NYS Stroke Data –
Quality Measure Report from Coverdell
5th Annual New York State Stroke Conference
Looking Forward in Stroke Care
Ian Brissette, Ph.D., Bonnie Eisenberg, M.S. Kathleen Wales
Division of Chronic Disease Prevention
New York State Department of Health
:
Presentation Overview
• Review data on trends in stroke deaths in the 10
years and population metrics associated with
advances in stroke systems of care
• Review performance data collected through the NY
Stroke Designation Program, including detailed
information on reasons for transfer;
• Describe the process for selecting performance
measures that will be the focus of improvement
activities that are part of NYS Coverdell Program
1
Stroke Deaths and Age-Adjusted Mortality
Rates in NYS and US, 2000-10
Age-Adjusted Stroke Mortality Rate
2000-2010
Number of Stroke Deaths in NY
2000-2010
10,000
60.9
8,000
60
40
8,006
6,213
40.9
39.1
27.9
20
0
# of NY Deaths
Mortality Rate per 100,000
80
6,000
4,000
2,000
0
2000
2005
NYS
2010
2000
2005
2010
US
Data Source: Centers for Disease Control and Prevention, National Center for Health Statistics. Compressed Mortality File 1999-2010
on CDC WONDER Online Database, released January 2013. Data are compiled from Compressed Mortality File 1999-2010 Series 20
No. 2P, 2013. Accessed at http://wonder.cdc.gov/cmf-icd10.html on Apr 29, 2013 10:20:46 AM
2
Trends in Stroke Deaths in New
York State
• Age-adjusted death rate for stroke declined by 32%
between 2000 and 2010 in New York
• Between 2000 and 2010, 13,000 fewer New Yorkers
died from stroke than expected if the rate of death
from stroke remain stable.
• Stroke moved from 3rd to 4th leading cause of death
in NY (2005) and in the US (2008).
3
Factors Contributing to Population Trends in
Stroke Outcomes: Stroke Systems of Care
Schwamm, L. H. (2012) Major
advances across the spectrum of
stroke care Nat. Rev. Neurol.
doi:10.1038/nrneurol.2011.225
4
Review of Population
Metrics Related to Stroke
Systems of Care in
New York State
5
Pre-Event Community Education:
Percentage of Adults 18 and Older Aware of Specific Signs and
Symptoms of Stroke, NYS BRFSS 2009
100
Percentage of Adults
90
90
93.8
85.9
71.6
80
60.3
70
60
50
40
30
20
10
0
Sudden confusion Sudden numbness
or trouble speaking or weakness of
face, arm or leg
Sudden trouble
seeing in one or
both eyes
Sudden trouble Severe headache
walking, dizziness with no known
or loss of balance
cause
Stroke warning signs and symptoms
6
Pre-Event Community Awareness:
Percentage of Adults 18 Years and Older Aware of All 5 Signs and
Symptoms of Stroke and 9-1-1 as First Action, NYS BRFSS 2001-2009
50
42.0
45
40
34.7
37.1
Percentage of Adults
35
30
25
20
15
10
5
0
2001
2005
Year
2009
7
Pre-Event Community Awareness – EMS Response:
Use of Emergency Transport Among Stroke Patients in NY and US,
2009-2012 (Get with the Guidelines, Stroke)
100
Percent of patients
80
60
56.8
56.3
55.7
53.9
48.3
45.6
42.9
40
40.7
20
0
NYS
2009
US
2010
2011
2012
8
Acute Treatment and Care:
Percentage of Stroke Discharges Resulting in
In-Hospital Mortality, SPARCS NY 2003-2011
12
Percent
9
7.9
6.5
6.7
2007
2011
6
3
0
2003
Data Source: Statewide Planning and Research Cooperative System (SPARCS) 2003-2011; Acute
Stroke defined as ICD-9-CM of 430-436
In-Hospital mortality defined as disposition 20
9
Acute Treatment and Care:
Percentage of Hospital Discharges for Ischemic Stroke
(ICD-9-CM 433 434) in which tPA was administered,
SPARCS NY 2003-2011
12.6
14
12
Percentage
10
8
6
4
6.3
3.9
4.0
6.9
7.1
7.9
8.9
4.7
2
0
2003
2007
2011
Data Source: Statewide Planning and Research Cooperative System (SPARCS) 2003-2011
Ischemic stroke defined as principal diagnosis of ICD-9-CM 433-434
tPA defined as principal procedure code of ICD-9-CM 99.1 or Federal DRG code of 061, 062,
063, 559 or NYS DRG of 880
10
New York Stroke Designation Program
Number of Discharges for Stroke from All NY
Hospitals and Designated Stroke Centers
2003-2011
Number of Designated
Stroke Centers
2003-2011
60,000
120
108 109
114
118 120
# of Hospitals
96
80
61
17
0
2003 2004 2005 2006 2007 2008 2009 2010 2011
56,037
50,000
49,954
45,998
40,000
(78% of
strokes)
30,000
20,000
2003
40
0
# of Stroke Discharges
58,654
2004
(89% of
strokes)
2005
2006
2007
2008
2009
2010
Total # of stroke discharges
# of stroke discharges at designated centers
Data Source: Statewide Planning and Research Cooperative System
(SPARCS) 2003-2011
Stroke defined as principal diagnosis of ICD-9-CM 430-438
11
Summary from Trends in
Population Data on Stroke
