Stroke QUERI Review January 26, 2011 Linda Williams, MD Dawn Bravata, MD Glenn Graham, MD, PhD Teresa Damush, PhD

Overview VA-focused stroke data (5 minutes) Highlights of recent accomplishments and overview of 3-year strategic plan (35 minutes) –In-hospital care (Williams) –Risk factor management (Bravata) –Stroke policy (Graham) –Implementation goals (Damush) –Partnerships (Williams)

VA Stroke Performance Stroke-specific performance indicators: None FIM (functional) screening of inpatients with stroke, amputation, or spinal cord injury transitioned to a quality indicator without benchmark in FY08 Stroke-relevant performance indicators: Outpatient: BP, lipids, DM, smoking; none reported in stroke cohort Inpatient: VTE prophylaxis (IPEC measure, stroke not included in high risk group that makes up the denominator) Smoking cessation counseling (not reported for stroke patients specifically) Stroke QUERI is the primary advocate promoting effective measurement and active improvement projects that are advancing VA stroke care

VA Stroke Data Acute ischemic stroke is a common condition in VA with approximately: –6,000 veterans annually with primary discharge diagnosis of stroke This does not include post-operative strokes, strokes occurring with other primary conditions (e.g. MI), non- VA hospitalizations, or TIA diagnoses –5,000 veterans with admission or ED visit for TIA –60,00 veterans with an outpatient stroke-related encounter in FY09 –Stroke incidence and prevalence rates in veterans are unknown

VA Stroke Outcomes and Cost In FY07 OQP national VA ischemic stroke cohort: In-hospital mortality: 4% 6-month mortality: 8% 6-month readmission (VA only): 27% In FY05, the total VA cost of acute stroke treatment was $315M, with cost per veteran of 3.4x the average VA healthcare cost

Hospital Care Rehab Acute Treatment Stroke QUERI Works Across the Continuum of Care Primary Prevention In-hospital Management Recovery and Secondary Prevention Hypertension control Identification of high-risk patients Developing systems to measure in-hospital stroke care quality Implementation of System Redesign-based interventions to improve in-hospital care Rehabilitation structure and outcome models Telerehabilitation interventions Self-management of vascular risk factors Cross-cutting work: Quality measurement/OQP Stroke Special Project Policy decision support/Data for outcomes measurement

Stroke QUERI Goals In-hospital Care –Improve in-hospital management of stroke to reduce stroke mortality and morbidity Risk Factor Management –Develop, evaluate, and integrate interventions to improve risk factor control among veterans at high risk of stroke Stroke Policy Decision Support –Support VA stroke policy decisions by collecting and reporting VA system-level stroke data

In-hospital Care Goal: Improve in-hospital management of stroke to reduce stroke mortality and morbidity

In-hospital care: Quality Measurement OQP Stroke Special Project: Objectives Assess the quality of inpatient VA stroke care and post-stroke risk factor management Feedback performance data to VAMCs Provide a resource of improvement strategies and tools Sample 5000 veterans admitted to a VA facility with discharge diagnosis of ischemic stroke, FY07 100% of veterans at small volume centers (≤55 admissions) 80% of veterans at high volume centers (>55 admissions) Chart review and feedback Chart review based on electronic medical records only (not paper) by EPRP abstractors VAMCs provided opportunity to review and correct inpatient data

OQP Project: 14 Inpatient Processes of Care Early Hospitalization Dysphagia screening before oral intake NIH Stroke scale completed Thrombolysis (tPA) given In-Hospital Period Antithrombotic therapy, HD2 VTE prophylaxis Early ambulation Fall risk assessment (Morse Scale) Pressure ulcer risk assessment (Braden scale) Rehab consultation/FIM results Hospital Discharge Antithrombotic therapy, D/C Lipid management Atrial fibrillation management Smoking cessation counseling Stroke education Joint Commission based indicator (2007) VA-specific Among 131 VAMCs, 129 facilities cared for veterans who were eligible for at least one quality indicator

Final OQP In-Patient Data Summary Process of Care Eligible Patients N=3936 Process Present % Antithrombotic therapy, DC Antithrombotic therapy, HD Smoking cessation counseling Pressure ulcer risk assessment Early ambulation Rehabilitation consultation Lipid management Fall risk assessment VTE prophylaxis Anticoagulation for atrial fibrillation NIH Stroke Scale documented Dysphagia screening Stroke education Thrombolysis (tPA) given Joint Commission 2007 VA-specific

In-hospital care: Quality measurement Intentionally working in two distinct areas of quality measurement development: –Using existing data resources What do we have available that can support improved stroke care now? –Developing a stroke-specific decision support system Can we develop and implement a robust system to support acute stroke care decision making and also collect data to facilitate ongoing quality of care assessments?

