Stroke QUERI

Strategic Plan and Goal Develop

Develop

Linda Williams, MD

Dawn Bravata, MD

October 12, 2010
Outline

• Background

– St k ro e f t ac s, VA and non‐VA

• Current stroke quality improvement act

– J i o nt C i i /G ommission/Get Wi ht the G id li u e nes

– VA OQP Stroke Special Project

– VA St k ro e T k as Force

• Our process for setting clinical goals

– Ei i x st ng work, partner i i nterv ews, mod li e n

• Planned FY11‐14 goals and rationale
Audience response questio

• With what organization organization or group are yo

closely affiliated?

– VA QUERI– VA HSR&D

– VA clinical service

– VA operations/managerial service

– VA other

– Non‐VA researcher– Non‐VA clinician
Stroke Epidemiology in US

AHA Heart and Stroke Facts 2009

• Incidence: 795,000 strokes annually

• Prevalence: 6.5M stroke survivors

• Cost: $69B direct and indirect cost in 2009

• 3rd leading cause of death

• CMS 30‐day risk standardized mortality:

• 15.3% in stroke

• 15.9% in MI

• Mortality Mortality decreased decreased overall overall 1995‐2005 by 30%• Still a strong marker of 1‐year mortality risk:

• Age 49‐69: 14‐20%

• Age ≥70: 24‐27%
Stroke Epidemiology in VA

• Stroke incidence and prevalence rates among v

are unknown

• In FY2007, more than 6000 veterans were adm

a VAMC for an acute ischemic stroke

• Does not include patients with TIA (approximatel

diagnosed annually), those admitted with stroke another acute medical condition, or in‐hospital st

• In FY07 national VA cohort with ischemic strok

• In‐hospital mortality was 4%

• 6‐month mortality mortality was 8%

• 6‐month readmission (VA only) was 27%

• In FY05, the total VA cost of stroke treatment w

$315M, with cost per veteran veteran of 3 4x . the avera

avera

healthcare cost
Current VA Stroke Performance Me

• Stroke‐specific measures:

• None• FIM (functional) screening of inpatients with 

amputation, or spinal cord injury transitioned 

“ lit qua y i di t n ca or with t ou b h k” enchmark” in FY0

• Stroke‐relevant measures:

• Outpatient:

• BP, lipids, DM, smoking; none reported in stroke co

• Inpatient:

• DVT prophl i y ax s (IPEC measure, stroke not i ld

nc u e

risk group that makes up the denominator)

• Smoking cessation counseling (not reported for st

patients specifically)
Stroke Improvement Activitie

Joint Commission Primary Stroke Center Certif

• Collaboration with the American American Stroke

Association and the Brain Attack Coaliti

• Process Process of data collection collection and review

• Registry of patients

• Staff, including core stroke team, and train

• 4 months of data on eight core measures

• Action plans for performance improvemen

• One‐year certification, then bi‐annual r

• More than 600 PSCs as of October October 2009
JC Primary Primary Stroke Center Data Elem

Elem

• Thrombolytic therapy therapy • Stroke educatio• DVT prophylaxis• Antithrombotic therapy

Stroke educatio

• Discharge on sta

Antithrombotic therapy • Discharged on

by day 2

• Assessed for

Discharged on

antithrombotic 

Assessed for • Anticoagulation 

rehabilitation

Anticoagulation 

atrial fibrillation

Two former measures recently excluded:

• Dysphagia screening before oral intake• Smoking cessation counseling counseling
Stroke Improvement Activitie

AHA/ASA Get With the Guidelines‐Str

• Hospital Hospital‐based quality quality improvement improvement pr

pr

• Online data collection and sharing with 

program participants

• Harmonized achievement measures wit

JC PSC plus:

• Other measures (e.g., dysphagia screening• Other processes (e.g., door to CT time)

• Other outcomes ( g e. ., in‐hospital mortality
Current VA Participation in

National Stroke QI programs

• JC PSC certified certified or pending: pending: Bay Pines,

Houston, Miami, ? others

• GWTG certified: certified: Bay Pines, ? others• Other VA facilities have or are pursuing

various state certifi i cat ons

• Some states are requiring certification for 

transport of patients wi ht suspected strok
Stroke Measurement Activities:

Centers for M di e care & M di id Medicaid S i erv ces 

• Current Current proposal proposal for two national national facili

facili

stroke quality indicators:

