Quality Standards: Information challenges in clinical practice (Stroke)

1. Quality Standards: Information challenges in clinical practice (Stroke) Tony Rudd

2. What are the problems that need solving? • Unacceptable variation in the quality of care between hospitals • Variable quality of clinical and managerial leadership • Variable resources provided for stroke care • UK slow to adopt new technologies e.g. Thrombolysis • Still a belief amongst many people (professionals and public) that stroke untreatable disease of old people

3. National Initiatives for Change NAO 2005 National Stroke Strategy 2007 National Sentinel Stroke Clinical Audit 2010 Round 7 ICSWP Stroke Guidelines 2008 NICE Acute Stroke and TIA Guidelines StrokeImprovement Programme No shortage of policy documents!

4. Data requirements for Stroke • Accelerated metrics • NICE Quality Standards • Integrated Performance Measures Reporting (Vital signs) • Local stroke and cardiac network requirements • Commissioning Outcomes Framework • Quality Outcomes Framework • National audits • SINAP • Sentinel • carotid • HES Data • Patient satisfaction • CQC

5. Stroke Quality Standards: criteria for inclusion • Standards covering whole pathway (therefore not just those in NICE Acute stroke and TIA guidelines). Used RCP National Clinical Guidelines • Important clinically and some areas resistant to change • Measurable, achievable and comparable between units • Evidence based or very strong clinical consensus • Excluded secondary prevention because already well covered by QOF • Largely process measures where the process is known to affect outcome

6. Using Quality Standards • Setting the national agenda for Quality improvement • Informing providers • Including the QS in quality accounts • Comparing performance between provider units • Informing the users • Public release of data on performance

7. Using Quality Standards • Informing commissioners • Providing framework for commissioning of services • But cannot be used as the exclusive document for defining components that are needed for a service. Indicative of the type of care needed • Challenging the conventional models of care • Use for CQUINS (Commissioning for Quality Improvements) and for World Class Commissioning • Informing the regulators • Informing the politicians

9. National Sentinel Audit Data 2004-2010

10. SINAP Audit 2011

11. Thrombolysis • 5% of patients received altepase in 2010 Sentinel Audit (increased from 1.8% in 2008) • 14% of patients should be receiving it (presented within 3 hours, 80 yrs or under, infarction) • Still many areas of the country where hyperacute stroke care not adequately provided

12. SINAP Audit 2011

13. Thrombolysis rates in London after introduction of London Stroke Strategy Feb – Jul 2009 AIM Feb – Jul 2010 Thrombolysis rates have increased since implementation began to a rate higher than that reported for any large city elsewhere in the world 12% 10% 3.5%

15. SINAP Audit 2011

17. Duration of Rehabilitation • Research evidence to show a link between intensity of therapy after stroke and outcome • In UK majority of rehabilitation resources concentrated in hospitals • Length of hospital stay falling after stroke (reduced from mean of 35 days to 20 days over last 10 years) • Patients frequently complain that they sit in hospital doing nothing for long periods of time

18. CERISE European Stroke Rehabilitation Study How much rehabilitation? Between 7.00 am and 5.00 pm

19. Appropriateness for Therapy

20. Intensity of Therapy Received

21. How deliver increased intensity? • Different patterns of working e.g. Cutting down on bureaucracy • Less one to one therapy and more group treatment • Using non specialist therapists to provide cover • Focussing treatment just on patients likely to benefit e.g. Stopping treatment earlier • More therapists

22. Stroke Data Collection in the Future: Sentinel Stroke National Audit Programme (SSNAP) • Replacing all other statutory data collection (except IPMR!). Includes data needed for: • NICE QS • NHS Outcomes Framework • Accelerated metrics • COF • Funded by HQIP

23. Information Challenges • Need to link datasets to cover the stroke pathway: • Ambulance trust data (often without an NHS number) • Acute hospital and primary care data • Social care data • Patient reported data • Data protection requirements and the Information Commissioner making life unbelievably complex to obtain section 251 approval

24. Information Challenges • Freedom of information act: • We will be reluctant to collect any data that might be in any way experimental • We will be reluctant to do analyses of data that are exploratory • We will be reluctant to collect any data that might be misinterpreted or not be statistically robust because of sample size issues

25. Information Challenges • Intellectual property rights • HQIP issues with IPR to the audits it funds including those of commercial web developers • HQIP (presumably therefore DH) wanting control over data analysis and publishing. Therefore at risk of losing clinical independence over national audit data

26. Information Challenges • Failure to make data collection in healthcare mandatory • Proliferation of private companies offering third rate data collection tools at great expense resulting in failure to adequately collect data in a format that can be used for national data reporting • Organisations that publish without any regard to accuracy or data quality

27. Information Challenges • Demands for reporting outcome data at a level that is clinically meaningless and misleading e.g. Individual stroke physician/hospital • Numbers too small • Difficulty adjusting for case mix • Outcomes dependent upon large teams working in collaboration

28. Conclusions • NICE Quality Standards alongside other quality initiatives have undoubtedly resulted in improvements in clinical practice • We need to simplify data collection; currently too great a burden for clinicians • Major threats to our ability to conduct national audit