Scottish Stroke Audit National Meeting 12th June 2007

Acknowledgements Robin Flaig Mike Mcdowall Audit coordinators Contributing clinicians and managers

Menu Proposed audit cycle Data quality and interpretation National performance in 2005 Performance of individual hospitals – learning lessons from good and bad practice Future plans

Proposed audit & reporting cycle Send SSCAS exports to Robin by 31 st March Prepare draft report by June 1 st National meeting in June MCNs report to SEHD on NHSQIS standards by June 30 th Incorporate data into MCN annual reports & QAF for Health Boards Finalise National report and publish in Sept

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% We have had problems with denominators NHS QIS ask % admitted SU within 1 day Is denominator 60 or 100?

Denominators We provide % based on two denominators with patients with missing data excluded which provides an optimistic estimate with patients with missing data included which is that defined by NHSQIS Large differences between the two often indicates incomplete data collection

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

Performance across Scotland in 2005 Aspect of service2005NHS QIS standard SU care73 SU within 1 day5170 Swallow screen on 1 st day44100 Scan within 2 days7980 Aspirin within 2 days58100

Comparisons between hospitals Inpatients

% of patients treated according to NHSQIS standard NHS QIS standard Mean in 2005 Hospital Number

Aberdeen Royal Infirmary1 Ninewells Hospital2 Perth Royal Infirmary3 Stracathro Hospital4 Royal Infirmary Edinburgh5 St Johns Hospital6 Western General Hospital7 Royal Infirmary Glasgow8 Stobhill Hospital9 Western Infirmary Glasgow10 Southern General Hospital11 Victoria Infirmary Glasgow12 Inverclyde Royal Hospital13 Royal Alexandra Hospital14 Ayr Hospital15 Crosshouse Hospital16 Hairmyres Hospital17 Monklands Hospital18 Wishaw General Hospital19 Forth Valley Hospital20 Borders General Hospital21 Dumfries & Galloway Royal Infirmary22 Raigmore Hospital23 Lorn & Islands24 Belford Hospital25 Caithness Hospital26 Queen Margaret Hospital27 Victoria Hospital, Kirkcaldy28 Orkney29 Shetland30 Western Isles31 Key to Hospital

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)

Observational studies of stroke unit implementation

% Admitted to a stroke unit during admission,including missing

Poor access in Perth, St Johns &Victoria Infirmary

Why such poor access? Lack of SU beds? Filled with non stroke patients? Problems with discharge?

% Admitted to a stroke unit within 1 day of admission, NHS QIS– 2006

WIG, SGH & Lorn & Islands

>10% improvement ARI, RIE, Crosshouse, Forth Valley

How do they do it? Direct admissions? Day & night? Medical staffing out of hours? Do they have a medical assessment unit? How many beds for how many admission? Fixed bed numbers or flexible? Ring fenced beds? How do they clear their beds?

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

% Swallow screened during admission, including missing

% Swallow screened on day of admission NHS QIS – 2006

GRI, WIG & Crosshouse

>10% improvement Aberdeen, Stobhill, Raigmore

How do they do it? 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

% Scanned during admission, including missing

% Scanned within 2 days of admission NHS QIS

Ninewells, WGH, SGH, WIG, Lorn & Islands

>10% improvement ARI, GRI, Stobhill, Crosshouse

How do they do it? Protocols or ICP? Where is the scanner? Week end scanning Out of hours scanning? Additional sessions?