• Adjusted Adjusted 30‐day mortality mortality rate• Adjusted 30‐day readmission rate

• P bli u c comment peri do recently cl d ose• Awaiting CMS decision about these 2

measures
Stroke Improvement Activitie

OQP/Stroke QUERI Stroke Special Pro

• Background

• S k tro e is a hi hg volume, hi hg acuity, hi hg impact c

with no current VA performance assessment

• To improve improve stroke care across the VA system, system, we 

measure stroke care quality, to identify gaps in ca

will serve as targets for future improvement proje

• Objectives

• Assess the quality of inpatient VA stroke care• Assess post‐stroke ri ks factor management

• Feedback data to VAMCs

• Provide Provide a toolkit toolkit of improvement improvement strategies strategies and t
OQP Stroke Study: Methods Methods

• Sample

• 5000 veterans adi d m tte to a VA f ili ac ty wi ht di h sc arge 

of ischemic stroke, FY07

• Excluded: hemorrhagic stroke and elective carotid

endt t ar erectomy, in‐h it l ospital st k ro e

• 100% of veterans at small volume centers (≤55 in FY0• 80% of veterans at high volume centers (>55 in FY07)

• Chart review

• Chart review based on electronic medical records only 

paper) by EPRP abstractors abstractors

• VAMCs provided opportunity to review and correct in

data
14 Inpatient Processes of Care

Early Hospitalization• Dysphagia screening before oral intake

k l l d

Hospital Discharg• Antithrombotic ther

• NIH Stroke scale completed• Thrombolysis (tPA) givenIn‐Hospital Period

• Lipid management• Atrial fibrillation ma

In‐Hospital Period • Smoking cessation c• Antithrombotic therapy, HD2• DVT prophylaxis• Early ambulation

Smoking cessation c

• Stroke education

• Early ambulation b • Fall risk assessment (Morse Scale)

• Pressure ulcer risk assessment

(B d l )

Joint Commission b

VA‐specific

(Braden scale)

• Rehab consultation/FIM results

•Among 5000 patients, 3936 were eligible for at least one quality indicato

•Among 131 VAMCs, 129 facilities cared for veterans who were eligible fo

least one quality indicator
Final National In‐Patient Data Summar

Eligible Process

Process of Care

Eligible

Patients

N=3936

Process

Present

%

Antithrombotic therapy therapy, DC 3514 96 4.Antithrombotic therapy, HD2 3523 95.6

Smoking cessation counseling 1268 94.9

Pressure Pressure ulcer risk assessment assessment 3789 91 8.Early ambulation 3009 86.1

Rehabilitation consultation 2796 86.0

Lipid management 3009 82.1Fall risk assessment 3673 79.3

DVT prophylaxis 1018 78.2Anticoagulation for atrial fibrillation 409 75.3

NIH Stroke Scale documented 3640 27.7

Dysphagia screening 3591 23.4

Stroke education 2524 18.1

Thrombolysis (tPA) given 227 8.4
National In‐Patient VA Data vs. Non‐V

Eligible Process 

Process of Care

Patients

N=3936 

Process

Present

%

Antithrombotic therapy DC Antithrombotic therapy, DC 3514 96 4. Antithrombotic therapy, HD2 3523 95.6 

Smoking cessation counseling 1268 94.9 

Pressure ulcer risk assessment Pressure ulcer risk assessment 3789 91 8. Early ambulation 3009 86.1 Rehabilitation consultation 2796 86.0 Lip d a age e id management 3009 82.1 Fall risk assessment 3673 79.3 DVT prophylaxis 1018 78.2 

Anticoag for atrial fibrillation 409 75.3 

NIH Stroke Scale documented 3640 27.7 

Dysphagia screening 3591 23.4 Stroke education 2524 18.1 

Thrombolysis (tPA) given 227 8.4 
Stroke Improvement Activitie

VA National Stroke Task Forc

• Based on OQP resu tsl a dn ED su ey rv of st 

r 

care, VA assembled a multidisciplinary teamake recommendations about improving stroke care

• ED, Neurology, Primary Care, Nursing, Allied H

Operations

• Recommendations in four areas:

• Templates/measures• Facility requirements

• Consent

• Education
VA Stroke Task Force

Recommendations:

• Each facility will assess and report its capabilities 

stroke care as:

• VHA Primary Stroke Center (24/7 acute stroke care)

• VHA Limited‐hours Stroke facility (acute stroke care at 

times)

• VHA Supporting Stroke facility (cannot provide acute s

care)

• For Primary and Limited Hours Stroke facilities:

• Stroke clinical pathway/protocol

• Radiology coverage

• Stroke team

• tPA provision for eligible patients

• Measurement of acute care quality indicators

• All facilities:

• Treatment or transfer policy• Patient and staff education
How do these ongoing activities 

to and inform our cl l inica goa

• Existing work:

• Where have we been?

