Source Kapral MK, Hall RE, Silver FL, Robertson AC, Fang J. Registry of the Canadian Stroke Network. Report on the 2004/05 Ontario Stroke Audit. Toronto: Institute for Clinical Evaluative Sciences; 2009.

Table of Contents Slides Background………………………………………………………....4-5 Methodology ………………………………………………………..6-7 Key Findings Pre-hospital and emergency stroke care………………......8-18 Emergency and in-hospital management………………....19-32 Length of stay, discharge status and destination and 30-day mortality………………………………………………33-53 Interpretive Cautions……………………………………………..54-55

Background Stroke is the fourth leading cause of death and a leading cause of adult disability in Canada. Previous studies in Ontario reveal variations in availability of stroke care resources as well as variations in treatment of stroke patients in facilities with similar resources. Beginning in 2000, Ontario developed a coordinated stroke strategy to address inconsistencies and improve access to and quality of stroke care resources. By 2005, the strategy was fully implemented and is known as the Ontario Stroke System (OSS).

Background (cont’d) Within the OSS, ongoing monitoring and evaluation are considered essential to ensure implementation of best practices and evidence-based stroke care. The Registry of the Canadian Stroke Network (RCSN), established in 2001, performs a province-wide audit of stroke care in Ontario every two years, a process which began in 2002/03. The purpose of the RCSN Ontario Stroke Audit data is to evaluate the characteristics, management and outcomes of stroke patients in Ontario and to make comparisons by Local Health Integration Network (LHIN), Ontario Stroke System region; and by institutional designation with the Stroke System (Regional Stroke Centre, District Stroke Centre, non-designated hospital). This report presents data for fiscal year 2004/05, with comparisons to the previous audit performed in fiscal year 2002/03.

Methodology All Ontario acute care institutions, excluding children’s and mental health care hospitals and those with fewer than 10 stroke or transient ischemic attack (TIA) separations per year, were invited to participate. All patients seen in the hospital emergency department or admitted to hospital with a “most responsible” diagnosis of stroke or TIA were eligible for inclusion in the audit, as identified from the Discharge Abstract Database (DAD) and the National Ambulatory Care Reporting System (NACRS) maintained by the Canadian Institute for Health Information (CIHI). Overall, 153 acute care institutions (with 154 individual hospital sites) were eligible; all agreed to participate in the 2004/05 audit.

Methodology (cont’d) Based on this audit, there were 23,800 hospitalizations or emergency department visits for acute stroke or TIA in Ontario in fiscal year 2004/05. For individuals with more than one stroke or TIA during the sampling timeframe, only the first stroke or TIA event was included. The audit sample included a total of 4,913 patients, or approximately 21 percent of all cases.

Key Findings Pre-hospital and Emergency Stroke Care Ontario: Similar to the first audit in 2002/03, in 2004/05, almost a third (32.5%) of all stroke or TIA patients arrived at hospital within 2.5 hours of stroke onset. In 2004/05, more than half (55.2%) of stroke or TIA patients were transported to hospital by ambulance. Almost two-thirds (65.2%) were admitted to hospital. In 2004/05, rates of neuroimaging (CT/MRI) within 25 minutes of hospital arrival was almost 6%, compared to almost 3% in 2002/03.

Key Findings Pre-hospital and Emergency Stroke Care Ontario: In 2004/05, thrombolysis was administered to almost 4% of patients with acute ischemic stroke, an increase from 3% observed in 2002/03. In the subgroup of patients presenting within 2.5 hours of stroke symptom onset, 14% received thrombolysis, significantly improving from almost 10% observed in 2002/03. Among patients receiving intravenous thrombolysis in 2004/05, the median door-to-needle time was 84.2 minutes, with no significant change from 2002/03.

Key Findings Pre-hospital and Emergency Stroke Care Ontario Stroke System (OSS) designation: The proportion of patients who arrived at the emergency department within 2.5 hours of stroke onset increased significantly at regional stroke centres from 23% in 2002/03 to 33% in 2004/05. Patients seen at regional stroke centres were more likely than those seen at other hospital types to be transported by ambulance and to be admitted to hospital. Between 2002/03 and 2004/05, there were significant increases in neuroimaging rates (within 25 minutes of hospital arrival). Rates of neuroimaging were highest at regional stroke centres and lowest at non-designated hospitals.

Key Findings Pre-hospital and Emergency Stroke Care Ontario Stroke System (OSS) designation: Rates of thrombolysis administration (overall or within 2.5 hours of symptom onset) were highest at regional stroke centres compared to other hospital types. Among patients receiving intravenous thrombolysis in 2004/05, the median door-to-needle times were shortest at regional stroke centres (73.1 minutes), followed by district stroke centres (95.5 minutes) and non-designated hospitals (119.8 minutes).

