Unwarranted clinical variation in ischaemic stroke. Actions from the NSW Stroke Network.

1. SESSION 1: Responding to Unwarranted Clinical Variation: A Case Study Conjoint Associate Professor John Worthington Clinical Co-Chair, ACI Stroke Network Unwarranted clinical variation in ischaemic stroke. Actions from the NSW Stroke Network. NSW Health Symposium Breakout. Sydney 2014.

2. Unwarranted clinical variation in ischaemic stroke. Actions from the NSW Stroke Network. NSW Health Symposium Breakout. Sydney 2014. South Western Sydney Clinical School, Faculty of Medicine, UNSW 1Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia. 2Associate Professor (Conjoint) South Western Sydney Clinical School, The University of New South Wales. 3 Senior Staff Specialist Department of Neurology, Liverpool Health Service, Sydney, Australia. 4 Medical Co-chair Stroke Services New South Wales, Agency of Clinical Innovation. John M Worthington,1,2,3, 4

3. Evidence based practice in ischaemic stroke There is substantial evidence around what constitutes good ischaemic stroke care. The major elements of good stroke care include: • Stroke units. With co-localised stroke beds served by a multidisciplinary stroke team that uses evidenced-based pathways improve stroke outcomes by approximately 30%, at all ages. What reduces death reduces disability.1 • Clot-busting. IV rt-PA within three hours, reduces death and disability by 44% (Cochrane), with more modest benefits at 3-4.5 hours (favourable Odds Ratio 1.34). There is an all-hours cost-of-readiness and no DRG. 1Gattellari et al Stroke 2009; 40: 10-7. 2 Wardlaw et al, Cochrane Database of Systematic Reviews. 2003 (3).

4. Ischaemic stroke care in NSW • 20 Acute Thrombolysis Centres (ATCs) are now nested in 30 acute stroke units across NSW. Nine other hospitals have stroke services. • The 30 and 365 day ischaemic stroke mortality in NSW is 17 and 27%, respectively (Gattellari et al, Cerebrovascular Diseases, 2011). • 35% of stroke patients are discharged to in-patient public rehabilitation, 5% are discharged directly to nursing home and 20-25% return directly to independent living. • NSW outcomes for stroke compare favourably with OECD countries (BHI). • However, many patients do not reach a stroke unit hospital or stroke unit bed (NSF) and there is unwarranted clinical variation between hospitals. In 2012 BHI published de-indentified hospital level data on 30 day stroke mortality in NSW (Health Care in Focus). This analysis, by hospital of death, started a collaborative process to examine unwarranted clinical variation and the 2012 analysis itself.

5. Unwarranted clinical variation in Stroke. Process 2013.

6. Six rural and metropolitan pilot site visits. The ACI team selected 6 rural and metropolitan sites with above or below average mortality on the 2012 BHI analysis and different service characteristics The NSW Stroke Network accepts that stroke care varies and there is a clinical variation in stroke outcomes.

7. Example: Hospital 6 Audit and Feedback ACI Stroke Audit Tool • Rural site. Favourable 30 day mortality. • Stroke Unit and Acute Thrombolysis Centre. • All ischaemic strokes were admitted to the stroke unit! • 75% were on a clinical pathway during the admission. • 65% had a CT within 2 hours and 100% in 24 hours. • Stroke investigation rates shown in the figure. • 100% received neurological observations in the first 24 hours. • 72% received aspirin in the first 24 hours. • Documented swallow assessment within 4 hours of 40% (45% in speech impaired patients). No hospital unit performed consistently well across all clinical care processes that are likely to influence patient outcomes. Where outcomes appeared worse the gaps in evidence-based care were generally greater There was local surprise at rates of pathway use and swallow assessment with an immediate QI response

8. Extracted details from the three metropolitan site audits. The face-to-face feedback to managers and clinicians was almost universally well met and has impacted on care

9. A comparison of some processes that may influence or reflect outcomes. No hospital performed consistently well across all the clinical care processes likely to influence patient outcomes. Where outcomes appear worse the gaps in evidence-based care are generally greater.

10. A catalyst for further work: The BHI publication of 30 day ischaemic stroke mortality with identification of hospitals in 2013.* After the pilot audits the BHI analysis was modified to measure outcomes according to hospital of first presentation. There is a strong argument to benchmark against the better hospitals rather than an arithmetic mean *The Insights Series: 30-day mortality following hospitalisation, five clinical conditions, NSW, July 2009 – 2012

11. Conclusions: Where do we go next? Unwarranted clinical variation in stroke is explicable variation. At present stroke patients do not always receive evidenced-based care. This may be the result of being admitted to a smaller hospital with no organised stroke care and little prospect of providing it, admission to a hospital where stroke unit care could reasonably be provided but no unit has been established, because patients fail to reach stoke unit beds in a hospital with a stroke unit or because of a variations in the quality of care in existing stroke units. A process is needed and underway to reduce unwarranted variation in stroke care. • Expanding access to stroke unit care with new units and consider further bypass of sites. • Improving access to stroke unit beds in stroke unit hospitals. • Improving existing organised stroke care through the ACI Statewide Stroke Clinical Variation Strategy (SSCVS) which offers expansion of the piloted process of audit and feed-back to 30-40 sites. Evaluate and improve Stroke Thrombolysis and the Early Stroke Reperfusion Programme. • Reinforce local Thrombolysis Committee governance, deploy a qualitative audit tool (SRAT) to assess barriers to rapid door-to-needle times and collect an already agreed minimum dataset needed for QI. • With the ABF Taskforce develop a DRG for thrombolysis and re-cost existing stroke care DRGs. • Improve access to stroke thrombolysis through deployment of Tele-Stroke, with HealthShare. Improve data quality and analysis and provide site reporting to management, clinicians and consumers. • Use audit and feedback and consultation to drive improved data collection, analysis and reporting.

12. Thank you Special thanks to Mark Longworth (ACI), Melina Gattellari (Ingham Institute), Kim Sutherland and Doug Lincoln (BHI), Dominique Cadhillac (Florey Institute), site auditors and the clinicians and managers of the 6 pilot sites and the ACI Unwarranted Clinical Variation Taskforce.