ObjectiveDespite widespread interest in many jurisdictions in monitoring and improving the quality of stroke care delivery, benchmarks for most stroke performance indicators have not been established. The objective of this study was to develop data-derived benchmarks for acute stroke quality indicators.DesignNine key acute stroke quality indicators were selected from the Canadian Stroke Best Practice Performance Measures Manual.ParticipantsA population-based retrospective sample of patients discharged from 142 hospitals in Ontario, Canada, between 1 April 2008 and 31 March 2009 (N = 3191) was used to calculate hospital rates of performance and benchmarks.InterventionThe Achievable Benchmark of Care (ABC™) methodology was used to create benchmarks based on the performance of the upper 15% of patients in the top-performing hospitals.Main Outcome MeasuresBenchmarks were calculated for rates of neuroimaging, carotid imaging, stroke unit admission, dysphasia screening and administration of stroke-related medications.ResultsThe following benchmarks were derived: neuroimaging within 24 h, 98%; admission to a stroke unit, 77%; thrombolysis among patients arriving within 2.5 h, 59%; carotid imaging, 93%; dysphagia screening, 88%; antithrombotic therapy, 98%; anticoagulation for atrial fibrillation, 94%; antihypertensive therapy, 92% and lipid-lowering therapy, 77%. ABC™ acute stroke care benchmarks achieve or exceed the consensus-based targets required by Accreditation Canada, with the exception of dysphagia screening.ConclusionsBenchmarks for nine hospital-based acute stroke care quality indicators have been established. These can be used in the development of standards for quality improvement initiatives.

Background: Reported incidence rates of pediatric stroke and transient ischemic attack (TIA) range widely. Treatment gaps are poorly characterized. We sought to evaluate in ­Ontario, the incidence and characteristics of pediatric stroke and TIA including care gaps and the predictive value of International Classification of Diseases (ICD) codes. Methods: A retrospective chart review was conducted at 147 Ontario pediatric and adult acute care hospitals. Pediatric stroke and TIA cases (age < 18 years) were identified using ICD-10 code searches in the 2010/11 Canadian Institute for Health Information’s Discharge Abstract Database (CIHI-DAD) and National Ambulatory Care Reporting System (NACRS) databases in the Ontario Stroke Audit. Results: Among 478 potential pediatric stroke and TIA cases identified in the CIHI-DAD and NACRS databases, 163 were confirmed as cases of stroke and TIA during the 1-year study period. The Ontario stroke and TIA incidence rate was 5.9 per 100,000 children (3.3 ischemic, 1.8 hemorrhagic and 0.8 TIA). Mean age was 6.4 years (16% neonate). Nearly half were not imaged within 24 h of arrival in emergency and only 56% were given antithrombotic treatment. At discharge, 83 out of 121 (69%) required health care services post-discharge. Overall positive predictive value (PPV) of ICD-10 stroke and TIA codes was 31% (range 5–74%) and yield ranged from 2.4 to 29% for acute stroke or TIA event; code I63 achieved maximal PPV and yield. Conclusion: Our population-based study yielded a higher incidence rate than prior North-American studies. Important care gaps exist including delayed diagnosis, lack of expert care, and departure from published treatment guidelines. Variability in ICD PPV and yield underlines the need for prospective data collection and for improving the pediatric stroke and TIA coding processes.

Introduction Since 2002, the Ontario Telestroke Program has provided hospitals in under-served regions of the province the opportunity to offer intravenous thrombolysis with tissue plasminogen activator (IV tPA) to eligible patients. The purpose of this study was to determine whether telestroke-assisted IV tPA patients had similar risks of 7- and 90-day mortality, symptomatic intracerebral haemorrhage (sICH), and poor functional outcome compared to patients who received IV tPA with on-site expertise. Methods Data from two audits of patients with acute ischaemic stroke hospitalized in Ontario, Canada in 2010 and 2012 were analysed. We modelled the risk of all-cause death within 7 and 90 days of receiving IV tPA using proportional hazards adjusting for hospital type, patient characteristics, and whether IV tPA was administered as part of a telestroke consultation. Outcomes of sICH and modified Rankin Scale ≥ 3 at discharge were modelled using generalized estimating equations adjusting for the same variables used in the mortality model. Results There was no difference in 7- or 90-day mortality among those who received IV tPA with telestroke ( n = 214) compared to those without ( n = 1885) (7-day adjusted hazard ratio (aHR) 1.29 (95% confidence interval (CI) 0.68, 2.44); 90-day aHR 1.01 (95% CI 0.67, 1.50)). Complications were similar between groups, with an adjusted odds ratio (aOR) for sICH of 0.71 (95% CI 0.29, 1.71) and an aOR of 0.75 (95% CI 0.46, 1.23) for poor functional ability at discharge. Discussion Patients receiving IV tPA supported by telestroke had similar outcomes to those managed with on-site expertise.

