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Scottish Stroke Care Audit Annual Meeting 24 th June 08 RCPE

Acknowledgements Robin Flaig Mike McDowall Audit coordinators Contributing clinicians and managers Margaret Farquhar & team RCPE

Menu A Scottish perspective Performance of individual hospitals 2005 – 2007 learning lessons from good and bad practice –Inpatients –Outpatients Swallowing - Karen Krawczyk Plans to review NHSQIS standards Future plans for the audit Tea Carotid endarterectomy

Reasons for variation in “Performance” Method of collection data Definitions, case ascertainment and audit period Method of analysing data Which numerator and denominator Chance Actual performance of service

Proportions Numerator / Denominator = Proportion 100 patients admitted 60 enter stroke unit Proportion is 60/100 = 0.6 or 60% NHS QIS ask % admitted SU within 1 day Denominator is 100 for NHSQIS standards? Most challenging

Data Quality Complete ascertainment? Data extraction? –Finding info –Clinical support Keeping up to date

National Performance

Comparisons between hospitals Inpatients

Stroke unit care

Organised inpatient (stroke unit) care Absolute outcomes at 6-12 months -3 (-6, -1)*26 %22 %Dead -2 (-5, 0)*20 %18 %Institutional care 0 (-2, 3)16 % Home (dependent) 5 (1, 8)*38 %44 %Home, (independent ) Risk difference ControlStroke unit Outcome SUTC (2001)

Mean delay (days) from admission to entry into any Stroke Unit

% of patients admitted to a Stroke Unit ≤ 2 days of admission (NHS QIS Standard = 70%)

% of patients admitted to a Stroke Unit ≤ 2 days of admission (NHS QIS Standard = 70%)

How did you improve access? Direct admissions? Day & night? Medical staffing out of hours? Do you have a medical assessment unit? How many beds for how many admissions? Fixed bed numbers or flexible? Ring fenced beds? How do you clear your beds?

Why is access getting worse? Lack of SU beds? Filled with non stroke patients? Problems with discharge?

Swallow screen

Why screen for swallowing problems 50% of patients cannot swallow safely Increased risk of pneumonia & death Need for fluids Need for nutrition – modified diet or tube Need for medication

Mean delay (days) from admission to Swallow screen

% of patients with a Swallow screen on day of admission (NHS QIS Standard = 100%)

How did you improve performance? Who does the screening? How were they trained? Where do they do it? How is it documented? Are they missing cases?

Brain scanning

To exclude alternative diagnoses To distinguish haemorrhage and infarction To allow safe use of antithrombotic treatment

Mean delay (days) from admission to Scan

% of patients Scanned ≤2 days of admission (NHS QIS = 80%)

Brain scanning Most places with a scanner meet NHSQIS standards HTA review suggested immediate scan is most cost effective timing English strategy emphasises earlier scanning ? A case for changing the NHSQIS standard

Early aspirin use

Effect of two weeks of aspirin in acute ischaemic stroke Treat 1000 patients 9 avoid recurrence 12 avoid death or dependency 10 more make a complete recovery

Effect of aspirin in acute stroke: hours from stroke onset

% of patients with Ischaemic event given Aspirin ≤2 days of admission (NHS QIS Standard = 100%)

Almost everyone is improving? Protocol or ICP? Rapid scanning? No scanning? Immediate reporting or PACS on ward? Nurse prescription?

Blood pressure lowering after stroke

PROGRESS - Stroke All participants Proportion with event Follow-up time (years) 28% risk reduction 95%CI % p< Placebo Active

% of stroke patients discharged alive on any anti-hypertensive medication

Why such variation in blood pressure lowering? Chance – low numbers? Different views on risks vs benefits? Preferring to start after discharge Different levels of co-morbidity? Presence or absence of protocols? Data collection?

