Best Practice Recommendations for Inpatient Stroke Care: Rationale and Evidence for Integrated Stroke Units in North Simcoe Muskoka LHIN

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1 Best Practice Recommendations for Inpatient Stroke Care: Rationale and Evidence for Integrated Stroke Units in North Simcoe Muskoka LHIN Physician Education Session May 24, 2013 Dr. Mark Bayley,, Cheryl Moher,, Matthew Meyer

2 Objectives By the end of this session you will be able to: name key best practices for stroke care, in particular acute and rehabilitation stroke unit care discuss how HSFR and QBP for stroke can be aligned with LHIN planning identify the principles of the proposed system change for cross-continuum stroke care in NSM LHIN discuss the benefits of implementing Integrated Stroke Units to enhance stroke care in view of the geography of NSM LHIN

3 Impact of Stroke Stroke is the third leading cause of death and long term disability in Canada. 50,000 Canadians experience a stroke each year; and over 14,000 Canadians die as a result. 20,000 in Ontario 682 in North Simcoe Muskoka (based on average admissions per yr over 5 yrs) 300,000 living with the effects of stroke 25% recover with a minor impairment 40% are left with a moderate to severe disability (Heart and Stroke Foundation of Ontario 2010). 22% of residents in LTC age 65 or older have had a stroke (Heart and Stroke Foundation of Ontario, 2000) and stroke is the third most common diagnosis in long-term care (Price Waterhouse Cooper 2001).

4 Objective Understand the evidence and rationale for the Ontario Stroke Reference Panel recommendations for Specialized Stroke Units Early admission to rehabilitation Intensity of therapy Access for Severe stroke Outpatient Rehabilitation

5 Models of Stroke Care General Medical Ward Acute Stroke Units Combined acute and subacute stroke units (also known as Integrated Stroke Units) Subacute Stroke Rehab units Roving/Mobile Stroke Teams

6 Pooled Analysis for Death and Dependency Model of Care OR (95% CI) Acute stroke care 0.70 (0.56, 0.86) Combined acute 0.56 ( ) and subacute Subacute Rehab 0.63 ( ) Mobile stroke team 1.00 ( ) Overall 0.68 ( )

7 Specialized Stroke Units in Ontario More likely to provide best practice stroke care: increased access to acute thrombolysis admission to stroke units discharge to inpatient rehabilitation, and access to secondary prevention clinics higher rates of appropriate medications at discharge, and lower 90 day rates of stroke recurrence Ontario Stroke Evaluation Report 2012

8 Why Consolidate Stroke Care? Is there a relationship between Volumes and outcomes?

9 Methodology Data Sources and Patient Sample The Canadian Institute for Health Information Discharge Abstract Database (DAD) was used to identify all adult ischemic stroke separations (> 18 years old) at 128 acute hospitals in the province of Ontario between April 1, 2005 to March 31, We excluded hospitals with <15 ischemic stroke discharges per year, in-hospital strokes and elective admissions. Ischemic stroke patients were identified if the most responsible diagnosis code was either ICD-10-CA I63 (excluding I63.6), I64 or H34.1. We took the first ischemic stroke event for each individual in each fiscal year. N = 70,895

10 Methodology Statistical Analyses Hospital Volume: Hospital annual ischemic stroke discharge volume was assigned as the mean (+/- SD) at each hospital over 7 years (April 1, 2005 to March 31, 2012). Spline plots were used to evaluate if there was a linear relationship between hospital ischemic stroke volume and 30-day all-cause mortality. Small, medium and high volume-based categories used to describe the association between hospital ischemic stroke volume and 30-day allcause mortality. Risk-adjusted Mortality: We used a modified version of the Canadian Institute for Health Information stroke 30-day mortality risk adjustment model 7 and included year. Multivariate logistic regression with the generalized estimating equations approach to account for within hospital patient clustering.

11 Ontario Results 30 day Mortality Adjusted OR 95% CI Small volume hospital ( annual volume) Medium volume hospital ( annual volume) High volume hospital ( annual volume)

12 Findings As with other medical conditions ischemic stroke volume and 30-day all-cause mortality is non-linear and becomes attenuated at greater volumes ( >= 165, the volume-mortality curve begins to flatten). After taking into account case-mix across hospitals, hospitals that have average annual stroke volumes greater than 15 but less than 130 per year have 30-day risk-adjusted all-cause mortality rates 38% higher than high volume hospitals that see on average 300 ischemic stroke patients per year.

13 Goal. Earlier Onset of Rehabilitation

14 Benefit of Early Therapy in Animals Methods: Biernaskie et al. (2004) subjected rats to rehab x 5 weeks beginning at 5, 14 and 30 days post small strokes Control animals social housing

15 Benefit of Early Therapy in Animals- Results: All received 5 weeks of enriched environment Day 5 admission marked improvement Day 14 moderate improvement Day 30 no improvement vs. controls Corresponding cortical reorganization in brain around stroke

16 % D/C SRU GMU Weeks

17 * OT PT SRU GMW Mean hrs/pt

18 PSROP (Post-Stroke Rehabilitation Outcomes Project) Study of 7 stroke rehab centers (6 in United States, n=1161; 1 in New Zealand, n=130) Comprehensive study of stroke rehabilitation examining the black box PSROP study, Archives of PM&R Dec 2005 suppl

