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									CSS Core Performance Indicator
         Update 2010

               Developed by:
 CSS Information & Evaluation Working Group


        Finalized February 21st, 2010
Canadian Stroke Strategy                                        Core Indicator Review Panel 2009


                        Performance Indicators of CSS Stroke Strategy Impact

                          Stroke Performance Indicator Review Panel 2009

                                       Report of Proceedings

1.0    Background
The Canadian Stroke Strategy (CSS) was established in 2005 as a partnership between the
Canadian Stroke Network (CSN) and the Heart and Stroke Foundation of Canada.
Monitoring and evaluation is a strategic priority of the CSS Steering Committee and
encompasses two levels: the implementation of the stroke strategy nationally and
provincially; and the impact that the strategy is having on the quality of stroke care
delivery and patient outcomes.

The Information and Evaluation Working Group of the CSS was established in 2005 and an
evaluation framework was developed at that time. Through the consultation process
used to develop the original evaluation framework, it became clear that a set of stroke
measures was needed that addressed key aspects of stroke care, and collectively would
provide a valid assessment of the quality and comprehensiveness of stroke care delivery in
jurisdictions wishing to establish coordinated stroke services. These ‘core’ indicators were
not intended to reflect every aspect of stroke care, but rather be representative of the
areas of stroke organization and management that were supported by the highest levels
of research evidence and be readily interpretable in terms of evaluating the quality and
comprehensiveness of stroke care delivery. The original set of core performance
measures were identified through a consensus process in September 2005. These
indicators have been disseminated across Canada and each province has now
incorporated some or all of these into their provincial evaluation monitoring plans.

Since 2005, four key initiatives have occurred that have prompted the current core
indicator review. First, the evidence-based Canadian Best Practice Recommendations for
Stroke Care have been developed and are updated every two years. Within the stroke
Best Practice Guidelines, a set of targeted evidence-based or consensus-based
performance measures have been identified for each recommendation. These
performance measures include some of the core indicator set, as well as additional
indicators to ensure that all key aspects of the recommendation are monitored. This
broader group of performance measures is described in detail in the CSS Performance
Measurement Manual (www.canadianstrokestrategy.ca).

Second, the Canadian Stroke Network has partnered with Accreditation Canada to
establish a Stroke Distinction Program for stroke centres of excellence, and a mandatory
component of this program is submission of CSS core indicator data to Accreditation
Canada. Third, the Canadian Stroke Network has undertaken the development and
production of a Canadian Stroke Report to be released in the fall of 2010. This report will
focus on the achievements and impacts of the Canadian Stroke Strategy. Data will be
gathered from administrative databases and through primary chart audit. The CSS core
indicators will be the foundation for much of the information presented in the Stroke
Report. Most recently, the CSS updated the evaluation framework and it is important to
ensure that the core indicators remain relevant and responsive to current priorities in stroke
care delivery and outcomes monitoring.


Report of Proceedings                    February 2010                                   Page 1
Canadian Stroke Strategy                                                                  Core Indicator Review Panel 2009



The key objectives of the Stroke Performance Indicator Review Panel 2009 were:
    i. to discuss and confirm a updated set of core performance measures for the CSS
       that align with the updated evaluation framework and the Accreditation Canada
       Stroke Distinction Program;
   ii. to define the case definitions for acute stroke to be the reference for all analyses,
       using ICD-10 coding;
  iii. to develop benchmarks or thresholds for each performance measure where
       possible.


2.0     CSS Stroke Evaluation Framework 2009
This evaluation framework has evolved as integrated stroke strategies have been
implemented by provincial, regional, and local stroke champions and as best practices
have been adopted by providers. The evaluation framework is multidimensional. It
considers measurement of successes and opportunities related to the implementation of
the CSS from a national perspective. Secondly, the framework is structured to consider
the extent to which integrated stroke strategies have been implemented at the provincial,
regional, and local levels. Thirdly, the framework addresses the impact implementation
has had on quality of care and outcomes.