Percentage of patients with stroke or transient ischemic attack who arrived in the emergency department (ED) within 2.5 hours of stroke onset, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack transported to hospital by ambulance, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack admitted to hospital, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with ischemic stroke receiving neuroimaging within 25 minutes of hospital arrival, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with ischemic stroke receiving thrombolysis, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with ischemic stroke receiving thrombolysis among those presenting within 2.5 hours of symptom onset, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Median door-to-needle time among patients with ischemic stroke receiving intravenous thrombolysis, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Key Findings (cont’d) Emergency and in-hospital management Ontario: Increases were observed among stroke patients for the following indicators in 2004/05: Almost 69% of patients underwent neuroimaging (CT and/or MRI of the brain) within 24 hours of hospital arrival. A significant improvement from 47% observed in 2002/03. Neuroimaging at any time before hospital discharge, was almost 82%, an increase from 77% in 2002/03. Carotid imaging (performed or scheduled) was 55%, up from from 44% in 2002/03. Dysphagia assessment (a swallowing assessment) was 51%, an increase from 47% in 2002/03. Drug therapy at discharge (i.e.,antithrombotic therapy, warfarin for atrial fibrillation, ACE inhibitors and lipid-lowering therapy) significantly increased from 2002/03, with the exception of warfarin for atrial fibrillation. Stroke unit admission was 11%, an increase from almost 3% observed in 2002/03. Referrals to stroke secondary prevention clinics was 29%, up from 14% in 2002/03.

Key Findings (cont’d) Emergency and in-hospital management Ontario Stroke System (OSS) designation: There were statistically significant improvements in neuroimaging rates (within 24 hours of hospital arrival or at any time before hospital discharge) at all types of hospital between 2002/03 and 2004/05. In 2004/05, neuroimaging rates were markedly higher at regional stroke centres compared to other types of hospitals, with imaging rates prior to hospital discharge of 96%, 84% and 77% at regional stroke centres, district stroke centres and non-designated hospitals, respectively. In 2004/05, rates of carotid imaging (performed or scheduled), were higher at regional stroke centres compared to other types of hospitals, with rates of almost 70%, 61% and 49% at regional stroke centres, district stroke centres and non-designated hospitals, respectively.

Key Findings (cont’d) Emergency and in-hospital management Ontario Stroke System (OSS) designation: In 2004/05, dysphagia screening rates were highest at regional stroke centres (56% of patients), followed by district stroke centres (54% of patients) and non-designated hospitals (48% of patients). In 2004/05, there were variations in rates of prescribing ACE inhibitors and lipid-lowering therapy after hospital discharge across hospital types, but no significant variations in prescribing of antithrombotic agents or warfarin for atrial fibrillation. Between 2002/03 and 2004/05, increases in rates of prescribing of antithrombotic therapy, ACE inhibitors and lipid-lowering medications for secondary prevention of stroke, were observed across all hospital types.

Key Findings (cont’d) Emergency and in-hospital management Ontario Stroke System (OSS) designation: Direct admission to stroke unit increased markedly at regional stroke centres, from almost 4% in 2002/03 to 41% in 2004/05. Increases were also observed at district stroke centres from almost 2% in 2002/03 to 7% in 2004/05. Rates of stroke unit admission were lowest at non-designated hospitals (ranging between 2-3%) in 2002/03 and 2004/05. Referral rates to stroke secondary prevention clinics were highest at regional stroke centres (67%) compared to district stroke centres (27%) and non-designated hospitals (21%). However, the largest increase in referral rates was observed at non-designated hospitals, at 7% in 2002/03 to 21% in 2004/05.

