.9 28.4 4.6 30.3 Q4 24.0 6.0 30.0 10.0 30.0 Q5 12.6 22.3 34.0 3.9 27.2 Q6 17.4 10.9 29.7 4.3 37.7 Q7 9.4 17.2 32.0 5.5 35.9 Q8 12.3 19.7 27.0 5.7 35.2 0 10 20 30 40 50 60 70 80 90 100 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
IV tpa eligible distribu7on Citywide 17
Citywide Rela7ve Contraindica7ons Relative Contraindications - Citywide 0-3 Hour Window 3-4.5 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 0 5 10 15 20 25 Quarter: Baseline Excludes: SAH, ICH, and Other Patients / In- Patient Strokes / IV tpa Received at Outside Hospital / NIHSS=0 / Symptoms to Door > 4 Hours Q12 0 5 10 15 20 25 Q13
AIM 1: Acute Intervention Rate, IV tpa & IA - Citywide Percent 15 10 10.7 12.5 11.2 14.3 10.8 10.2 9.0 13.1 13.9 14.5 14.7 13.7 15.3 12.1 11.3 19 5 0 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
120 Door to IVtPA Time - By Site 20 110 100 90 80 Median Minutes 70 60 50 40 30 20 10 0 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
100 Percentage having a follow-up visit w/in 105 days Citywide Time to First Follow- Up Visit - Citywide 21 80 Percent of FU 60 40 Q1 Baseline Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Stroke Type AIS TIA SAH ICH
Median Time to 1 st follow-up visit Citywide Time to First Follow-Up Visit - Citywide 22 50 40 Median Days to 1st FU 30 20 10 Baseline Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11 Q12 Q13 Stroke Type AIS TIA SAH ICH
100 Medication Persistence/Compliance Citywide AIS Medication Persistence: AIS - Citywide 23 90 80 Percent 70 60 50 40 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
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
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
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
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
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
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
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
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?
Sample Data Elements 2016 Four regional hospitals (blinded) One large academic hospital Two medium-sized community hospitals One small community hospital
Percent all pa1ents arriving via EMS with pre- arrival no1fica1on 100 90 80 70 60 50 40 30 20 10 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4
Pre- arrival no1fica1on content includes pre- hospital stroke scale and last known well 100 90 80 70 60 50 40 30 20 10 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4
18 % ischemic strokes receiving IV tpa at hospital 16 14 12 10 8 6 4 2 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4
% DTN 60 min 100 90 80 70 60 50 40 30 20 10 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4
Median Door To Needle Time 100 90 80 70 60 50 40 30 20 10 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4
Percent ischemic stroke 70 60 50 40 30 20 10 0 Hospital 1 Hospital 2 Hospital 3 Hospital 4
70 Stroke Diagnosis by Hospital 60 50 40 30 20 10 0 % isch stroke % TIA % SAH % ICH Stroke not No stroke diagnosis otherwise specified Hospital 1 Hospital 2 Hospital 3 Hospital 4
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
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