        Figure 1: CSS Evaluation Framework

                                                 Canadian Stroke Strategy
                                                   Strategic Priorities 2008

    I
    P
    L
    E
   M               Best              Engage                Measurement              Economic        Professional
    E            Practices        Stakeholders             & Evaluation              Model          Development
   N
   TA
    T
    I    NU YK    BC         AB     SK            MB          ON               QC    NS        NB       NL         PEI
   O      NWT
   N

        I
        M
        P                                                Region
        A
        C                                              Organization
        T
                                             Patient/Family/Caregiver




Evaluation of integrated stroke strategy initiatives and stroke care occurs at all levels of
engagement and from the perspectives of a range of stakeholders. National, provincial,
and regional/local stroke organizations have established goals and priorities, and the
activities to measure stroke performance need to align with these differing priorities (Figure
2). The core indicators identified by the CSS serve as building blocks from which we can
create a system or structure of interlinking multi-level indicators that show the impact of
integrated stroke strategies and implementation of best practices on patients,
communities, and provinces.




Report of Proceedings                              February 2010                                                         Page 2
Canadian Stroke Strategy                                          Core Indicator Review Panel 2009


At the national level, CSS participates in stroke surveillance initiatives in partnership with
the Public Health Agency of Canada and the Canadian Institute of Health Information.
Performance measures at this level focus on broader outcome measures including rates of
stroke patient admission to acute care hospitals and inpatient rehabilitation, hospital
length of stay, mortality rates, and readmission of recurrent stroke. They reflect national
chronic disease prevention and management directions. Measurement of specific
indicators that reflect the development and implementation of the Canadian Stroke
Strategy and are aligned with strategic and operational priorities are currently in
development.

At the provincial level, measurement and monitoring of stroke care addresses
infrastructure and service accountability with regions in provinces where provincial
funding has been allocated for stroke care. These may include ambulance bypass
agreements, access to rehabilitation beds and community services for stroke. Provinces
also engage in surveillance, using indicators that are similar to those used at the national
level, including hospitalization, mortality, and stroke recurrence rates.

Within regional health authorities and local stroke service providers, mechanisms are being
established to monitor more detail regarding the processes of stroke care delivery and
direct interfaces with patients. The focus at this level is on service delivery and quality of
care in meeting the needs of the stroke
population and individual patients. Measures
at this level include: emergency medical
services coordination and rates of hospital                 National
bypass; proportion of patients receiving                   Surveillance




                                                                                           IMPACT
neuroimaging; rates of acute
thrombolysis; swallowing screening;
stroke unit availability and
utilization; assessment for signs              Provincial                Provincial
of depression; and, access to                 Surveillance                Service
                                                                       Accountability
stroke prevention clinics for
rapid assessment of
transient ischemic
attack patients who                Regional/local         Regional/local           Regional/local
                                    Surveillance            processes               continuum of
are not admitted to                                           of care            care & transitions
hospital.

                    Figure 2: Stroke Performance indicator Cascade Model


3.0    Stroke Performance Indicator Panel 2009
The 2009 CSS core indicator review panel consisted of current members of the CSS
Information and Evaluation Working Group, as well as invited experts in stroke care and
stroke evaluation (See Appendix 1 for member list).

Literature reviews were conducted for stroke performance measures and the strength of
the research evidence for the best practice recommendations associated with each
indicator was identified. A search for similar sets of stroke core indicators from individual
provinces and other countries was also conducted and the results reviewed by the panel


Report of Proceedings                   February 2010                                      Page 3
Canadian Stroke Strategy                                      Core Indicator Review Panel 2009


leads. A modified Delphi approach to the panel process was applied, similar to the
process in 2005. All panel members received a pre-meeting survey package that
consisted of the revised CSS evaluation framework, the existing core indicators established
in 2005, and the mandatory and optional indicators included in the pilot phase of the
Accreditation Canada Stroke Distinction Program.