• Partner interviews:

• Where should we be?

• Systems Dynamics modeling:

• If we go there, what will happen? happen?
Stroke QUERI Existing Work Across the Continuum o

I h it l

Hospital Care Rehab Acute Treatment

Stroke Risk Factor Management

Inhospit

al

Management Reco

Treatment Care

• Hypertension

control

• Self management

•Developing systems todocument inpatient careprocesses

• Rehabi

structur

outcome

• Self

‐management

of multiple vascular

risk factors

p• Implementation of QI

interventions aimed at

i i ti t

• Telerehinterven

• Identification of

high

‐risk patients

various inpatien

t

processes

• Depresmanage

Cross

‐cutting projects projects:

• OQP Stroke Special Project (national quality assessme

• Systems Dynamics modeling of VHA stroke care
Process for Goal Setting:

Partner Interviews

• Purpose: to solicit opinions from various partners 

how the Stroke QUERI could maximize its efforts to 

the burden of stroke within VHA

• Process: drafted series of questions, spoke directly 

partners, summarized findings for executive comm

• “Should we focus on multiple risk factor management 

individual risk factor projects?”

• “Should we focus on low volume/high impact or high

volume/low impact indicators?”

• “If we could do one thing to improve VA stroke care, w

you want the Stroke QUERI to do?”

• Partners: leaders from patient care services (prima

neurology, rehabilitation, SLP, etc.), HSRD, operatio

(IPEC), OQP, veteran veteran stroke survivors survivors
Partner Interviews Summary

• Si l ng e vs. muli l t p e vascular ri ks :

• Consensus that HTN is a key stroke risk factor

• Many entities in VHA are working on HTN so Stroke Q

sh ld ou focus on specific targets wi hi t n HTN

• Veterans with HTN have multiple vascular risk factors

• Gaps in clinical areas:

• No other national VA groups have major focus on imp

thrombolysis, atrial fibrillation management, or carot

• Access to rehabilitation services:

• More important than evaluation of specific rehabilitat

interventions

• Many unknowns about provision of rehab post‐stroke

• Measurement:

• Consensus on need for improved systematic measure

key processes and outcomes post‐stroke

• Assumptions about stroke volume not always consiste

data
Veteran stakeholder inpu

• Conducted 4 focus groups of 17 veteran st

survivors from two VAMCs ( y, Ind Houston

• Presented clinical goals and asked for feed

on importance to veterans

• All groups unanimously chose acute stroke 

as the most important priority area

• Access to tPA• Cost concern in going to community hospital 

• Remaining NPO while waiting for dysphagia s

• Most felt VA was doing a good job empha

prevention in Primary Care

• Most reported reported being satisfied satisfied with the lev

rehabilitation services
Process for Goal Setting:

Systems Dynamics Modeling

• Problem: Many possible interventions exist for impro

t k ti t d h bilit ti b t 

Systems Dynamics Modeling

stroke prevention, acute care and rehabilitation, but 

difficult to compare their relative effectiveness

• Approach Approach: System Dynamics Dynamics methodology methodology to conside

conside

system factors, patient factors, and intervention effe

compare various intervention

• Mdl o e VA care over 5, 10, and 20 year i l ntervals

• Include degree of intervention implementation,

heterogeneous treatment effects, aging population

trends in health risk behavior

• Outcomes: disability adjusted life years (DALYs) and 

related fatalities

QUERI RRP 09‐146, Hayden Bosworth and Kristen Hassmiller‐Lich, Dur
VA Stroke Systems Dynamics Mo

P i

NON‐EVENT

VA USER POPN POST‐STROKE

VA USER POPN

Primary

prevention efforts

(HTN & AF mgmt)

b & b f

1st Strokes in

New VA Users

VA USER POPN

1st stroke

Rankin 2 & 3Rankin 0 & 1

by age group & subsets ofsmokers, hypertensives,atrial fib, diabetes, CVD;and interventions targetingparticular subsets Post‐1st stroke

