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• Kapral MK, Hall RE, Silver FL, Robertson AC, Fang
  J. Registry of
• the Canadian Stroke Network. Report on the
  2004/05 Ontario
• Stroke Audit. Toronto Institute for Clinical
  Evaluative Sciences
• 2009.

3
Table of Contents
Slides

• Background....4-5
• Methodology ..6-7
• Key Findings
• Pre-hospital and emergency stroke
  care......8-18
• Emergency and in-hospital management....19-3
  2
• Length of stay, discharge status and destination
  and
• 30-day mortality33-53
• Interpretive Cautions..54-55

4
Background

• Stroke is the fourth leading cause of death and a
  leading cause of adult disability in Canada.
• Previous studies in Ontario reveal variations in
  availability of stroke care resources as well as
  variations in treatment of stroke patients in
  facilities with similar resources.
• Beginning in 2000, Ontario developed a
  coordinated stroke strategy to address
  inconsistencies and improve access to and quality
  of stroke care resources.
• By 2005, the strategy was fully implemented and
  is known as the Ontario Stroke System (OSS).

5
Background (contd)

• Within the OSS, ongoing monitoring and evaluation
  are considered essential to ensure implementation
  of best practices and evidence-based stroke care.
• The Registry of the Canadian Stroke Network
  (RCSN), established in 2001, performs a
  province-wide audit of stroke care in Ontario
  every two years, a process which began in
  2002/03.
• The purpose of the RCSN Ontario Stroke Audit data
  is to evaluate the characteristics, management
  and outcomes of stroke patients in Ontario and to
  make comparisons by Local Health Integration
  Network (LHIN), Ontario Stroke System region and
  by institutional designation with the Stroke
  System (Regional Stroke Centre, District Stroke
  Centre, non-designated hospital).
• This report presents data for fiscal year
  2004/05, with comparisons to the previous audit
  performed in fiscal year 2002/03.

6
Methodology

• All Ontario acute care institutions, excluding
  childrens and mental health care hospitals and
  those with fewer than 10 stroke or transient
  ischemic attack (TIA) separations per year, were
  invited to participate.
• All patients seen in the hospital emergency
  department or admitted to hospital with a most
  responsible diagnosis of stroke or TIA were
  eligible for inclusion in the audit, as
  identified from the Discharge Abstract Database
  (DAD) and the National Ambulatory Care Reporting
  System (NACRS) maintained by the Canadian
  Institute for Health Information (CIHI).
• Overall, 153 acute care institutions (with 154
  individual hospital sites) were eligible all
  agreed to participate in the 2004/05 audit.

7
Methodology (contd)

• Based on this audit, there were 23,800
  hospitalizations or emergency department visits
  for acute stroke or TIA in Ontario in fiscal year
  2004/05.
• For individuals with more than one stroke or TIA
  during the sampling timeframe, only the first
  stroke or TIA event was included.
• The audit sample included a total of 4,913
  patients, or approximately 21 percent of all
  cases.

8
Key FindingsPre-hospital and Emergency Stroke
CareOntario

• Similar to the first audit in 2002/03, in
  2004/05, almost a third (32.5) of all stroke or
  TIA patients arrived at hospital within 2.5 hours
  of stroke onset.
• In 2004/05, more than half (55.2) of stroke or
  TIA patients were transported to hospital by
  ambulance. Almost two-thirds (65.2) were
  admitted to hospital.
• In 2004/05, rates of neuroimaging (CT/MRI) within
  25 minutes of hospital arrival was almost 6,
  compared to almost 3 in 2002/03.

9
Key FindingsPre-hospital and Emergency Stroke
CareOntario

• In 2004/05, thrombolysis was administered to
  almost 4 of patients with acute ischemic stroke,
  an increase from 3 observed in 2002/03. In the
  subgroup of patients presenting within 2.5 hours
  of stroke symptom onset, 14 received
  thrombolysis, significantly improving from almost
  10 observed in 2002/03.
• Among patients receiving intravenous thrombolysis
  in 2004/05, the median door-to-needle time was
  84.2 minutes, with no significant change from
  2002/03.