In-hospital care: Quality measurement accomplishments VistA-based quality indicators (Chumbler RRP PI) Anticoagulation for atrial fibrillation Lipid lowering medication at discharge VTE prophylaxis (by hospital day 2 in non-ambulatory patients) Iterative construction of algorithms, partnership with VISN 11 VERC/CACs Our methodology to collect non-pharmacologic VTE interventions in use by VISN 11 Numerators and denominators compared to chart abstraction are promising –Kappas are.70 to.90 –Ongoing work to further define VTE denominator

In-hospital care: Quality measurement plans VistA quality indicators next steps: –Planned RRP/SDP to implement at other facilities, evaluate ease of implementation and accuracy, develop standard reports –Discussions with IPEC regarding collecting the VTE indicator for stroke patients –Dissemination to other interested staff/facilities via SQUINT network

In-hospital care: Quality measurement accomplishments Stroke Quality Improvement Decision Support System (SQUIDSS): Kent/Anderson PIs –Designed to interface with CPRS to collect relevant data, prompt evidence-based decisions, and document important processes of care related to providing acute stroke evaluation and treatment –Completed end-user evaluations of mock-ups, usability assessments –Programming ongoing, plan to beta-test in Houston ED in 2011

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In-hospital care: Quality measurement plans SQUIDSS next steps: Complete version 1.0 Working with Dr. Tyndall, OHI, others to plan next development cycle (SDP) for FY12 Interface SQUIDSS with EDIS 2.0 in several EDs Technical feasibility Test data collection from multiple facilities Improve product via additional user input

In-hospital care: QI accomplishments Stroke Toolkit developed as part of the OQP project –Tools linked to each of the 14 indicators –Disseminated as part of National Report in 2009 –Over 12,000 hits in FY10 Stroke Quality Improvement Network –Developed with PCS Neurology, also at time of OQP National Report in 2009 –Monthly calls for any VA clinician interested in improving stroke care –Dr. Graham and Dr. Jane Anderson, RNP, PhD co- lead –Ongoing RRP to evaluate effectiveness of SQUINT group and the Toolkit

Stroke Quality Improvement Toolkit Look for tools for specific indicators or by tool type

In-hospital care: QI accomplishments System Redesign-based interventions –Developed SR training program with VISN 11 VERC, delivered in a collaborative setting with follow-up coaching –Worked with 7 VISN 11 facilities to improve 2 inpatient stroke indicators Dysphagia screening before oral intake Discharge on lipid lowering medication –Achieved improvements over 6 months in both indicators and in spread of SR techniques Dysphagia improved 26% to 48% Lipid lowering medications improved 83% to 87% –Median of 4 rapid improvement cycles per facility and 3 facilities spread SR methods to other improvement issues

In-hospital care: QI accomplishments Dysphagia-focused interventions –Redesign of nurse-based intake screener Shorter, improved screener as part of standardized nurse admission template –Pilot project to train and implement nurse screening in the Emergency Department Developed and tested nurse training module including bedside water swallow testing Developed CPRS dysphagia reminder template Houston ED showed significant improvement over time in dysphagia screening rates

In-hospital care: QI accomplishments VA Stroke Task Force collaboration Based on OQP results and ED survey of stroke care, VA assembled a multidisciplinary team to make recommendations about improving acute stroke care ED, Neurology, Primary Care, Nursing, Allied Health, Operations (Dr. Gary Tyndall, Chair) Recommendations in four areas: Templates/measures (Williams/Anderson) Facility requirements (Graham) Consent Education (Daggett) Active planning for 2011 National VA Acute Stroke meeting

In-hospital care: QI Plans System Redesign focused interventions: INSPIRE/RE-INSPIRE –Completing baseline interviews and in- hospital QI data collection at 12 sites –Randomize sites to SR-based collaborative vs. data feedback alone in late April 2011 –6 month intervention and 12 months of data collection, complete evaluation in 2013 –RE-INSPIRE in-depth context interviews and site assessments to begin in May 2011

