Improving the Quality of Stroke Care

Improving the Quality of Stroke Care

Tony Rudd

“it is the duty of the physician to explain to the patient, or to his friends, that the condition is past relief, that medicines and electricity will do no good, and that there is no possible hope of cure”

William Osler

St Thomas’ Hospital

St Thomas’ Hospital Stroke Care in 1988

Patients admitted under care of any of 17 general physicians to any one of 15 wards

Very little happened acutely

Brain scans difficult to obtain and therefore rarely done

Referred to geriatricians for rehabilitation – long wait

No stroke specialist service either in hospital or community

(Adjusted incremental costs (US$/PPP) and hazard ratios (with 95% CI) by centre (Riga (Latvia) as reference) The EC BIOMED 1 Stroke Project)

The EC BIOMED 1 & 2 Stroke Project

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What are the problems that still need solving?

Unacceptable variation in the quality of care between hospitals Variable quality of clinical and managerial leadership Variable resources provided for stroke care

UK slow to adopt new technologies e.g. Thrombolysis

Still a belief amongst many people (professionals and public) that stroke untreatable disease of old people

Early Stroke Audit Results (1998/9) 18% of patients through stroke unit 23% cognitive assessment 44% visual fields recorded 55% rehabilitation goals set 41% G.P. contacted within 3 days of discharge

Key Forces for Change Research Guidelines summarising the research evidence and

clinical consensus (RCP Guidelines and NICE Guidelines on Acute Stroke and TIA and NICE Technology Appraisal on alteplase)

National Audit Sentinel audit SINAP Carotid endarterectomy audit

National Audit Office report National Stroke Strategy

Key Forces for Change NICE Quality Standards Commissioning Outcomes Framework (COF) standards Performance standards set by Care Quality

Commission Stroke Improvement Programme and Stroke and

Cardiac Networks Stroke Research Network Public opinion Media reports Voluntary sector campaigning

Stroke Programme at the RCP Guidelines

NICE Guidelines on Acute care and TIA Intercollegiate Guidelines on the rest 4th edition to be published Sept 2012

National Audit Sentinel audit (1998-2012) Carotid interventions audit Acute Continuous Stroke Audit (SINAP) SSNAP

Change management Presentations Workshops Peer Review Politics/lobbying Stroke Improvement Programme links

History of Stroke Audit in the UK 1997 Department of Health commissioned

national stroke audit Intercollegiate stroke working party Audits conducted every 2 years

Structure Process (Outcome)

Patient experience (Picker survey) Primary care audit Now funded by HQIP

Features of Audit 1

100% participationRun by cliniciansExceptional level of data quality and completenessDetailed analysis centrally to allow tailored interrogation of dataPerformed every 2 years allowing time for implementation of changeRapid production of results

Individual detailed hospital reports with results benchmarked against national/regional averagesReports to Strategic Health Authorities, Healthcare Commission, Networks, Department of Health and ParliamentExtensive media coverage because public data of key indicators

Features of Audit 2

Other sources of data

Primary care – Quality Outcomes Framework (QOF)

Vital signs data Accelerated metrics for SIP Routine Hospital Statistics (HES). Used by Dr

Foster

Results: Stroke unit provision –comparison over time

2002 2004 2006 2008

Stroke unit in hospital 73% 79% 91% 92%

Median (IQR) stroke beds

20 (14-27) 20 (15-29) 24 (16-30) 25 (20-34)

Specialist community/ domiciliary

rehabilitation team31% 27% 32% 70%

Sentinel Stroke Audit 2010. RCP London

Nationally1 Patients treated for 90% of stay in a Stroke Unit 62.2

2 Screened for swallowing disorders within first 24 hours of admission 84.1

3 Brain scan within 24 hours of stroke 70.54 Commenced aspirin by 48 hours after stroke 94.1

5 Physiotherapy assessment within first 72 hours of admission 93.0

6 Assessment by an Occupational Therapist within 4 working days of admission 87.1

7 Weighed at least once during admission 89.28 Mood assessed by discharge 84.4

9 Rehabilitation goals agreed by the multi-disciplinary team by discharge 97.3

Average for 9 indicators for 2010 82.4

9 Key Process Indicators

Number of 9 Key Indicators Achieved

Only 32% of patients who were eligible for all 9 indicators received all 9.