10
Key FindingsPre-hospital and Emergency Stroke
CareOntario Stroke System (OSS) designation

• The proportion of patients who arrived at the
  emergency department within 2.5 hours of stroke
  onset increased significantly at regional stroke
  centres from 23 in 2002/03 to 33 in 2004/05.
• Patients seen at regional stroke centres were
  more likely than those seen at other hospital
  types to be transported by ambulance and to be
  admitted to hospital.
• Between 2002/03 and 2004/05, there were
  significant increases in neuroimaging rates
  (within 25 minutes of hospital arrival). Rates of
  neuroimaging were highest at regional stroke
  centres and lowest at non-designated hospitals.

11
Key FindingsPre-hospital and Emergency Stroke
CareOntario Stroke System (OSS) designation

• Rates of thrombolysis administration (overall or
  within 2.5 hours of symptom onset) were highest
  at regional stroke centres compared to other
  hospital types.
• Among patients receiving intravenous thrombolysis
  in 2004/05, the median door-to-needle times were
  shortest at regional stroke centres (73.1
  minutes), followed by district stroke centres
  (95.5 minutes) and non-designated hospitals
  (119.8 minutes).

12
Percentage of patients with stroke or transient
ischemic attack who arrived in the emergency
department (ED) within 2.5 hours of stroke onset,
2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
13
Percentage of patients with stroke or transient
ischemic attack transported to hospital by
ambulance, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
14
Percentage of patients with stroke or transient
ischemic attack admitted to hospital, 2002/03 and
2004/05
By Ontario Stroke System (OSS) designation
15
Percentage of patients with ischemic stroke
receiving neuroimaging within 25 minutes of
hospital arrival, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
16
Percentage of patients with ischemic
stroke receiving thrombolysis, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
17
Percentage of patients with ischemic stroke
receiving thrombolysis among those presenting
within 2.5 hours of symptom onset, 2002/03 and
2004/05
By Ontario Stroke System (OSS) designation
18
Median door-to-needle time among patients with
ischemic stroke receiving intravenous
thrombolysis, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
19
Key Findings (contd)Emergency and in-hospital
managementOntario

• Increases were observed among stroke patients for
  the following indicators in 2004/05
• Almost 69 of patients underwent neuroimaging (CT
  and/or MRI of the brain) within 24 hours of
  hospital arrival. A significant improvement from
  47 observed in 2002/03. Neuroimaging at any time
  before hospital discharge, was almost 82, an
  increase from 77 in 2002/03.
• Carotid imaging (performed or scheduled) was 55,
  up from from 44 in 2002/03.
• Dysphagia assessment (a swallowing assessment)
  was 51, an increase from 47 in 2002/03.
• Drug therapy at discharge (i.e.,antithrombotic
  therapy, warfarin for atrial fibrillation, ACE
  inhibitors and lipid-lowering therapy)
  significantly increased from 2002/03, with the
  exception of warfarin for atrial fibrillation.
• Stroke unit admission was 11, an increase from
  almost 3 observed in 2002/03.
• Referrals to stroke secondary prevention clinics
  was 29, up from 14 in 2002/03.

20
Key Findings (contd)Emergency and in-hospital
managementOntario Stroke System (OSS)
designation

• There were statistically significant improvements
  in neuroimaging rates (within 24 hours of
  hospital arrival or at any time before hospital
  discharge) at all types of hospital between
  2002/03 and 2004/05.
• In 2004/05, neuroimaging rates were markedly
  higher at regional stroke centres compared to
  other types of hospitals, with imaging rates
  prior to hospital discharge of 96, 84 and 77
  at regional stroke centres, district stroke
  centres and non-designated hospitals,
  respectively.
• In 2004/05, rates of carotid imaging (performed
  or scheduled), were higher at regional stroke
  centres compared to other types of hospitals,
  with rates of almost 70, 61 and 49 at regional
  stroke centres, district stroke centres and
  non-designated hospitals, respectively.

21
Key Findings (contd)Emergency and in-hospital
managementOntario Stroke System (OSS)
designation

• In 2004/05, dysphagia screening rates were
  highest at regional stroke centres (56 of
  patients), followed by district stroke centres
  (54 of patients) and non-designated hospitals
  (48 of patients).
• In 2004/05, there were variations in rates of
  prescribing ACE inhibitors and lipid-lowering
  therapy after hospital discharge across hospital
  types, but no significant variations in
  prescribing of antithrombotic agents or warfarin
  for atrial fibrillation. Between 2002/03 and
  2004/05, increases in rates of prescribing of
  antithrombotic therapy, ACE inhibitors and
  lipid-lowering medications for secondary
  prevention of stroke, were observed across all
  hospital types.

