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Scottish Stroke Audit. 3rd National Meeting 7th Dec 04. Welcome. NHS QIS funded audit - Oct 02 - 05 Original plan - 6 to 10 hospitals Impact of CHD & Stroke strategy NHS QIS standards and visits. Program. Comparisons between hospitals Control charts

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scottish stroke audit

Scottish Stroke Audit

3rd National Meeting

7th Dec 04

welcome
Welcome
  • NHS QIS funded audit - Oct 02 - 05
  • Original plan - 6 to 10 hospitals
  • Impact of CHD & Stroke strategy
  • NHS QIS standards and visits
program
Program
  • Comparisons between hospitals
  • Control charts
  • Demonstration of real time data capture system
  • Audit of swallow screening
  • Update on “MCNs on the Web”
how can these data help improve patient care
How can these data help improve patient care?
  • Identify variation in “performance” and to raise questions about cause of variation
  • Identify methods which increase performance?
  • Highlight services requiring more investment or re design
reasons for variation in performance
Reasons for variation in “Performance”
  • Method of collection data
  • Definitions, case ascertainment and audit period
  • Method of analysing data
  • Which numerator and denominator?
  • Chance
  • Actual performance of service
some statistical terms
Some statistical terms
  • Proportions (%)
  • 95% confidence intervals
  • Means and medians
  • Inter quartile range
proportions
Proportions
  • Numerator / Denominator = Proportion
  • 100 patients admitted
  • 60 enter stroke unit
  • Proportion is 60/100 = 0.6 or 60%
  • We have had problems with denominators
  • NHS QIS ask % admitted SU within 1 day
  • Is denominator 60 or 100?
denominators
Denominators
  • If admit 100 stroke patients
  • 60 enter the stroke unit
  • therefore 60% managed in a stroke unit
  • if half get into stroke unit within a day
  • % admitted to SU <1day = 50% or 30%
  • NHS QIS want 30% figure
95 confidence intervals
95% confidence intervals
  • Measure the proportion entering your stroke unit once
  • Calculate the 95% Confidence intervals
  • Measure the proportion a further 100 times and one would expect 95 estimates to lie within the 95% confidence intervals.
a normal distribution
A normal distribution

No. of

patients

Mean = 10

Median = 10

Length of stay in Days

length of stay
Length of stay

Mean = 10

Median = 10

No of

people.

Length of stay (days)

Mean = total no. of days / total no. of people

Median = LOS where half the people have longer ones and

half shorter ones

quartiles quarters
Quartiles (quarters)

No.

Mean = 10

Median = 10

Days

Interquartile range (IQR)

(half the patients are included)

comparisons between hospitals

Comparisons between hospitals

A few hospitals which are currently collecting data are not included because too few data are available.

data collection periods vary
Data collection periods vary
  • Longer period will provide more patients and more precise estimates
  • Longer period will include older data
  • Recent short period will not include patients still in hospital - therefore may give biased estimates
no of admissions available for analysis group 1
No. of admissions available for analysis – Group 1

Ninewells estimates will have wide Confidence intervals

so differences are more likely to be due to chance

no of admissions per year group 1
No. of admissions per year Group 1

At Ninewells may be missing cases - not identified or

simply not yet discharged

no of admissions per year group 4
No. of admissions per year -Group 4

The estimate in your hand out for St Johns is incorrect

length of stay in hospital mean median group 1
Length of Stay in HospitalMean MedianGroup 1

Patients with longer LOS in Ninewells not yet discharged

Why is LOS shorter in ARI than Edinburgh??

length of stay in hospital mean median group 2
Length of Stay in HospitalMean MedianGroup 2

Length of Stay in HospitalMean MedianGroup 2

length of stay in hospital mean median group 3
Length of Stay in HospitalMean MedianGroup 3

Length of Stay in HospitalMean MedianGroup 3

Two fold difference Monklands & Falkirk - why?

length of stay in hospital mean median group 4
Length of Stay in HospitalMean MedianGroup 4

Length of Stay in HospitalMean MedianGroup 4

length of stay in hospital mean median group 5
Length of Stay in HospitalMean MedianGroup 5