19 What did the more efficient Stroke centers do? Admitted to specialized inter-disciplinary stroke rehab units Admitted earlier and more disabled More intensive therapy (incl. W/E) Less time in assessments Move to high level tasks early Well developed outpatient services

20 Therapy Intensity

21 Reality Check: Therapy is Cheap; Length of Stay is Not Therapists are not replaced when sick or absent Laissez-faire attitude towards rehab therapies even though it is what we are supposed to be doing At least 60% of stroke rehab budget costs are nursing (versus <20% of core therapies) Stroke rehab patient gets an average of a little over one hour of therapy per day Need to ensure standards for daily therapy

22 Severe Strokes: Who should be Rehabilitated?

23 Rehab of Severe Strokes These are patients who are major contributor to ER/ALC issue Patients with severe strokes improve to a lesser degree and at slower rate Benefit of rehab more prevention of complications and improved discharge planning

24 Jorgensen et al. (2000) Comparative trial N = 1241 consecutive stroke patients Group 1 (n = 305) - general and neurological wards Group 2 (n = 936) - single stroke unit Patients similar in two groups 88% of all strokes admitted to hospital

25 Jorgensen et al. (2000) For severe strokes poor outcome reduced by 86%; relative risk of 1 and 5 year mortality reduced by 40% and 70% Authors attributed it to an interdisciplinary rehab approach

26 Outpatient Rehab Outpatient therapy improves short-term functional outcomes Hospital same as home-based Outpatient therapy is relatively inexpensive (1 PT/1 OT/0.5 SLP/0.5 SW = cost of 1 rehab inpt bed) 30% reduction in bad outcomes, including institutionalization and allows earlier discharge home Estimated savings is $2 for every $1 spent on outpatient therapies

27

28 Health System Reform and QBP Organizations will be paid on a per patient basis as long as they follow the evidence above Admission to stroke unit Rehab starts day 5 (ischemic) and Day 7 (hemorrhagic stroke) Rehab intensity of 3 hours per day Shorter lengths of stay Enhanced outpatient rehab (phase 2)

29

30

31 Reason for System Change in NSM There is an opportunity to develop a cost effective and integrated stroke care model that supports enhanced patient outcomes and is aligned with best practice.

32 Case for Change Four pillars: 1. interprofessional stroke units (acute and rehabilitation) 2. earlier access to rehabilitation 3. increased intensity of stroke rehabilitation, and 4. increased outpatient rehabilitation. founded in evidence-based practices for stroke care validated through consultation and collaboration

33 Integrated Stroke Model of Care The Case for Change recommended the preferred model for stroke system design for NSM LHIN as an integrated stroke model of care cross-continuum stroke care provided at appropriate centres across the LHIN beginning with Integrated Stroke Units (ISUs) Recommendations are: Stroke care clustered at 2 3 sites Hospitals with integrated stroke units provide acute and inpatient rehabilitation stroke care Stroke care will be supported by all health service providers across the LHIN

34 Guiding Principles for System Change Critical mass to develop and maintain interprofessional stroke expertise Patient centred care closer to home when possible Existing infrastructure

35 Considerations Cross-LHIN stroke service planning for the Parry Sound and Alliston populations and other NSM residents. Establish cross-continuum stroke services at each site including prevention clinics, outpatient rehabilitation, and potentially t-pa delivery. TIA (22% of current admissions) Regional bed registry Seasonal variations Impact on other programs (CCC slow stream rehab)

36 Service Provision: Community Phase Recommendations are for: Outpatient/ambulatory stroke rehabilitation programs associated with each ISU Satellite clinics in sub-lhin areas without ISU Ability for teams to provide therapy in the community when needed (mobile teams) Developed and validated with stakeholder input Interprofessional team care Stroke Care Expertise Appropriate therapy intensity (2 3 visits per week for each required discipline for a minimum of 8-12 weeks) Coordination with CCAC services (e.g. home safety assessments) System Navigation as a key component

37 Stroke Care in NSM: Opportunities for Improvement On average between 2007 and 2011: -153 TIA admissions annually (22%) ~$3,400 each, ~$518,000 total ALC bed days annually ~$600/day, ~$1.38M total

38 Stroke Care in NSM: Opportunities for Improvement On average between 2007 and 2011: Estimated Direct Cost of Stroke Care: $5,256,457 Cost of 10-day mean LOS $4,266,934 (-$989,523) Best-practice $2,788,900 (-$2,467,558)

39 Stroke Care in NSM: Opportunities for Improvement Estimated need for O/P or Community Rehab: 5729 OT and PT sessions (each) 2865 SLP Estimated Cost: Outpatient program: $1,361,086 Community program: $1,877,366

40 Stroke System Redesign: Anticipated Benefits Improved patient outcomes Improved quality of life, independence, ability to perform self care, return home, return to work,... Quality of Care Improved access to care Improved patient flow Reduced Length of Stay in hospital More people returning home after stroke Less people returning to hospital within 30 days of discharge Emerging evidence indicates that best practice stroke rehabilitation can help to minimize the economic burden of stroke on the healthcare system. Reduce length of stay Reduce ALC time

41 Questions? For those on live webcast questions for the presenters can be submitted to

42 Thank you.

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