Rankin 4 & 5

Fatal

Survived

Rankin 2 & 3 Rankin score

Post‐recurrent stroke POST‐TIA VA USER POPN

1st TIA 1st TIAs in New VA Users

Stroke rehab Survived 

effort

change in Rankin

Post TIA CEA

& 2o

Recurrent TIA prevention

Undx Dx

‐ Total strokes & TIAs

l k

OUTCOMES IN

VA USER POPN

Stroke acute care efforts:

‐Timely to hospital

‐ Effective tPA use

‐DVT prophylaxis

P t t k

efforts

TIA

diagnosis

effort

‐ Fatal strokes

‐ DALYs‐ Medical costs

‐Dysphagia screening Post stroke

CEA & 2o prevention

efforts
Systems Dynamics Model Outco

Outco

• Outcomes: Disability‐adjusted Life Years (DALYs) and 

related deaths

• 20‐year base case scenario predicted total of 2.55M 

and 98,099 stroke‐related deaths

• E l va uate rel i at ve effect of si l ng e i i nterventions or

combinations of interventions at 5, 10, and 20‐year t

horizons

• Theoretical maximum benefit: 300,000 fewer DA

and 15,201 fewer stroke‐related deaths

• CyberSeminar CyberSeminar on this modeling modeling work planned planned for la

year
Planned Planned Goals for 2011‐20

• Goal 1. Improve in‐hospital management of stro

reduce stroke mortality mortality and morbidity morbidity

• Stroke decision support systems

• Active implementation projects

• Goal 2. Develop Develop, test, and integrate integrate strategies strategies to 

control of stroke risk factors in veterans at high r

stroke

• Uncontrolled hypertension• Post‐stroke and Transient Ischemic Attack (TIA)

• Goal 3. Support VA stroke policy decisions by col

and reporting VA pati t en ‐ and system‐l l eve d t a a

• Risk‐adjusted mortality tracking

• Access and systems data
Goal 1. In‐Hospital Hospital Managem

Managem

• Improve in‐hospital management of str

reduce stroke mortality and morbidity

• Goal 1A: Develop systems to document, m

and improve inpatient stroke care process

quality

• Goal 1B: Conduct active implementation p

to foster ongoing inpatient stroke quality

improvement acti ii v t es and improve stroke 
In‐Hospital Management Activi

Systems Systems to document document, measure measure and improve improve processes processes 

• SQUIDSS SDP: acute stroke decision suppo

documentation documentation tool that interfaces interfaces with C

• Mock ups and end‐user input complete, beta‐

FY11 (Tom Kent, MD; Jane Anderson, PhD)

• RRP: t ti es ng ad i i t ti l dministratively‐did er ve sub 

a

inpatient quality indicators

• DVT p py , ro hylaxis, Lipid manag , ement Atrial fib

management (Neale Chumbler, PhD)

• Planned work: SQUIDSS 2.0 SDP, Inpatient

administrative QI SDP

• Implementation in multiple high‐volume VAM
In‐Hospital Management Activi

Active QI projects

• INSPIRE SDP: 12‐site randomized trial of System

Redesign‐based improvement collaborative vs. 

feedback alone

• Site interviews and baseline data collection ong 

o

intervention phase begins FY11

• REINSPIRE SDP: pending; rich‐context evaluati

local contextual contextual elements elements and their relationshi

relationshi

improvement in intervention and control sites 

INSPIRE (Edward Miech, EdD)

• Planned Planned RRP: characterize characterize responses responses to VA nat

nat

acute stroke directive

• Identify and spread successful strategies to addre

stroke treatment needs
In‐Hospital Rationale

Strength of existing work Partner interest Model s

(Y/

Strong Strong Y

Evidence Summary:

• GWTG‐Stroke programs associated with significant imp

in in‐h il osp tal stroke process measures

• Organized inpatient care has similar benefit on improv

outcomes as tPA

• Approximately 1/3 of patients arrive in ED at US acade

hospitals within 2 hours of symptom onset (stable 200

but % receiving tPA increased from 14% to 37.5%

• Systems to structure transport to stroke‐ready hospita

proportion receiving tPA fourfold (9.5% to 23.4%)

Toronto pre‐hospital project)