12 Key Process Indicators (2010)This round we have added four additional indicators and removed one (rehab goals agreed by discharge)

Number of 12 Key Indicators AchievedOnly 16% of patients who were eligible for all 12 indicators received all nine.

How are the data used to influence change?

Workshops Slide toolkits Publicity

“I’ve been trying to get the trust to offer scanning for stroke patients for 5 years, within a day of receiving the audit report the chief executive had convened a meeting with stroke service and radiology” A stroke physician after publication of performance indicators 2004 audit

Influencing policy at a national level Influencing policy at SHA level

Transforming Stroke care in London:Case for change

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TargetBelow Target

Above Target

London Stroke Providers against Sentinel Audit 12 key indicators 2006

Change in London Stroke Providers against Sentinel Audit 12 key indicators 2006 vs 2004 scores

London Stroke Units Sentinel Audit Comparison 2004 and 2006

The scale of the problem of stroke in London

• Second biggest killer and most common cause of disability• Population >8 million• 11,500 strokes a year in London – 2,000 deaths

30-minute blue light ambulance travel time from the hyper-acute stroke units

The green area shows the areas that are within 30 minutes travel time (under ambulance blue light conditions) of a proposed HASU

London Stroke Strategy Additional £20m per year for stroke care but only

paid if hospitals delivering the required quality Centralise hyperacute (hyperacute stroke units

HASU) care into 8 units situated to provide easy access to the whole population (no more than 30 minutes by ambulance)

All acute stroke patients admitted to HASU. This is not just a thrombolysis service

Further 20 stroke units for on going rehabilitation Improve community care and longer term

rehabilitation Neurovascular services for patients with TIA

London SHA Stroke Strategy

Bidding process to provide care London Clinical Director Regular inspections to ensure quality of care

maintained Obliged to submit continuous audit

Prophets of Doom Predictions Not possible to implement major system

reorganisation in London for a condition as complex as stroke

Staffing requirements unachievable (400 nurses and 100 therapists)– Recruitment – where will staff come from?– Training – how will staff develop the necessary skills?– Leadership – who can provide the necessary leadership? – There is a risk that the available workforce will be consumed by

early implementers, leaving later implementers unable to recruit to posts.

Prophets of doom predictions Patients will not accept being taken to a hospital

that is not local to them Not possible to transport people within 30

minutes to a HASU Repatriation will fail and HASUs will quickly

become full Even if get acute services working it will fail

because impossible to change community services

Unsustainable

1 year outcomes

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% of patients spending 90% of their time on a dedicated SU

1 year outcomes

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1 year outcomes

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Feb-July 2009 Aim Feb-July 2010

Thrombolysis rates

14%

Jan-March 2011

London Stroke Survival vs Rest of England

Hazard ratio for survival in London 0.72 95%CI 0.67-0.77 p<0.001

Cost-effectiveness analysis of the London Stroke Service: Results based on 6438 strokes per annum

Differences in Unadjusted AdjustedDifferences in total costs at 30 days 3,307,677 3,763,472Differences in total deaths at 30 days -214 -68Differences in total QALYs at 30 days 51 44Incremental cost per death averted at 30 days 15,451 55,371Incremental cost per QALY gained at 30 days 64,478 86,106Differences in total costs at 90 days -5,393,533 -3,544,210

Differences in total deaths at 90 days -238 -98

Differences in total QALYs at 90 days 112 86

Incremental cost per death averted at 90 days Dominant Dominant

Incremental cost per QALY gained at 90 days Dominant Dominant

Differences in total costs at 10 years -21,318,180 -22,786,954

Differences in total QALYs at 10 years 4,492 3,886

Incremental cost per QALY gained at 10 years Dominant Dominant

Professor Steve Morris et al


Differences in Unadjusted AdjustedDifferences in total costs at 30 days 3,307,677 3,763,472



Incremental cost per death averted at 30 days 15,451 55,371

Incremental cost per QALY gained at 30 days 64,478 86,106

Differences in total costs at 90 days -5,393,533 -3,544,210Differences in total deaths at 90 days -238 -98Differences in total QALYs at 90 days 112 86Incremental cost per death averted at 90 days Dominant DominantIncremental cost per QALY gained at 90 days Dominant DominantDifferences in total costs at 10 years -21,318,180 -22,786,954