Indicators
• Increase awareness of signs and symptoms of stroke
(2001-2009) but no evidence of corresponding
increase in use of EMS transport
• Increase administration of tPA for ischemic stroke in
NYS, & reduction in in-hospital mortality from stroke
• Evidence of a greater proportion of stroke patients
in NY receiving care from designated stroke centers
12
2013 NYS Stroke Designation Review Tool
Time Targets
Performance Measures
13
Performance on NYS Time Targets
All NYS Designated Hospitals, 2012
Door to MD Assessment
68.9
Door to Stroke Team Assessment
75.9
Door to Brain Imaging Completed
53.8
Door to Brain Imaging Read
65.7
Door to IV rt-PA within 60 mins
42.3
0
10
20
30
40
50
60
70
80
90
100
Percent of patients
14
Door to IV rt-PA in 60 minutes by year
(Percent of ischemic stroke patients receiving IV t_PA who are treated
within 60 min after triage (ED arrival)
50
42.3
Percent of patients
40
30
20
35.9
28
25.5
28.7
27.6
39.2
29.9
29.1
33.5
10
NYS
US
0
2008
2009
2010
2011
2012
Year
15
NYS Performance Measures Above 85%
All NYS Stroke Designated Hospitals, 2012
IV rt-PA Arrive by 2 Hr, Treat by 3 HR
Stroke Education
Dysphagia Screening
Rehabilitation Considered
Smoking Cessation
LDL 100 or ND Statin
Anticoagulation for Afib
Antithrombotics at Discharge
DVT Prophylaxis
Early Antithrombotics
0
20
40
60
Percent of patients
80
100
16
NYS Performance Measures Below 85%
All NYS Stroke Designated & US Hospitals, 2012
62.1
NIHSS on Discharge
83.3
NIHSS on Admission
69.5
0
10
20
30
40
50
60
70
80
90
100
Percent of patients
NY
US
17
Performance Measures and Time Targets
• Performance for NYS Designated Stroke Centers
surpassed 85% on 10 of 12 performance measures
• NYS Stroke Centers exceeded performance of US
hospitals on 2 performance measures for 2012 that
were below 85%
• NYS Stroke Centers continue to exceed performance
of US hospitals on door to IV t_PA in within 60
minutes of triage.
18
Opportunity of Improvement
IV t_PA within 60 Minutes
Across NYS Stroke Centers, performance achieving the
time target has improved from 28% to 42% between
2008-2012, but…
• Nearly 60% of patients receiving IV t_PA received
treatment after the time target (within 60 minutes
of admission)
• For 55 NYS Stroke Centers performance achieving
the time target declined from 2011 to 2012; For 41
of the 55, the absolute decline in performance was
more than 10% (e.g., 95% to 85%)
19
Opportunity of Improvement
Stroke Education
Performance delivering stroke education among NYS
Designated Stroke Centers was high during the 2012
performance year (90.8%) but…
• For 19 NYS Stroke Centers performance was below
85%.
• For 27 NYS Stoke Centers performance was lower in
2012 than in 2011; For 14 of the 27, the absolute
decline in performance was more than 5%.
20
NYS Coverdell Initiative
NY received funding to promote improvement activities
on in-hospital care for acute stroke.
21
Focused Measures for Coverdell Initiative
• Determined by stroke physician workgroup during a
meeting on March 12th.
• Selection was based on review of data on
distribution of performance across stroke centers
and guiding questions.
• Measures will be the focus of QI and data quality
assurance activities during the next 12 months.
22
Guiding Questions (Sample)
• Which measures (performance and time target)
represent the most significant opportunity for
improvement?
• Which measures are associated with known or tested
improvement strategies for improving stroke care?
• Which measures reflect aspects of care that should
have the greatest impact on stroke outcomes
(preventable complications, readmissions, disability,
mortality)?
23
Sample histogram of stroke center performance
(stroke education, 2011 performance year) used in
selection of Coverdell focus measures.
24
Sample histogram of stroke center performance
(Statin at Discharge, 2011 performance year) used in
selection of Coverdell focus measures.
25
NYS Stroke Center Performance on Selected
Coverdell Focus Measures, 2011 & 2012
Door to IV rt-PA in 60
min
Stroke Education
LDL 100 or ND-Statin
IVtPA Arrive by 2 hr,
Treat by 3 hr
Dysphasia
0
2011
2012
20
40
60
80
100
Percent of patients
26
Next Steps for NYS Coverdell Initiative
• Establishing objectives for the initiative and
participating hospitals for each of the 5 performance
measures
• Developing materials and learning opportunities to
support quality improvement (QI consultant)
• Reporting and quality assurance activities: data reabstraction, dissemination of data quality and
performance reports
27