In-hospital care: QI Plans Dysphagia screening –Training tools developed in RRP planned to add to Stroke Toolkit, disseminate via SQUINT, INSPIRE. VA Stroke Task Force –Planning larger implementation roll-out to further integrate screening with formal SLP evaluation and refine screening tool

Vascular Risk Factor Goal: Develop, evaluate, and integrate interventions to improve risk factor control among veterans at high risk of stroke

Veterans at high risk of stroke High risk groups include veterans with: Recent stroke or transient ischemic attack (TIA) Multiple poorly controlled stroke risk factors –Includes activities aimed at both primary and secondary prevention Accomplishments and Strategic Plan for: A.Identifying patients at high risk of stroke B.Evaluating risk factor management quality C.Stroke risk factors: QI interventions

A. Identifying High Risk Patients: Risk of First Stroke Accomplishments Cheng RRP: used VistA data to build and test Framingham risk calculator Plans Continue to improve tool to identify veterans at risk of stroke by including data readily available within VA but that were not included in Framingham models Implement this tool in future intervention studies that seek to reduce the risk of stroke (e.g., the Cross- QUERI collaborative project)

A. Identifying High Risk Patients: Risk of Recurrent Stroke Accomplishments Examination of national VA data over past 3 years demonstrates relatively constant number of TIA admissions and post-TIA event rates –5135 veterans with TIA (FY09) –VA data only: 15% had a stroke in the first 90-days post-TIA –VA data only: 29% had any recurrent vascular event or died in first 90-days post-TIA –wide variation in event rates across VAMCs: 12.5% to 48.2% among the highest volume facilities Plans RRP FY10-11 to assess practice patterns and outcomes after TIA VA-Medicare study to accurately describe the recurrent event rate among veterans with stroke

B. Evaluate Risk Factor Control for Veterans with Stroke and TIA Accomplishments OQP data used to evaluate risk factor management among veterans with stroke and TIA –Most veterans have multiple co-existing vascular risk factors –Opportunities exist to improve post-stroke risk factor control

National OQP Outpatient Data Summary Veterans with follow-up within 6 months post-stroke Process of Care Eligible Patients Process Present % Blood pressure measured INR measured Hemoglobin A1c measured LDL measured BP measured and meets goal Hemoglobin A1c measured and meets goal INR measured and meets goal LDL measured and meets goal

B. Evaluate Risk Factor Control for Veterans with Stroke and TIA Plans Ongoing analysis of OQP data for veterans with stroke seeks to: –Identify facility characteristics/policies that are associated with either very good or very poor risk factor quality –Identify any potential age-, race-, or geographic- disparities in risk factor management Cheng RRP is examining gaps in TIA care nationwide to target for future implementation projects Ongoing evaluation of group visits for veterans with poorly controlled risk factors post-stroke/TIA Explore the possibility of having EPRP risk factor control data reported for patients with stroke and TIA

C. Stroke Risk Factors: QI interventions Accomplishments Hypertension –Series of projects focused on HTN improvement (Dr. Bosworth) –Lessons learned: Patient-focused intervention component is necessary for ongoing improvement in BP control Behavior change for BP is relevant to other vascular RF Behavioral interventions after stroke or TIA –Several projects testing self-management interventions for behavior change (Drs. Damush, Anderson) –Lessons learned: Immediate post-stroke period has benefits and challenges to behavior change Tailoring of standardized programs is key: physical, cognitive, situational elements post-stroke

C. Stroke Risk Factors: QI interventions Interventions in veterans with stroke and TIA: –Conduct the submitted SDP to improve care and outcomes for veterans with TIA at high volume centers using a remote multidisciplinary team to provide guideline concordant care –Develop a SDP to improve risk factor management for patients with recent stroke exploring the question of whether to use existing VA risk factor management programs or a stroke-specific program Interventions in veterans with multiple risk factors: –Continue to seek approvals for the Cross-QUERI collaborative program to implement a stepped care intervention for veterans with multiple poorly controlled vascular risk factors

Stroke Policy Goal: Support VA stroke policy decisions by collecting and reporting VA system-level stroke data