• Telestroke consultation and radiology can improve acc

and can be done safely
Goal 2. Patients Patients at High Risk of S

• Develop, test, and integrate strategies t

improve control of stroke risk factors in

veterans at high risk of stroke

• Goal 2A: Develop and evaluate strategi

improve blood pressure control among

veterans with uncontrolled hypertensio

• Goal 2B: Develop Develop and test approaches approaches t

improve risk factor management amon

veterans veterans post‐stroke and TIA
Risk Factor Management Management Activ

Activ

Post‐stro

•TOOLS (D

•STOP Str

• Go To Sleep (Bravata) Uncontrolled Hypertension •TIA (Che• Go To Sleep (Bravata) • Group visits (Cheng)• Cross‐QUERI Collaborative

(Bosworth)

• VA PATRIOTS (Bravata, Zillich)

•HTN Improve (Bosworth)

•Stroke risk Dashboard (Merchant)

•Telephone‐based BP intervention intervention

(Natarajan)
National Outpatient Data Summary

Veterans with follow‐up within 6 months pos

Eligible Proce

Process of Care

g

Patients Prese

%

Blood pressure measured 2031 98.1

INR measured 271 86.3Hemoglobin A1c measured 641 68.6LDL measured 1426 58 1.BP measured and meets goal 2031 55.4Hemoglobin A1c measured and at goal 641 46.6INR measured measured and meets goal 271 43 2.LDL measured and meets goal 1426 35.0
Risk Factor Management Ration

Strength of existing work Partner interest Model 

(Y

Strong Strong (debate on specifics) 

Evidence Summary:

• HTN: highest population attributable risk of any stroke • 10mm reduction reduction in blood pressure pressure associated associated with 30

reduction in stroke risk

• Approximately 80% of veterans with stroke have hype

• Despite Despite VA system‐wide attention attention to HTN performanc

performanc

with stroke commonly have uncontrolled HTN

• More than half uncontrolled at discharge from VA

• One‐third uncontrolled uncontrolled at 6‐months post‐discharg

discharg

• Among 5135 veterans with TIA (FY09), 29% had a recu

vascular event or died in first 90‐days post‐TIA

• R id ap TIA management has been associtd a e with large

reductions in post‐TIA event rates
Goal 3. Support Support VA Stroke Po

• Support VA stroke policy decisions by

collecting and reporting VA patient‐leve

system‐level data

• Goal 3A: Develop and implement a nation

risk‐adjusted stroke mortality tracking and

reporting system

• Goal 3B: Develop and evaluate models of 

care systems to inform VA stroke care orga
Policy Rationale

Strength of existing work Partner interest Model s

(Y/

Moderate Moderate N/

Evidence Summary:

• Data are fundamental to informed decision‐making

• Unknowns: VA stroke prevalence, incidence, mortal

of rehabilitation use

• Emerging data suggest that inpatient rehabilitation 

effective compared to short‐term nursing home bas

• CMS is evaluating risk‐adjusted mortality and readmissi

facility‐level stroke q y ualit indicators

• Organized stroke care improves outcomes

• VA needs VA‐specific patient and system data to sup

decisions about how stroke care organization shoul
Policy‐Relevant Activities

Stroke mortality assessment

• OQP Stroke Special Project

• FY07 inpatient and outpatient (post‐stroke

q y ualit data for 5000 veterans admitted to ischemic stroke

• Risk‐adjustment and quality‐mortality ana

ongoing

• Planned p j ro ect: SDP to develop ischem

stroke identification and risk‐adjusted

mortality assessment system
Policy‐Relevant Activities

Models of stroke care systems

• Systems Dynamics Dynamics modeling modeling RRPs (Krist

(Krist

Hasmiller‐Lich, PhD, Hayden Bosworth, 

• tPA mapping mapping RRP (Glenn Graham, MD, 

• Veteran access to VAMCs capable of giving 

• Rehabilitation structure, cost, and outco

analysis (Bruce Vogel, PhD)

• Telerehabilitation model to increase acc

rehabilitation (Neale Chumbler, PhD)
Other Clinical Goals Conside

Conside

• Emerging Areas of Activity:

• Anticoagulation for atrial fibrillation

• Some projects ongoing in partnership but not 

alone focus (Adam Rose, MD; RRP)

• Carotid stenosis management

• RRP examining patterns of use in symptomatic 

(Salomeh Keyhani, MD; RRP)

• Readmission

• G th i a er ng more d t a a ab t ou prevalence and as

factors (Salomeh Keyhani, MD; IIR submission
4 Coordinators

Co-Clinical Coordinator

Goal leaders, collaborators

Met

lea

Collaborators

Stroke QUERI’s collaborators