Transcript Comparisons between hospitals

Scottish Stroke Audit
National Meeting
12th June 2007
Acknowledgements
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Robin Flaig
Mike Mcdowall
Audit coordinators
Contributing clinicians and managers
Menu
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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
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Send SSCAS exports to Robin by 31st March
Prepare draft report by June 1st
National meeting in June
MCNs report to SEHD on NHSQIS standards
by June 30th
• 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
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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 service
2005
SU care
SU within 1 day
Swallow screen on 1st day
Scan within 2 days
Aspirin within 2 days
73
51
44
79
58
NHS QIS
standard
70
100
80
100
Comparisons between hospitals
Inpatients
% of patients treated according to
NHSQIS standard
100
90
80
70
60
50
40
30
20
10
0
NHS QIS standard
Mean in 2005
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Hospital Number
Key to Hospital
Aberdeen Royal Infirmary
1
Hairmyres Hospital
17
Ninewells Hospital
2
Monklands Hospital
18
Perth Royal Infirmary
3
Wishaw General Hospital
19
Stracathro Hospital
4
Forth Valley Hospital
20
Royal Infirmary Edinburgh
5
Borders General Hospital
21
St Johns Hospital
6
Western General Hospital
7
Dumfries & Galloway Royal
Infirmary
22
Royal Infirmary Glasgow
8
Raigmore Hospital
23
Stobhill Hospital
9
Lorn & Islands
24
Western Infirmary Glasgow
10
Belford Hospital
25
Southern General Hospital
11
Caithness Hospital
26
Victoria Infirmary Glasgow
12
Queen Margaret Hospital
27
Inverclyde Royal Hospital
13
Victoria Hospital, Kirkcaldy
28
Royal Alexandra Hospital
14
Orkney
29
Ayr Hospital
15
Shetland
30
Crosshouse Hospital
16
Western Isles
31
Stroke unit care
Organised inpatient (stroke unit) care
Absolute outcomes at 6-12 months
Outcome
Stroke unit
Control
Risk difference
Home,
(independent)
Home
(dependent)
44 %
38 %
5 (1, 8)*
16 %
16 %
0 (-2, 3)
Institutional
care
18 %
20 %
-2 (-5, 0)*
Dead
22 %
26 %
-3 (-6, -1)*
SUTC (2001)
Observational studies of stroke unit
implementation
% Admitted to a stroke unit during
admission,including missing - 2006
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Poor access in Perth, St Johns
&Victoria Infirmary
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
WIG, SGH & Lorn & Islands
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
>10% improvement 2005-2006
ARI, RIE, Crosshouse, Forth Valley
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
How do they do it?
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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
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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 - 2006
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
% Swallow screened on day of
admission NHS QIS – 2006
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
GRI, WIG & Crosshouse
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
>10% improvement 2005-2006
Aberdeen, Stobhill, Raigmore
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
How do they do it?
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Who does the screening?
How were they trained?
Where do they do it?
How is it documented?
Are they missing cases?
Brain scanning
Brain scanning
• To exclude alternative diagnoses
• To distinguish haemorrhage and infarction
• To allow safe use of antithrombotic treatment
% Scanned during admission,
including missing - 2006
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
% Scanned within 2 days of
admission NHS QIS - 2006
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Ninewells, WGH, SGH, WIG, Lorn
& Islands
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
>10% improvement 2005-2006
ARI, GRI, Stobhill, Crosshouse
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
How do they do it?
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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 1000
9 avoid event
in 2 weeks
10
9
Antiplatlet
Control
8
7
Acute stroke
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 - 2006
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
% Received aspirin within 2 days of
admission NHS QIS – 2006
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
SGH, WIG, Caithness, Orkney
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
>10% improvement 2005-2006
GRI, WIG, Ayr, Crosshouse, Orkney,
Shetland
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
How do they do it?
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Protocol or ICP?
Rapid scanning?
No scanning?
Immediate reporting or PACS on ward?
Nurse prescription?
Blood pressure lowering
after stroke
PROGRESS - Stroke
All participants
28% risk reduction
95%CI 17 - 38%
p<0.0001
Proportion with event
0.20
0.15
0.10
Placebo
Active
0.05
0.00
0
1
2
Follow-up time (years)
3
4
Updated Overview of BP-Lowering in
Patients With Cerebrovascular Disease
Trial
N
Patients with hypertension
Carter
97
HSCSG
452
INDANA subgroups 514
Subtotal
1,063
Event rate
Study Control
20.4%
18.5%
11.4%
15.2%
43.8%
23.7%
15.3%
21.6%
Patients with or without hypertension
TEST
720
19.9%
19.8%
Dutch TIA
1,473
7.1%
8.4%
PATS
5,665
5.6%
7.7%
PROGRESS
6,105
10.1%
13.8%
Subtotal
7,858
7.2%
8.9%
Odds ratio
and 95% CI
35% SE 13
reduction
26% SE 7
reduction
0.0
0.5
1.0
1.5
2.0
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.
