1. Scottish Stroke Audit 3rd National Meeting 7th Dec 04

2. Welcome NHS QIS funded audit - Oct 02 - 05 Original plan - 6 to 10 hospitals Impact of CHD & Stroke strategy NHS QIS standards and visits

3. Program Comparisons between hospitals Control charts Demonstration of real time data capture system Audit of swallow screening Update on “MCNs on the Web”

4. How can these data help improve patient care? Identify variation in “performance” and to raise questions about cause of variation Identify methods which increase performance? Highlight services requiring more investment or re design

5. 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

6. Some statistical terms Proportions (%) 95% confidence intervals Means and medians Inter quartile range

7. 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?

8. Denominators If admit 100 stroke patients 60 enter the stroke unit therefore 60% managed in a stroke unit if half get into stroke unit within a day % admitted to SU <1day = 50% or 30% NHS QIS want 30% figure

9. 95% confidence intervals Measure the proportion entering your stroke unit once Calculate the 95% Confidence intervals Measure the proportion a further 100 times and one would expect 95 estimates to lie within the 95% confidence intervals.

10. Effect of sample size

11. A normal distribution Mean = 10 Median = 10 Length of stay in Days No. of patients

12. Length of stay Mean = 10 Median = 10 Length of stay (days) No of people. Mean = total no. of days / total no. of people Median = LOS where half the people have longer ones and half shorter ones

13. A skewed distribution e.g. length of stay in acute stroke unit Mean = 7.3 Median = 6 Days No.

14. A very skewed distribution e.g. delay to CT scan Mean = 4.9 Median = 3 Days No.

15. Quartiles (quarters) Mean = 10 Median = 10 Days No. Interquartile range (IQR) (half the patients are included)

16. Comparisons between hospitals A few hospitals which are currently collecting data are not included because too few data are available.

17. Inpatients

18. Data collection periods vary Longer period will provide more patients and more precise estimates Longer period will include older data Recent short period will not include patients still in hospital - therefore may give biased estimates

19. Variable data collection times

20. No. of admissions available for analysis – Group 1 Ninewells estimates will have wide Confidence intervals so differences are more likely to be due to chance

21. No. of admissions per year Group 1 At Ninewells may be missing cases - not identified or simply not yet discharged

22. No. of admissions available for analysis – Group 2

23. No. of admissions per year – Group 2

24. No. of admissions per year – Group 3

25. No. of admissions per year - Group 4 The estimate in your hand out for St Johns is incorrect

26. No. of admissions per year – Group 5

27. Length of Stay in Hospital Mean Median Group 1 Patients with longer LOS in Ninewells not yet discharged Why is LOS shorter in ARI than Edinburgh??

28. Length of Stay in Hospital Mean Median Group 2

29. Length of Stay in Hospital Mean Median Group 3 Two fold difference Monklands & Falkirk - why?

30. Length of Stay in Hospital Mean Median Group 4

31. Length of Stay in Hospital Mean Median Group 5 Imprecise estimates because small numbers Shetland a different model of service?

32. Proportions admitted to Stroke Unit – Group 1 Note the 95% CI vary with amount of data collected 77 beds42 beds 18 beds

33. Proportions admitted to Stroke Unit – Group 2 Ayr & Crosshouse are doing well! - ? chance because only 3 month 7.6-8.3 pts/SU bed/yr cf 14 pts/SU bed/yr in Inverclyde 35 beds 43 beds 16 beds 30 beds 10 beds

34. Proportions admitted to Stroke Unit – Group 3 24 beds 24 bed 25 beds 30 beds 15 male

35. Proportions admitted to Stroke Unit – Group 4 17 beds 15 beds 8 beds 0 beds 21 beds 14 beds

36. Proportions admitted to Stroke Unit – Group 5 6 beds Variable

37. Mean Delay in accessing SU – Group 1

38. Mean Delay in accessing SU – Group 2

39. Mean Delay in accessing SU – Group 3

40. Mean Delay in accessing SU – Group 4 X

41. Mean Delay in accessing SU – Group 5 X

42. Proportion of admission in Stroke Unit – Group 1 X Reflects delay in admission % entering SU and exit from SU before discharge