Antiplatelet or anticoagulant treatment after ischaemic stroke

Absolute effects of antiplatelet treatment - % with vascular events Treat avoid event in 29 months Treat avoid event in 2 weeks

% of Ischaemic patients discharged on Antiplatelet, Warfarin

Lowering cholesterol after ischaemic stroke

% discharged on statin

Warfarin for patients with ischaemic events and Atrial Fibrillation

Effect on stroke risk in the randomised trials of warfarin vs aspirin in fibrillating patients (Hart et al 1999)

% of Patients in AF discharged on Warfarin

Why such variation in Warfarin use? Chance – low numbers Different views on risks vs benefits Delaying treatment till after discharge Different levels of co-morbidity Variation in quality of anticoagulation service

Outpatients

High early risk of stroke after TIA Days Risk of stroke (%) OXVASC OCSP Lancet 2005; 366: % risk of stroke by 7 days

EXPRESS: Clinic-referred population Days from medical attention Risk of stroke (%) P< Slow clinic Same day clinic

Mean (days) from receipt of referral to examination

Patients with Days from receipt of referral to examination <14 days – NHS QIS (80%)

Patients with Days from receipt of referral to examination <7 days - NHS QIS (80%)

How do you do it? Method of getting referrals? Management of clinic slots? Number of clinic slots – capacity? Informing patients of appointments

Delays in accessing Neurovascular clinic Is the NHSQIS standards of 14 days out of date?

Mean (days) from examination to 1st Carotid Duplex

Mean days from Examination to Brain Scan, for Scan done

NHS QIS swallowing Karen Krawczyk

Reviewing NHS QIS standards

Plan Raise the standards to fit in with latest evidence and SIGN guidelines –Earlier scanning -? 80% in 1 day –Earlier access to SU - ? 80% in 1 day –Earlier access to Neurovascular clinics – 90% in 7 days –Target for thrombolysis –Targets for applying secondary prevention Publish revised criteria with SIGN guidelines in Dec 08 Scope major revision to cover whole patient pathways – aim 2010

Consultation on the “Refreshed Stroke Strategy”

Future plans for audit ISD taking over management of audit Possible restructuring –Local data entry and storage as now but download into central data repository –Allow local data analysis –Quality assurance and linkage easier –Easier maintenance of software

Other stroke related national audits SAIVMS – an audit of the management of Intracranial vascular malformations SCIP – using routine data to monitor survival after carotid intervention SHARE – a planned audit to monitor delivery of thrombolysis in Scotland

Scottish Hyperacute stroke Activity Register and Evaluation (SHARE) Aims to monitor introduction of thrombolysis services in Scotland Funded by Scottish Government for 2 yrs Lead by Peter Langhorne Collect minimum dataset on each treated patient Allow data entry by several means –SSCAS –Web –SITS

Tea

Oxford, England Henry Barnett London, Ontario Melbourne November, 2000 Carotid surgery

The vast majority of TIA patients do not get near a surgeon! 1000 TIA patients 300 recognised by GP and referred to hospital 40 with severe stenosis 500 present to medical attention 250 in the carotid territory 30 willing to take risk of surgery

The effectiveness of surgery with increasing delays Weeks between symptomatic event and randomisation ARR (%), 95% CI 70-99%50-69%

Number patients who had a Carotid Interventions performed in 2007

Mean number of days from event to Carotid Surgery

Average delays (days) from event to surgery

Reducing delays to surgery in Lothian

Reducing the delays to carotid surgery Reducing delays to TIA assessment Streamline investigation –Same day confirmatory scan for significant stenosis –Agreed protocol with surgeons Faxed referrals Involving enough surgeons to ensure capacity Appropriate surgical prioritisation

Percentage of patients who Survived 30 days from intervention

% of patients who had a stroke within 30 day of a carotid intervention

Scottish Carotid Interventions Project (SCIP) Partnership between ISD and vascular surgeons Use of routine data to monitor survival after surgery Can link operations to subsequent events but accuracy unclear Aims to improve data quality over several cycles

Carotid endarterectomy Should we continue to monitor delays? Should we monitor outcomes? What is happening in rest of UK? –UK Carotid Endarterectomy Audit Should we set NHSQIS standard –80% operated within 30 days of referral to neurovascular services? –Median delay should be <20 days?

Other Issues Good to include audits of – all NV clinics –Thrombolysis –Carotid endarterectomy –Other aspects of care? Do we have the resources to do all of this?

Other Issues Should the final report contain a commentary on the results?

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Percentage of Ischaemic patients discharged on a Statin or in a relevant Trial