1832 Rodgers Slides #48
% Strokes discharged alive on any
antihypertensive or Trial - 2006
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
High use – Stobhill & WIG
Low use – RAH & Fife
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Why such variation in blood
pressure lowering?
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Chance – low numbers?
Different views on risks vs benefits?
Different levels of co-morbidity?
Cost?
Presence or absence of protocols?
Data collection?
> 10% improvement 2005-2006
WIG, WI
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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 1000
9 avoid event
in 2 weeks
Treat 1000
36 avoid event
in 29 months
25
20
15
Antiplatlet
Control
10
5
0
Acute stroke
Secondary prevention
% Pts with Def. Ischaemic event
discharged alive on Antiplatelet,
Warfarin or a Trial- 2006
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Low use in Caithness, Belford &
Fife hospitals
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
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 Trial2006
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
>10% improvement 2005-2006
PRI, RIE & Raigmore
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
How did they do that?
• Protocol or ICP?
• Chance?
Low use of statins in Fife?
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Why are statins used less in Fife?
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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
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
>10% improvement 2005-2006
GRI, WIG, Ayr
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
How did they do that?
• Protocol or ICP?
• Chance?
High in Ninewells, WIG, D&G,
Raigmore, Lorn and Shetland
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Low in Victoria, Forth Valley &
Fife hospitals
100
90
80
70
60
50
40
30
20
10
0
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Why such variation in Warfarin use?
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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
Risk of stroke (%)
14
OXVASC
OCSP
12
10
8
6
10% risk of stroke by 7
days
4
2
0
0
Lancet 2005; 366: 29-36
7
14
Days
21
28
EXPRESS: Rothwell et al
Slow Clinic
Same day
P
Call for aid - clinic
≤ 6 hours
≤ 24 hours
1.6%
22.9%
26.3%
54.2%
<0.0001
<0.0001
One month F/U
On a statin (%)
On A + C
Mean SBP/DBP
CEA < 1 month
63.2%
8.0%
141/79
12%
84.1%
46.5%
136/75
67%
<0.0001
<0.0001
<0.0001
0.001
Risk of stroke
30-days
90-days
6.2%
9.3%
0.9%
1.3%
0.0004
<0.0001
EXPRESS: Clinic-referred population
Risk of stroke (%)
10
Slow
clinic
8
6
P<0.0001
4
Same day clinic
2
0
0
30
60
Days from medical attention
90
% Patients with Days from receipt of
referral to examination within 14
days, NHS QIS– 2006
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
% Patients with Days from receipt of
referral to examination within 7
days, desirable NHS QIS– 2006
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Stracathro, Crosshouse & Lorn &
islands
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
> 10% improvement 2005-2006
ARI, WGH, Crosshouse, Raigmore
100
90
80
70
60
50
40
30
20
10
0
1 2
3 4
5
6 7
8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
How do they do it?
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Method of getting referrals?
Management of clinic slots?
Number of clinic slots – capacity?
Informing patients of appointments
WGH – a high volume
neurovascular clinic
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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)
Days from receipt of referral to examination < 7d, and <
14d for patients with definite TIA/ stroke,
NHS QIS Standard is to achieve > 80% for both
100
90
80
Percentage
70
60
50
40
30
20
10
0
Jan- Feb- Mar- Apr- M Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- M Jun- Jul- Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar05 05 05 05 ay- 05 05 05 05 05 05 05 06 06 06 06 ay- 06 06 06 06 06 06 06 07 07 07
06
05
Months
WGH Percentage seen within 7 days
WGH Percentage seen within 14 days
Target
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
Carotid surgery
Melbourne
November, 2000
The vast majority of TIA patients do not
get near a surgeon!
1000
TIA patients
500
present to
medical attention
300
recognised by GP
and referred to
hospital
250
in the carotid
territory
40
with severe
stenosis
30
willing to take
risk of surgery
The effect of surgery by time since last event
before randomisation in patients with 50-99%
stenosis
Absolute risk reduction (%)
20
Slope = 2.9% per month, P=0.01
15
10
5
0
-5
-10
0
30
60
90
120
Time since last event (days)
150
180
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?