3.1 Core Stroke Performance Indicators
Panel members were asked to review the indicators for the ongoing relevance and
appropriateness for stroke measurement and monitoring. Participants completed a pre-
meeting review in which they provided an initial vote for each indicator in one of three
categories:
              o Retain as presented – remains as part of the core indicator set with the
                 existing 2005 wording
              o Revise and Retain – remains as part of the core indicator set with
                 modifications to the existing wording
              o Delete – from core performance indicator set for 2010

A conference call was held with all panel members after the initial survey was completed.
Results of the pre-meeting survey were presented and discussed by members. Discussions
focused on relevance of the indicators in relation to stroke care priorities, the strength of
evidence supporting the indicators, and the feasibility of collecting each indicator.
Decisions were then made regarding the status of each indicator, and, where applicable,
revisions and wording changes were confirmed.

As a result of this consensus process, the following changes to the 2005 CSS core indicator
set were made:

         All 19 original core indicators were retained in some form for 2010
         Nine of the original core indicators were retained without additional edits
         Six of the original core indicators were retained with revisions/updates to the
         wording (stroke incidence changed to admission volumes, symptom onset to
         hospital arrival changed to 3.5 hours, stroke unit revised to include duration of
         stay, CT/MRI changed to within 24 hours, minor word editing to prevention service
         referrals, minor edits to wording for carotid interventions)
         Four original core indicators related to discharge disposition from acute care
         were combined into one indicator
         Five additional indicators were added to the core indicator set that were
         previously included within the broader best practice indicators as the panel
         considered these relevant measures of system functioning or key markers of
         quality of care. Some of these indicators also increased the alignment between
         the CSS core indicators and the indicators included in the Accreditation Canada
         Stroke Distinction Program. These indictors include hospital length of stay,
         readmission rates, dysphagia screening, acute antiplatelet therapy, early
         rehabilitation assessments.
         One further indicator on documentation of patient education was considered for
         inclusion in the core indicator set. Previous experience by panel experts has
         demonstrated that there are significant data quality issues with this indicator,
         resulting in very low interpretability and utility of the measure. However, there was
         also general agreement that this is a very important topic. The CSS Information


Report of Proceedings                 February 2010                                    Page 4
Canadian Stroke Strategy                                        Core Indicator Review Panel 2009


             and Evaluation Working Group engaged in a follow-up discussion of this indicator
             and agreed that it should be included as a ‘developmental’ indicator for 2010 to
             help drive improvement in data capture and data quality.

The panel members also discussed the rationale, intended purpose and target audience
for the information generated from each indicator under consideration for the core set.
Following in-depth discussions, it was decided to organize and present the core indicators
within two broad categories of ‘system-level’ indicators and ‘clinical’ indicators. System-
level indicators are generally considered structure or process indicators that provide
broader information at a population level for planning and system coordination. Clinical
indicators are generally process or outcome indicators that have a demonstrated link to
quality of care.

Table One (below) provides a listing of the updated CSS core indicator set for 2010 within
the categories of system-level and clinical indicators. For detailed information regarding
operational definitions, calculation formulas, inclusion and exclusion criteria and data
sources, please refer to revised CSS Performance Measurement Manual which can be
found at www.canadianstrokestrategy.ca.

3.2     Case Definitions
The ICD10 case definitions for stroke currently being used by the Canadian Stroke
Strategy, researchers within the Canadian Stroke Network, the Canadian Institute for
Health Information, the Public Health Agency of Canada, and international stroke
researchers were reviewed and presented to the panel for discussion. A further review
was undertaken by members of the CSS Information and Evaluation working group. The
outcome of these discussions is the development of a final set of case definitions for stroke
care monitoring and evaluation. The goal of the CSS is to broadly disseminate these
definitions and have them adopted by all researchers, CIHI, PHAC and other institutions or
agencies conducting stroke care research in Canada. This will lead to increased
standardization and greater comparability of research findings. