# Presentation: 321066

## American Academy of Neurology Presentation: “Drip and Ship” for stroke patients receiving rt-PA:the need for a V code

- Joseph Broderick, MD
- Dawn Kleindorfer, MD
- March 20th, 2008

## Overview

- Background of Acute Stroke Therapy
- Description of Current Issue: Drip and Ship
- Proposed Solutions

## Background

**#3 killer and #1 cause of disability**, costing the healthcare system over $50 billion annually
- With the growing elderly population, the situation will only worsen
- Approximately 70% of stroke patients are over 65 years of age
- Patients treated in stroke DRGs are the second leading contributor to Medicare post-acute care spending.  Medicare spends more on post-acute care for these patients than what it pays for acute inpatient hospital care.

**Notes:**
Be clear that the additional resources we are asking for:
Incremental product development funding
Incremental headcount funding

## Background

- There is only 1 approved drug for treating an Acute Ischemic Stroke: rt-PA
- Successful administration of rt-PA has been proven to improve long term outcomes and reduces costs to the healthcare system

## Slide 5

**Notes:**
Middle line is where stroke patients end up with no rt-PA
Bottom line is what happens when the same 16 patients get rt-PA.  No effect on mortality, but saves disability

## Cost Effectiveness of rt-PA

- In the original NINDS rt-PA Stroke Trial, the
**average length of stay was significantly shorter** in rt-PA-treated patients than in placebo-treated patients (10.9 versus 12.4 days; p = 0.02)
**More rt-PA patients were discharged to home** than to inpatient rehabilitation or a nursing home (48% versus 36%; p = 0.002).
- Markov model estimate: Per 1000 eligible patients, **4 million dollars saved over their lifetimes**
- increase in hospitalization costs of $1.7 million,
- decrease in rehabilitation costs of $1.4 million and
- decrease in nursing home costs of $4.8 million
- The estimated impact on long-term health outcomes was 564 (3 to 850) quality-adjusted life-years saved over 30 years of the model per 1,000 patients.

- Fagan, S., Morgenstern, L., Petitta, A., Ward, R., Tilley, B., Marler, J., Levine, S., Broderick, J., Kwiatkowski, T., Frankel, M., Brott, T., Walker, M., and NINDS rt-PA Stroke Study Group, *Cost-effectiveness of tissue plasminogen activator for acute ischemic stroke.* Neurology, 1998. **50**: p. 883-890.

## What is “drip and ship” and why is it increasing?

## Drip and Ship

- Use of rt-PA in smaller community and rural hospitals is increasing because of support relationships with regional comprehensive stroke centers, similar to trauma models of care
- However, patients still need to be cared for in major stroke centers to optimize recovery

## Drip and Ship

- With telephone support and direction from nearby tertiary care “comprehensive stroke center”, community hospital is able to diagnose ischemic stroke and institute rt-PA treatment within 3 hour window.

## Drip and Ship

- Because community and rural hospitals may not have resources, including neurology expertise, to care for these complex stroke patients and to monitor rt-PA treatment, patient is emergently transferred to nearby stroke center.

## The ‘Drip and Ship’ Scenario A 

**Stroke Center hospital gives rt-PA **
**and admits patient**
- ER performs history/examination, head CT scan, blood work
- Administers rt-PA in ER
- Admits patient to neurological ICU
- Close monitoring for worsening
- Blood pressure, neurologic exams by neuro trained staff
- Additional radiology, cardiology testing and bloodwork
- Protocol-driven care to improve outcomes and prevent medical complications (part of stroke center certification), neurosurgical expertise available

## Scenario B

**Outside ER gives rt-PA (DRIP) **
**then transfers patient to **
**stroke center ER (SHIP) **
- Outside ER obtains history/examination, a head CT, blood work
- Calls stroke center physician for treatment recommendations
- Outside ER gives rt-PA after phone consultation with stroke center
- Patient transferred to stroke center ER (often while rt-PA dripping)
- Stroke center ER obtains history/examination, may repeat head CT if needed
- Admits patient to neurological ICU
- Close monitoring for worsening
- Blood pressure, neurologic exams by neuro trained staff
- Additional radiology, cardiology testing and blood work
- Protocol-driven care to improve outcomes and prevent medical complications (part of stroke center certification), neurosurgical expertise available