Differences in total QALYs at 90 days 4,492 3,886

Incremental cost per QALY gained at 10 years Dominant Dominant


Differences in Unadjusted AdjustedDifferences in total costs at 30 days 3,307,677 3,763,472



Incremental cost per death averted at 30 days 15,451 55,371

Incremental cost per QALY gained at 30 days 64,478 86,106

Differences in total costs at 90 days -5,393,533 -3,544,210



Incremental cost per death averted at 90 days Dominant Dominant

Incremental cost per QALY gained at 90 days Dominant Dominant

Differences in total costs at 10 years -21,318,180 -22,786,954Differences in total QALYs at 90 days 4,492 3,886Incremental cost per QALY gained at 10 years Dominant Dominant

Sensitivity analysisResults were qualitatively unchanged after undertaking sensitivity analysis on the following:

• Stroke mimics• LOS in the HASU• Unit cost per day in the HASU• LOS in ICU• Neurosurgery rates• Discharge destinations

Effects (e.g., deaths, QALYs)

Costs (£)

CostBefore

OutcomeBef

ore

Before

Quadrant 1

Quadrant 2

Quadrant 3

Quadrant 4

Cost-effectiveness plane

Better outcomes

Worse outcomes

Higher costs

Lower costs

Areas where work still needed

Early supported discharge Bed based intermediate care Longer term rehabilitation Vocational rehabilitation

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Click on the relevant number on the map or below to go to your region’s results

1 North East2 North West3 Yorkshire and the Humber4 West Midlands5 East Midlands6 East of England7 South West8 South Central9 London10 South East Coast

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SINAP

Hospital participation and quartiles

for participants

Thrombolysis Out of 32113 stroke

patients

Total number of patients given thrombolysis 2541Median (and IQR) number of patients per hospital given thrombolysis 12 (2-35)

Percentage of all patients given thrombolysis 8%Median (and IQR) percentage of patients per hospital given thrombolysis 6% (2-10%)

Median (and IQR) age of thrombolysed patients 72 (63-80)

Number of thrombolysed patients aged 81 or over 561 (22%)

Median (and IQR) time from door to needle (minutes) 60 (41-85)

Median (and IQR) time from scan to thrombolysis (minutes) 32 (20-50)

The effects of getting to a SU quickly% Compliance with KIs (n=30351) (does not include patients already in hospital at time of stroke)

SU within 4 hours

53% (15946)

SU within 24 hours

80% (24236)

SU within 72 hours

89% (27108)

Did not go to SU

6% (1822) KI 1 Scanned within 1 hour of arrival at hospital

42 33 30 14

KI 4 Stroke consultant 24h90 85 81 42

KI 6 Prognosis/diagnosis discussed with relative/carer within 72h where applicable 90 87 86 72

KI 7 Continence plan drawn up within 72h where applicable64 60 59 41

KI 8 Percentage of potentially eligible patients thrombolysed 67 57 56 17KI 9 Bundle 1: Seen by nurse and one therapist within 24h

and all relevant therapists within 72h 61 55 52 21

KI 10 Bundle 2: Nutrition screening and formal swallow assessment within 72 hours where appropriate 90 88 86 48

KI 12 Bundle 4: Patient given antiplatelet within 72h where appropriate and had adequate fluid and nutrition in all 24h periods*

66 62 60 39

Average Average of 12 KIs 77 67 64 34

• For every Key Indicator, the results are worse at each stage, showing that getting to a stroke unit quickly impacts on a range of process measures

Equity of care across hospitalsCompliance with KIs (median and interquartile range)

25th percentile Median 75th percentile

KI 1 Percentage of patients scanned within 1 hour of arrival at hospital 11 21 34

KI 3 Percentage of patients who arrived on stroke bed within 4 hours of hospital arrival (when hospital arrival was out of hours)

27 44 64

KI 4 Percentage of patients seen by stroke consultant or associate specialist within 24h 60 78 88

KI 7 Percentage of patients who had continence plan drawn up within 72h where applicable 31 58 86