Stroke Policy Goal Why have an explicit policy goal? –Partners need reliable data to make decisions –Some key data describing VA stroke care and outcomes are only available if a one-time research-directed data pull is done –Emerging national VA and non-VA stroke quality reporting activities necessitate improved access to VA stroke epidemiologic and outcome data Two foci: –Mortality/outcomes assessments –Stroke care models

Policy: Stroke Mortality Assessment Accomplishments VA risk-adjusted stroke mortality data not available CMS has proposed two national hospital-level stroke quality indicators: Adjusted 30-day mortality rate Adjusted 30-day readmission rate QUERI impact on these discussions to date include: –Risk adjusted mortality is lower for veterans admitted to a VAMC than nationally reported stroke mortality (OQP) –Risk adjusted readmission rates are as high or higher among veterans than other nationally reported data (OQP) –Stroke severity explains nearly all of the adjusted mortality risk at the patient level –VA has one of the only national datasets capable of evaluating the impact of stroke severity on risk-adjusted facility level mortality reports; Stroke QUERI is part of the ongoing CMS discussion around this issu e

Policy: Mortality Assessment Plans Develop robust risk-adjusted stroke mortality and outcome data for VA –Build on CMS contributions, remain informed by this national activity –Evaluate VA stroke mortality and readmission data to understand variations in care –Capture non-VA stroke admissions for accurate assessment of total veteran stroke mortality and readmission rates –Consider assessing functional outcomes

Policy: Mortality Assessment Plans Identify optimal methods for risk adjusting stroke outcomes –Explore OQP data (chart review “ideal” data) –Develop new dataset to include VA and non-VA stroke admissions (administrative data), planned RRP Optimize accuracy of case ascertainment Produce facility-level risk-adjusted in-hospital and 30- day mortality and readmission reports –Explore methods for estimating stroke severity in administrative datasets Inform decisions about methods and timing of enhancing stroke documentation in VA

Policy: Stroke Models Accomplishments System Dynamics modeling –Allows clinicians, researchers, and policy- makers to compare the relative effectiveness of different interventions –In 2009 we engaged researchers and policy makers in populating and using the VA model –Results informed strategic planning activities Interest in TIA Interest in combinations of risk factors –Focus on combinations of risk factors yields almost twofold reduction in cumulative 5-year stroke incidence compared to HTN alone

VA Stroke System Dynamics Model - Total strokes & TIAs - Fatal strokes - DALYs - Medical costs OUTCOMES IN VA USER POPN NON-EVENT VA USER POPN POST-STROKE VA USER POPN Rankin 4 & 5 1 st stroke Fatal Survived Recurrent stroke Fatal Survived Primary prevention efforts (HTN & AF mgmt) Stroke rehab effort Stroke acute care efforts: -Timely to hospital - Effective tPA use -DVT prophylaxis -Dysphagia screening Post stroke CEA & 2 o prevention efforts Rankin 2 & 3 Rankin 0 & 1 by age group & subsets of smokers, hypertensives, atrial fib, diabetes, CVD; and interventions targeting particular subsets Post-1 st stroke Rankin score Post-recurrent stroke change in Rankin Post TIA CEA & 2 o prevention efforts POST-TIA VA USER POPN 1 st TIA Recurrent TIA 1 st TIAs in New VA Users 1 st Strokes in New VA Users UndxDx TIA diagnosis effort

Policy: Rehabilitation Models Accomplishments Rehabilitation cost (Vogel, PI): –Adjusted acute rehab bed costs are 25% lower than subacute bed costs, while delivering higher quality care –Assistive device costs are lower in VA than in Medicare, but device provision varies widely Rehabilitation structure (Chumbler, PI): –Telerehabilitation may be associated with improved outcomes compared to usual care

Policy: Stroke Models Plans Systems Dynamics Modeling –Provide better estimates of cost-quality- outcome associations –Explore partnership with VISN 11 VERC to make interactive tool so operational partners can explore various interventions and their projected impact on stroke outcomes

Policy: Stroke Models Plans Other stroke care models under active or planned study: –Rehabilitation cost-quality estimates (Vogel) –GIS mapping of acute stroke care capabilities (Graham RRP FY11) –Response to Acute Stroke Task Force (Damush FY11 planned RRP) –Telerehabilitation intervention models in CBOCs (Chumbler planned project) –Teleconsultation (TIA SDP)