Length of Stay in HospitalMean MedianGroup 5

Imprecise estimates because small numbers

Shetland a different model of service?

proportions admitted to stroke unit group 1
Proportions admitted to Stroke Unit – Group 1

77 beds

42 beds

18 beds

Note the 95% CI vary with amount of data collected

proportions admitted to stroke unit group 2

43 beds

35 beds

30 beds

16 beds

10 beds

Proportions admitted to Stroke Unit – Group 2

Ayr & Crosshouse are doing well! - ? chance because only 3 month

7.6-8.3 pts/SU bed/yr cf 14 pts/SU bed/yr in Inverclyde

proportions admitted to stroke unit group 3
Proportions admitted to Stroke Unit – Group 3

24 bed

24 beds

25 beds

30 beds

15 male

proportions admitted to stroke unit group 4
Proportions admitted to Stroke Unit – Group 4

15 beds

14 beds

21 beds

17 beds

8 beds

0 beds

proportion of admission in stroke unit group 1
Proportion of admission in Stroke Unit – Group 1

Reflects delay in admission

% entering SU and exit from

SU before discharge

X

proportions scanned group 1
Proportions scanned – Group 1

ARI seem to be having problems getting scans

proportions scanned group 2
Proportions scanned – Group 2

Delays in Ayr and Crosshouse

proportions scanned group 4
Proportions scanned – Group 4

Raigmore and Victoria Hospital Kirkaldy having problems

proportions scanned group 5
Proportions scanned – Group 5

Shetland understandably not scanning all patients

Western Isles have excellent access to CT

proportion of ischaemic stroke given aspirin within 2 days group 1
Proportion of ischaemic stroke given aspirin within 2 daysGroup 1

Does ARI perform well because they don’t bother to wait for CT?

proportion of ischaemic stroke given aspirin within 2 days group 2
Proportion of ischaemic stroke given aspirin within 2 days– Group 2

May be bad luck because of small numbers but odd given excellent

access to SU & CT - are they giving an alternative antiplatelet drug?

proportion of ischaemic stroke discharged on secondary prevention group 1
Proportion of ischaemic stroke discharged on secondary preventionGroup 1

X

Ninewells get most patients on triple therapy

proportion of ischaemic stroke discharged on secondary prevention group 4
Proportion of ischaemic stroke discharged on secondary prevention - Group 4

VHK and QMH stand out

proportion of ischaemic stroke discharged on secondary prevention group 5
Proportion of ischaemic stroke discharged on secondary prevention - Group 5

Statins not used in Western Isles

proportions of pts with ischaemic stroke and af discharged on warfarin group 1

Warfarin

Antiplatelet

Proportions of pts with ischaemic stroke and AF discharged on Warfarin – Group 1

X

Very varied use of warfarin in AF

proportion of ischaemic stroke in af given aspirin or warfarin group 2
Proportion of ischaemic stroke in AF given Aspirin or Warfarin– Group 2

Warfarin

Antiplatelet

Where columns add up to >100 then combination used?

proportion of ischaemic stroke in af given aspirin or warfarin group 3

Warfarin

Antiplatelet

Proportion of ischaemic stroke in AF given Aspirin or Warfarin– Group 3

?

?

Something odd about data from Lanarkshire

proportion of ischaemic stroke in af given aspirin or warfarin group 5
Proportion of ischaemic stroke in AF given Aspirin or Warfarin– Group 5

Warfarin

Antiplatelet

Proportion of ischaemic stroke in AF given Aspirin or Warfarin– Group 5

1 patient !

delays from assessment to duplex days
Delays from Assessment to Duplex (days)

St Johns reported 3 year data - now sorted

Ninewells & RIE get Duplex before clinic and only few patients

delays from assessment to brain scan for stroke days
Delays from Assessment to Brain scan for stroke (days)

In some places scans are obtained before clinic

conclusions
Conclusions
  • We have seen considerable variation in the processes of care
  • We need to understand these to strive to provide the best possible service for all
  • No hospital can be complacent - there is room for improvement everywhere
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