KI 8 Percentage of potentially eligible patients thrombolysed 19 46 76

KI 9 Bundle 1: Seen by nurse and one therapist within 24h and all relevant therapists within 72h (proxy for NICE QS 5) 28 44 60

KI 11 Bundle 3: Patient's first ward of admission was stroke unit and they arrived there within four hours of hospital arrival 31 48 65

KI 12*

Bundle 4: Patient given antiplatelet within 72h where appropriate and had adequate fluid and nutrition in all 24h periods*

39 60 76

Average of 12 KIs 48 60 66

• There is huge variation between hospitals, particularly for continence, thrombolysis and the ‘nursing/therapy bundle’

Normal Hours Out of Hours Inpatient

N of patients in “arrival category” 14632 (46%) 15719 (49%) 1762 (5%)

Arrival to stroke team (median and IQR) (mins)

87 (9-315) 188 (15-870) 1142 (360-3390)

Arrival to stroke bed (median and IQR) (mins) 211 (121-407) 234 (132-870) 1785 (682-4690)

Arrival to scan (median and IQR)(mins)

120 (45-301) 170 (50-885) 801 (185-1645)

Equity of care based on when the patient arrives at hospital

The New World of SSNAP

A wish by certain people to have prospective data collection for stroke

The ‘need’ to collect outcome data

The New World of SSNAP

A wish by certain people to have prospective data collection for stroke

The ‘need’ to collect outcome data Need for information about the whole

pathway Need for PROMS and PREMS

Data requirements Accelerated metrics NICE Quality Standards Vital signs Local stroke and cardiac network requirements Commissioning Outcomes Framework Quality Outcomes Framework National audits HES Data CQC

Sentinel Stroke National Audit Programme (SSNAP)

Replacing all other statutory data collection (except vital signs!). Includes data needed for: NICE QS NHS Outcomes Framework Accelerated metrics COF

Funded by HQIP

Development of SSNAP

Intercollegiate Stroke Working party Strategic data and audit group (SIP, RCP, IC,

etc)

SSNAP Prospective data collection for all stroke admissions Web tool for direct data entry

Good data validation systems Facility for instant local downloads Uploading facility from other data sets Quarterly national reporting with benchmarking against

national data Annual public reports 6 month follow-up data entry Linkage to ONS for mortality data HES linkage Option for user defined fields

SSNAP: Structure Core data set for all patients Comprehensive dataset (optional items) Spotlight audits

Audits on areas not covered by the core dataset. E.g. TIA, community rehabilitation

Sprint audits short specific audits focussing on specific areas of the pathway that

are of concern e.g. Therapy intensity, intermediate care. Organisational audit Hospital Community PROMS PREMS

SSNAP Reporting

Ability to download own data anytime 3 monthly reports benchmarked against

national data Annual public reports – ‘state of the nation’ Outcomes required by DH

Mortality at 30 days and 6 months Modified Rankin Score at 6 months Institutionalisation rate at 6 months

SSNAP Timetable

Some uncertainty We hope

May 2012 Organisational audit of hospital care August 2012 Clinical data set starts SINAP continues until SSNAP starts 1st Spotlight and Sprints audits in year 2 Initial funding 3 years

SSNAP Team

Intercollegiate Stroke Working Party overseeing the process

Clinicians at RCP in Associate Director Roles Geoff Cloud, Pippa Tyrrell, Martin James, Tony

Rudd Alex Hoffman, James Campbell, Sara Kavanagh

plus a statistician, web developer and admin support

SSNAP Risks Funding Can we agree a contract?

Currently debate/dispute over intellectual property Participation rates

Major burden for clinicians/trusts Freedom of information act Technical challenges DH want us to change our name!!

Conclusions

Stroke care has transformed over the last 20 years

Audit has been one of the factors that has driven improvements

No prospect of avoiding monitoring of quality of care that we provide

We are starting a new era of prospective audit Huge benefits for all if everyone participates

The Face of the Future of Stroke

Acknowledgements

Alex Hoffman and whole team at RCP James Campbell, Sarah Kavanagh, Sarah Martin,

and others Martin James, Pippa Tyrrell, Geoff Cloud ICSWP

Improving the Quality of Stroke Care

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