22
Key Findings (contd)Emergency and in-hospital
managementOntario Stroke System (OSS)
designation

• Direct admission to stroke unit increased
  markedly at regional stroke centres, from almost
  4 in 2002/03 to 41 in 2004/05. Increases were
  also observed at district stroke centres from
  almost 2 in 2002/03 to 7 in 2004/05. Rates of
  stroke unit admission were lowest at
  non-designated hospitals (ranging between 2-3)
  in 2002/03 and 2004/05.
• Referral rates to stroke secondary prevention
  clinics were highest at regional stroke centres
  (67) compared to district stroke centres (27)
  and non-designated hospitals (21). However, the
  largest increase in referral rates was observed
  at non-designated hospitals, at 7 in 2002/03 to
  21 in 2004/05.

23
Percentage of patients with stroke or transient
ischemic attack undergoing neuroimaging within 24
hours of arrival in the emergency department
(ED), 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
24
Percentage of patients with stroke or transient
ischemic attack undergoing neuroimaging at any
time before discharge, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
25
Percentage of patients with ischemic stroke or
transient ischemic attack receiving carotid
imaging, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
26
Percentage of patients with ischemic stroke or
transient ischemic attack receiving
antithrombotic therapy at discharge, 2002/03 and
2004/05
By Ontario Stroke System (OSS) designation
27
Percentage of patients with ischemic stroke or
transient ischemic attack receiving warfarin for
atrial fibrillation at discharge, 2002/03 and
2004/05
By Ontario Stroke System (OSS) designation
28
Percentage of patients with ischemic stroke or
transient ischemic attack receiving ACE
inhibitors at discharge, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
29
Percentage of patients with ischemic stroke or
transient ischemic attack receiving
lipid-lowering therapy at discharge, 2002/03 and
2004/05
By Ontario Stroke System (OSS) designation
30
Percentage of patients with stroke or
transient ischemic attack who underwent dysphagia
screening, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
31
Percentage of patients with stroke or transient
ischemic attack admitted directly to stroke
unit, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
32
Percentage of patients with stroke or transient
ischemic attack referred to a Secondary
Prevention Clinic, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
33
Key Findings (contd)Length of stay, discharge
status and destination and 30-day
mortalityOntario

• In 2004/05, the median inpatient length of
  hospital stay for patients with stroke/TIA was
  6.5 daysa decrease from 7.6 days observed in
  2002/03.
• In 2004/05, the majority (55) of stroke patients
  were discharged home and almost 16 were
  discharged to inpatient rehabilitation
  facilities. In the subgroup of patients with
  moderate to severe disability after stroke
  (Rankin score 3 to 5), the majority (35) were
  discharged to inpatient rehabilitation. This was
  a significant decrease compared to 42 observed
  in 2002/03.
• In 2004/05, the age- and sex-adjusted 30-day
  ischemic stroke mortality rate was almost 15
  this did not significantly change from 2002/03.
  The age- and sex-adjust hemorrhagic stroke
  mortality rate was almost 42 again, similar to
  that observed in 2002/03.

34
Key Findings (contd)Length of stay, discharge
status and destination and 30-day
mortalityOntario Stroke System (OSS)
designation

• In both 2002/03 and 2004/05, the median inpatient
  length of hospital stay for patients with
  stroke/TIA was greater at regional stroke centres
  compared to other hospital types. For all three
  OSS designations, the median inpatient length of
  stay decreased between 2002/03 and 2004/05.
• In 2004/05, patients seen at regional and
  district stroke centres were more likely to be
  transferred to inpatient rehabilitation, compared
  to patients seen at non-designated hospitals. At
  regional stroke centres, there was a decrease in
  the proportion of stroke patients discharged to
  inpatient rehabilitationfrom 25 in 2002/03 to
  almost 19 in 2004/05.