43. Proportion of admission in Stroke Unit – Group 2

44. Proportion of admission in Stroke Unit – Group 3

45. Proportion of admission in Stroke Unit – Group 4 X

46. Proportions of admission in Stroke Unit – Group 5 XX

47. Proportions scanned – Group 1 ARI seem to be having problems getting scans

48. Proportions scanned – Group 2 Delays in Ayr and Crosshouse

49. Proportions scanned – Group 3

50. Proportions scanned – Group 4 Raigmore and Victoria Hospital Kirkaldy having problems

51. Proportions scanned – Group 5 Shetland understandably not scanning all patients Western Isles have excellent access to CT

52. Proportion of ischaemic stroke given aspirin within 2 days Group 1 Does ARI perform well because they don’t bother to wait for CT?

53. Proportion of ischaemic stroke given aspirin within 2 days– Group 2 May be bad luck because of small numbers but odd given excellent access to SU & CT - are they giving an alternative antiplatelet drug?

54. Proportion of ischaemic stroke given aspirin within 2 days– Group 3

55. Proportion of ischaemic stroke given aspirin within 2 days– Group 4

56. Proportion of ischaemic stroke given aspirin within 2 days– Group 5

57. Proportion of ischaemic stroke discharged on secondary prevention Group 1 X Ninewells get most patients on triple therapy

58. Proportion of ischaemic stroke discharged on secondary prevention - Group 2

59. Proportion of ischaemic stroke discharged on secondary prevention - Group 3

60. Proportion of ischaemic stroke discharged on secondary prevention - Group 4 VHK and QMH stand out

61. Proportion of ischaemic stroke discharged on secondary prevention - Group 5 Statins not used in Western Isles

62. Proportions of pts with ischaemic stroke and AF discharged on Warfarin – Group 1 Warfarin Antiplatelet X Very varied use of warfarin in AF

63. Proportion of ischaemic stroke in AF given Aspirin or Warfarin– Group 2 Warfarin Antiplatelet Where columns add up to >100 then combination used?

64. Proportion of ischaemic stroke in AF given Aspirin or Warfarin– Group 3 Warfarin Antiplatelet ?? Something odd about data from Lanarkshire

65. Proportion of ischaemic stroke in AF given Aspirin or Warfarin– Group 4 Warfarin Antiplatelet

66. Proportion of ischaemic stroke in AF given Aspirin or Warfarin– Group 5 Warfarin Antiplatelet Proportion of ischaemic stroke in AF given Aspirin or Warfarin– Group 5 1 patient !

67. Discussion

68. Neurovascular clinics

69. No. of Neurovascular Clinic patients available for analysis

70. Diagnoses in Neurovascular clinic

72. Median delay from referral to assessment (days)

73. % seen within 14 days of referral

74. Delays from Assessment to Duplex (days) St Johns reported 3 year data - now sorted Ninewells & RIE get Duplex before clinic and only few patients

75. Delays from Assessment to Brain scan for stroke (days) In some places scans are obtained before clinic

76. Delays from Assessment to Echo for stroke/TIA (days) X XX

77. Treatment of Definite Ischaemic events with aspirin

78. % of Definite Ischaemic events treated with Clopidogrel

79. Treatment of Definite Ischaemic events with aspirin & dipyridamole

80. Mean delays from Last event to surgery (days)

81. Conclusions We have seen considerable variation in the processes of care We need to understand these to strive to provide the best possible service for all No hospital can be complacent - there is room for improvement everywhere

82. Mean delays from Assessment to Duplex (days)

83. Treatment of Definite Ischaemic events with dipyridamole

84. Treatment of Neurovascular clinic patients with definite ischaemic events with BP lowering