Early aspirin use

Effect of aspirin in acute stroke: hours from stroke onset

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

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

% Received aspirin during admission, including missing

% Received aspirin within 2 days of admission NHS QIS – 2006

SGH, WIG, Caithness, Orkney

>10% improvement GRI, WIG, Ayr, Crosshouse, Orkney, Shetland

How do they do it? 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

Updated Overview of BP-Lowering in Patients With Cerebrovascular Disease Event rate TrialNStudyControl Odds ratio Patients with hypertension Carter9720.4%43.8% HSCSG %23.7% INDANA subgroups %15.3% Subtotal1, %21.6% Patients with or without hypertension TEST %19.8% Dutch TIA1, % 8.4% PATS5, % 7.7% PROGRESS 6, %13.8% Subtotal7, % 8.9% NB mean BP reduction about half as great in patients with or without hypertension, quasi-randomization in PATS and subgroups of 5 trials with INDANA % SE 7 reduction 35% SE 13 reduction and 95% CI 1832 Rodgers Slides #48

% Strokes discharged alive on any antihypertensive or Trial

High use – Stobhill & WIG Low use – RAH & Fife

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

> 10% improvement WIG, WI

How did they do that? Protocol or ICP? Chance?

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

% Pts with Def. Ischaemic event discharged alive on Antiplatelet, Warfarin or a Trial- 2006

Low use in Caithness, Belford & Fife hospitals

Why such variation in antithrombotic use? Chance – low numbers Different views on risks vs benefits Different levels of co-morbidity

Lowering cholesterol after ischaemic stroke

Cholesterol reduction reduces vascular events meta-analysis of trials Confirmed by SPARCL trial specifically in Cerebrovascular disease

% Pts with Def. Ischaemic event discharged alive on Statin or a Trial- 2006

>10% improvement PRI, RIE & Raigmore

How did they do that? Protocol or ICP? Chance?

Low use of statins in Fife?

Why are statins used less in Fife? Consultants beliefs? Lack of protocol or ICP? Cost? Data collection?

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)

% Pts with Def. Ischaemic event in AF discharged alive on Warfarin or a Trial- 2006

>10% improvement GRI, WIG, Ayr

How did they do that? Protocol or ICP? Chance?

High in Ninewells, WIG, D&G, Raigmore, Lorn and Shetland

Low in Victoria, Forth Valley & Fife hospitals

Why such variation in Warfarin use? Chance – low numbers Different views on risks vs benefits 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: Rothwell et al Slow Clinic Same day P Call for aid - clinic ≤ 6 hours1.6%26.3% < ≤ 24 hours 22.9%54.2% < One month F/U On a statin (%) 63.2% 84.1% < On A + C8.0%46.5% < Mean SBP/DBP141/79136/75< CEA < 1 month12%67% Risk of stroke 30-days6.2%0.9% days9.3%1.3% <0.0001

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

% Patients with Days from receipt of referral to examination within 14 days, NHS QIS– 2006

% Patients with Days from receipt of referral to examination within 7 days, desirable NHS QIS– 2006

Stracathro, Crosshouse & Lorn & islands

> 10% improvement ARI, WGH, Crosshouse, Raigmore

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

WGH – a high volume neurovascular clinic About 800 patient per year 25 new slots per week – 3 days One stop imaging Faxed and electronic referrals Average delay 2 weeks

To reduce waiting time GP TIA hotline/ thrombolysis service single phone number Run by Stroke Consultant/ Stroke Neurologist 24/7

Taking a call on the hotline at home

Process Listen to details of event Sometimes take history from patients over phone If TIA likely give GP an appointment time –Ask them to take bloods –Initiate immediate aspirin & statin –Ask for SCI Gateway referral Deflect a significant number of referrals

Neurovascular clinic booking (often next day)

TIA hotline introduced

Future plans Discussions re future funding for audit beyond March 2008 SEHD supportive of continued audit Developing clinical systems to capture some of the data as part of clinical care

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 effect of surgery by time since last event before randomisation in patients with 50-99% stenosis Time since last event (days) Absolute risk reduction (%) Slope = 2.9% per month, P=0.01

Carotid Interventions audit Use of routine data to monitor survival after surgery Aim to improve data quality of several cycles 2007 – audit of delays which will hopefully drive improvements

Issues Should the final report contain a commentary on the results? Who should write that? How far should we disseminate the report?