IntroductionReport cards or scorecards typically reflect one particular sector along the care continuum; however, stroke patients typically require acute care, inpatient rehabilitation and community care highlighting the need to link data sources to demonstrate the interdependencies between and across sectors. Objectives and Approach1) Identify stroke best practice indicators from across the care continuum; 2) develop a one page report card that reports on the quality of the stroke system of care through data linkage and 3) visually impactful knowledge translation tool. The indicators cover five health care sectors starting with pre-hospital stroke symptom onset, then to management of the acute event, to institutional and community-based rehabilitative care, reintegration into the community and secondary prevention. The report card is a knowledge translation tool that identifies gaps in best practice, provides achievable benchmarks of regional and provincial stroke system performance to drive system change. ResultsUsing data linkage techniques, seven administrative datasets are used to populate the 20 indicators in the annual Ontario stroke report card. Indicator performance was trended by comparing the previous 3 years’ results to the most recent year of data. Fifteen of 17 indicators improved (11 statistically significant) compared to the previous three years and 2 indicators did not change / declined. Performance benchmarks were calculated using Achievable Benchmarks of Care™ methodology and 14 of 16 performance benchmarks improved since 2014/15. There was wide variation across indicators with only 4 indicators showing a reduction in regional variation. The Ontario stroke report card can be viewed at https://www.ices.on.ca/Publications/Atlases-and-Reports/2017/Stroke-Report-Cards. Conclusion/ImplicationsThe Ontario stroke report card spans the stroke care continuum, provides a snapshot of Ontario’s stroke system performance. Data linkage is essential for a system-wide opportunity to evaluate and influence system performance. This cross-continuum approach and report card format could be applied to other health related conditions.

Background: Previous studies have found that patients with TIA discharged from the emergency department (ED) have low rates of testing and treatment for secondary stroke prevention. Secondary Stroke Prevention Clinics (SPCs) were established in Ontario to increase access to diagnostics, treatment, and risk factor education programs for patients at risk of stroke. We aimed to characterize the management of patients with transient ischemic attack (TIA) and ischemic stroke referred to the SPCs following discharge from the ED. Method: The Ontario Stroke Registry performed a chart audit of 40 of 41 operational SPCs between April 1, 2011 and March 31, 2012. We included patients discharged from the ED and referred to a SPC with a diagnosis of probable stroke or TIA, and evaluated processes of best practice care. Using encrypted health card numbers, we linked to administrative databases to identify 7, 30 and 90 day outcomes after the index event. Results: Our study sample included 8,501 patients discharged from the ED and referred to a SPC with probable stroke/TIA. After evaluation in the SPC, 1,902 were given a final diagnosis of TIA and 1,126 ischemic stroke. The median age was 72 years and 46.6% were female. The median time from ED discharge to clinic visit was 8 days for TIA patients and 7 days for ischemic stroke patients. The majority of patients (>92%) received neuroimaging, carotid imaging and antithrombotic therapy, and rates of treatment were similar in those with TIA and stroke. The rate of death or recurrent stroke admission at 30 days was 3.6% among patients with confirmed ischemic stroke, and 0.4% in those with TIA. Conclusion: Ontario patients with TIA and ischemic stroke discharged from the ED with stroke secondary prevention clinic follow up receive high quality best practice secondary stroke prevention care. Further work will examine whether TIA patients discharged from EDs without SPC follow up have similar care and outcomes.