Percentage of patients with stroke or transient ischemic attack undergoing neuroimaging within 24 hours of arrival in the emergency department (ED), 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack undergoing neuroimaging at any time before discharge, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with ischemic stroke or transient ischemic attack receiving carotid imaging, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with ischemic stroke or transient ischemic attack receiving antithrombotic therapy at discharge, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with ischemic stroke or transient ischemic attack receiving warfarin for atrial fibrillation at discharge, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with ischemic stroke or transient ischemic attack receiving ACE inhibitors at discharge, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with ischemic stroke or transient ischemic attack receiving lipid-lowering therapy at discharge, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack who underwent dysphagia screening, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack admitted directly to stroke unit, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack referred to a Secondary Prevention Clinic, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Key Findings (cont’d) Length of stay, discharge status and destination and 30-day mortality Ontario: In 2004/05, the median inpatient length of hospital stay for patients with stroke/TIA was 6.5 days—a decrease from 7.6 days observed in 2002/03. In 2004/05, the majority (55%) of stroke patients were discharged home and almost 16% were discharged to inpatient rehabilitation facilities. In the subgroup of patients with moderate to severe disability after stroke (Rankin score 3 to 5), the majority (35%) were discharged to inpatient rehabilitation. This was a significant decrease compared to 42% observed in 2002/03. In 2004/05, the age- and sex-adjusted 30-day ischemic stroke mortality rate was almost 15%; this did not significantly change from 2002/03. The age- and sex-adjust hemorrhagic stroke mortality rate was almost 42%; again, similar to that observed in 2002/03.

Key Findings (cont’d) Length of stay, discharge status and destination and 30-day mortality Ontario Stroke System (OSS) designation: In both 2002/03 and 2004/05, the median inpatient length of hospital stay for patients with stroke/TIA was greater at regional stroke centres compared to other hospital types. For all three OSS designations, the median inpatient length of stay decreased between 2002/03 and 2004/05. In 2004/05, patients seen at regional and district stroke centres were more likely to be transferred to inpatient rehabilitation, compared to patients seen at non-designated hospitals. At regional stroke centres, there was a decrease in the proportion of stroke patients discharged to inpatient rehabilitation—from 25% in 2002/03 to almost 19% in 2004/05.

Key Findings (cont’d) Length of stay, discharge status and destination and 30-day mortality Ontario Stroke System (OSS) designation: Discharge destinations were similar among the subgroup of patients with moderate to severe disability (Rankin score 3-5), with the exception of discharge to inpatient rehabilitation. These rates were highest at regional stroke centres (40%), followed by district stroke centres (38%) and non-designated hospitals (almost 33%). Compared to 2002/03, there was a significant decrease in the proportion of patients with moderate to severe disability discharged to inpatient rehabilitation from both regional and district stroke centres.

Key Findings (cont’d) Length of stay, discharge status and destination and 30-day mortality Ontario Stroke System (OSS) designation: In 2004/05, age- and sex-adjusted 30-day ischemic stroke mortality rates were lower at regional stroke centres compared to those at non-designated hospitals. There were no statistically significant variations in the age- and sex-adjusted 30-day hemorrhagic stroke mortality rates across hospital types.

Median length of stay for patients with stroke or transient ischemic attack, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack discharged home, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack discharged to an inpatient rehabilitation facility, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack discharged to home care, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack discharged to a long-term care facility, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack discharged to an acute facility, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack discharged to other facility, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack with a Rankin Score of 0–2 and discharged home, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack with a Rankin Score of 0–2 and discharged to an inpatient rehabilitation facility, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack with a Rankin Score of 0–2 and discharged to home care, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack with a Rankin Score of 0–2 and discharged to a long-term care facility, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack with a Rankin Score of 3–5 and discharged home, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack with a Rankin Score of 3–5 and discharged to an inpatient rehabilitation facility, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack with a Rankin Score of 3–5 and discharged to home care, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Percentage of patients with stroke or transient ischemic attack with a Rankin Score of 3–5 and discharged to a long-term care facility, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Age- and sex-adjusted 30-day ischemic stroke mortality rate for patients with ischemic stroke seen in the emergency department (ED) or admitted to hospital, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Age- and sex-adjusted 30-day intracranial hemorrhagic stroke mortality rate for patients with intracranial hemorrhage seen in the emergency department (ED) or admitted to hospital, 2002/03 and 2004/05 By Ontario Stroke System (OSS) designation

Interpretive Cautions Overall rates of key quality indicators for acute stroke care are presented. Benchmarks have not been established for most of these indicators. Low rates of some indicators may be partially explained and/or related to the lack of timely neuroimaging or interpretation of test results in smaller treatment centres or by the limited number of physicians and other health care workers with stroke care expertise in certain facilities and geographic areas.

Interpretive Cautions (cont’d) Significant improvements in the use of evidence-based practices and interventions occurred between the 2002/03 and 2004/05 audits. Although the analysis does not allow one to evaluate the reasons for the observed improvements in care, there is a temporal association between the implementation of the Ontario Stroke System and improved stroke care delivery. However, variations in care delivery among hospital types continue to exist, with lower rates of many stroke care interventions at small community hospitals compared to other hospital types. LHIN-level analyses are based on where the patient received treatment and not where the patient resided. Therefore analyses in this report are facility based.