Implementation Science: Stroke QUERI Challenges, Activities, Contributions

Challenges with Implementation of Stroke Services Lack of ongoing stroke- specific performance measurement within the VA Contextual diversity related to varying levels of inpatient stroke services across VA facilities Challenges in integrating effective risk factor control in outpatient care Paucity of existing stroke clinical champions nation-wide Inadequate Primary Care-Specialty Care coordination and communication Shared decision making for risk factor management activities when multiple risk factors are present

In-Hospital Activities: Integrating and evaluating System Redesign strategies in VA Collaboratives External Facilitation – Coaches/ Engineers Internal Facilitation – Local Champion Vicarious Learning across sites Team Dynamics within a site Contextual diversity for delivery of stroke services Measure stroke care processes for feedback Qualitative codes to operationally define and measure implementation concepts

Risk Factor Management Activities: Patient-focused implementation Active Implementation in varying contexts to improve control of cardiovascular risk factors –Hypertension Improve (Bosworth)– Primary prevention –TOOLS (Damush)- Secondary prevention –Group Visits (Cheng)– Secondary prevention –Stop Clinic (Anderson) – Secondary prevention

Policy Implementation: Evaluation of Operations Activities Qualitative assessments of national stroke-related initiatives –Evaluation of how OQP Stroke Special Study data were received and used by the field (INSPIRE) –Planned study of response to Acute Stroke Task Force recommendations at various types of VAMCs

Implementation Models in Use REINSPIRE – CFIR INSPIRE – FAB Framework STARS – Precede- Procede Model Drs. Sundar (SMILE BP) and Friedberg (ASA) – Prochaska Transtheoretical Model of Stages of Change SQUIDSS – Knowledge Management Model and Process Model of Program Change Stroke Self- Management- Social Cognitive Theory Hypertension Improve –Determinants of effective innovation implementation in organizations –Social Cognitive Theory

Implementation Science Contributions Locally adapted existing secondary risk factor management tools based on provider and patient preferences– TOOLS study (Damush et al) –Methodology and theoretical framework for intervention mapping to locally adapt tools, Implementation Science 2010, Dec 15;5:97. Hypertension Improve – Adopting effective management program for veterans at risk for cardiovascular event in primary care. –Protocol Methodology and organizational change framework Implementation Science 2010; Jul 16;5:54

Implementation Science Contributions Formative evaluation of veterans, with stroke who smoke, preferences for smoking cessation efforts – Zillich, Hudmon, Damush, Topics in Stroke Rehabilitation, 2010 Implementation of patient self-management in VHA (Damush, Anderson, Bosworth, Cheng, JGIM, 2010 – National QUERI Meeting Workshop proceedings) AHA International Stroke Conference Feb 2010 invited symposium on behavioral change strategies for secondary stroke prevention (Damush)

Partnership Activities Explicit engagement of key partners via: –Executive Committee representation –Intentional discussion/interviews Key operational partners: –OQP (inpatient and outpatient quality measurement) –Neurology and ED/PCS (inpatient QI, policy) –VA Acute Stroke Task Force (inpatient QI, policy) –VISN 11 VERC (inpatient QI) Developing partners: –Primary Care (Ambulatory Care Sensitive Condition work with the Office of Productivity, Efficiency, and Staffing; exploring PACT collaborations on risk factor implementation projects) –IPEC (policy, mortality/outcomes reporting) –Specialty Care Transformation (in-hospital care, policy, telehealth projects)

Collaborators Stroke QUERI’s national network 4 Coordinators Goal leaders, key collaborators Co-Clinical Coordinator

Hospital Care Rehab Acute Treatment VA Stroke Care in 2014 Primary Prevention In-hospital Management Recovery and Secondary Prevention High risk patients identified in primary care panels National Cross- QUERI project ongoing In-hospital stroke care quality measurement in multiple VAMCs High volume facilities engaged in active stroke QI projects Vascular risk factor data reported in veterans with stroke/TIA TIA rapid assessment and treatment program Telerehabilitation intervention evaluations Data to inform VA policy: Risk-adjusted stroke mortality and readmission reports Projections comparing relative effectiveness of interventions; cost and quality data