35
Key Findings (contd)Length of stay, discharge
status and destination and 30-day
mortalityOntario Stroke System (OSS) designation

• Discharge destinations were similar among the
  subgroup of patients with moderate to severe
  disability (Rankin score 3-5), with the exception
  of discharge to inpatient rehabilitation. These
  rates were highest at regional stroke centres
  (40), followed by district stroke centres (38)
  and non-designated hospitals (almost 33).
• Compared to 2002/03, there was a significant
  decrease in the proportion of patients with
  moderate to severe disability discharged to
  inpatient rehabilitation from both regional and
  district stroke centres.

36
Key Findings (contd)Length of stay, discharge
status and destination and 30-day
mortalityOntario Stroke System (OSS) designation

• In 2004/05, age- and sex-adjusted 30-day ischemic
  stroke mortality rates were lower at regional
  stroke centres compared to those at
  non-designated hospitals. There were no
  statistically significant variations in the age-
  and sex-adjusted 30-day hemorrhagic stroke
  mortality rates across hospital types.

37
Median length of stay for patients with stroke
or transient ischemic attack, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
38
Percentage of patients with stroke or transient
ischemic attack discharged home, 2002/03 and
2004/05
By Ontario Stroke System (OSS) designation
39
Percentage of patients with stroke or transient
ischemic attack discharged to an inpatient
rehabilitation facility, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
40
Percentage of patients with stroke or transient
ischemic attack discharged to home care, 2002/03
and 2004/05
By Ontario Stroke System (OSS) designation
41
Percentage of patients with stroke or transient
ischemic attack discharged to a long-term care
facility, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
42
Percentage of patients with stroke or transient
ischemic attack discharged to an acute facility,
2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
43
Percentage of patients with stroke or transient
ischemic attack discharged to other facility,
2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
44
Percentage of patients with stroke or transient
ischemic attack with a Rankin Score of 02 and
discharged home, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
45
Percentage of patients with stroke or transient
ischemic attack with a Rankin Score of 02 and
discharged to an inpatient rehabilitation
facility, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
46
Percentage of patients with stroke or transient
ischemic attack with a Rankin Score of 02 and
discharged to home care, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
47
Percentage of patients with stroke or transient
ischemic attack with a Rankin Score of 02 and
discharged to a long-term care facility, 2002/03
and 2004/05
By Ontario Stroke System (OSS) designation
48
Percentage of patients with stroke or transient
ischemic attack with a Rankin Score of 35 and
discharged home, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
49
Percentage of patients with stroke or transient
ischemic attack with a Rankin Score of 35 and
discharged to an inpatient rehabilitation
facility, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
50
Percentage of patients with stroke or transient
ischemic attack with a Rankin Score of 35 and
discharged to home care, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
51
Percentage of patients with stroke or transient
ischemic attack with a Rankin Score of 35 and
discharged to a long-term care facility, 2002/03
and 2004/05
By Ontario Stroke System (OSS) designation
52
Age- and sex-adjusted 30-day ischemic stroke
mortality rate for patients with ischemic stroke
seen in the emergency department (ED) or admitted
to hospital, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
53
Age- and sex-adjusted 30-day intracranial
hemorrhagic stroke mortality rate for patients
with intracranial hemorrhage seen in
the emergency department (ED) or admitted to
hospital, 2002/03 and 2004/05
By Ontario Stroke System (OSS) designation
54
Interpretive Cautions

• Overall rates of key quality indicators for acute
  stroke care are presented. Benchmarks have not
  been established for most of these indicators.
• Low rates of some indicators may be partially
  explained and/or related to the lack of timely
  neuroimaging or interpretation of test results in
  smaller treatment centres or by the limited
  number of physicians and other health care
  workers with stroke care expertise in certain
  facilities and geographic areas.

55
Interpretive Cautions (contd)

• Significant improvements in the use of
  evidence-based practices and interventions
  occurred between the 2002/03 and 2004/05 audits.
  Although the analysis does not allow one to
  evaluate the reasons for the observed
  improvements in care, there is a temporal
  association between the implementation of the
  Ontario Stroke System and improved stroke care
  delivery. However, variations in care delivery
  among hospital types continue to exist, with
  lower rates of many stroke care interventions at
  small community hospitals compared to other
  hospital types.
• LHIN-level analyses are based on where the
  patient received treatment and not where the
  patient resided. Therefore analyses in this
  report are facility based.