## Why is stroke different?

- Why isn’t this as much of a problem for other conditions (eg. acute myocardial infarction)?
- Less stroke-trained neurologists
- ED physicians less comfortable with neurologic problems, esp. rt-PA
- No definitive test that diagnoses stroke
- No required training during ED residency, therefore less comfortable with neurologic exam and diagnoses
- Complications after rt-PA more common for stroke than for lytic for other conditions, and are life-threatening
- Monitoring for complications requires specialized stroke care and neurosurgical back-up

## How does drip and ship interfere with tracking of treatment and quality indicators?

## CDC grant for studying stroke 

- Currently, Dawn Kleindorfer is the principal investigator of a investigator-initiated grant from the CDC  to evaluate trends over time in:
- Rates of rt-PA use
- Quality of care indicators for stroke patients

*CDC TA#: U36/CCU319276 , CDC contact Henraya McGruder*

## Rt-PA Use is Increasing

- Using the Premier database, which allows pharmacy cross-referencing, evaluated rt-PA use
**Rt-PA use increased by 60% over 2 year period!**

|  | FY2001 | FY2002 | FY2003 | FY2004 | 

FY2005 | 

FY2006 |  |
| --- | --- | --- | --- | --- | --- | --- | --- |
| Total number of cases, DRG 14/15/524/559   | 54,772 | 59,893 | 58,570 | 56,129 | 

54,012 | 

59,334 |  |
|  # with pharmacy billing for thrombolytic (%)* | 875 (1.60%) | 1002 (1.67%) | 956 
(1.63%) | 1021 (1.82%) | 

1332 (2.47%) | 

1781
(3.0%) |  |

**JCAHO Stroke Centers**

## Treatment Rates?

- Without knowing whether the patient was treated at the original hospital, or transferred after treatment, we cannot determine:
- Treatment rates per hospital
- Proportion of eligible patients treated
- Complication rates of treatments given (often attributed to accepting hospital, even though they did not administer it)

## Time Targets?

- Many of the established quality indicators for evaluation of acute stroke patients are time-based:
- Door-to-triage
- Door-to-head CT
- Door-to-needle
- no antithrombotics given for 24 hours after rt-PA
- 24 hour safety head CT done
- Delays in outside hospitals could be assigned to accepting hospital

## How often does “Drip and Ship” occur?

## AAN Survey

- AAN Survey in Fall of 2007 – 33 Stroke Centers Responded
- 23  indicated substantial number of stroke patients admitted where rt-PA initiated at other hospital

## AAN Stroke Center Survey Results

- at 33 centers

- ~12,430 ischemic stroke patients

- 1083 ischemic stroke patients treated with rt-PA (8.7%)

- 375 stroke patients treated with rt-PA and transferred:        “**drip and ship**”

**AAN Stroke Center Survey Results**

**35% of rt-PA treatments**

## AAN Survey

- Some centers reported up to 73% of the rt-PA patients admitted to their hospital were drip and ship
- 6 centers out of 33 reported >50% were drip and ship

## Specific Case Study

**Working as a Regional Network****:**
- 70% of their acute intervention cases originate in another regional hospital.

**The Mid America Brain and Stroke Institute**
**Kansas City, MO**

## Specific Case Study Con’t.

- Cases January 2000 through September 2004
- Total ischemic strokes = 1694
- Transferred to them = 268
- Received IV rt-PA before transfer = 139
- Transferred from 47 different hospitals: 14 in the metro area; 33 within 150 miles.

## Current Best Case Scenario

- 663,000 ischemic stroke patients

- 19,890 ischemic stroke patients treated with rt-PA (3%)

- 6,962 stroke patients treated with rt-PA and transferred:        “**drip and ship**”

**Current Best Case Scenario**

- Lower U.S. rt-PA treatment rate than in AAN survey

## Proposed Solution:V code 

## Proposed Solution

- Proposed V code definition:
- 	**history of receiving rt-PA for acute ischemic stroke in another hospital’s emergency department within the last 24 hours**

## Why 24 hours?

- Most of the complications after rt-PA occur within the first 24 hours
- Especially bleeding complications
- Many of the time-based quality indicators are based on the 24-hour period
- Trying to avoid confusion with patients treated at 11pm and transferred at 1am
- Trying to separate from the patient treated 5 days ago with complications belatedly transferred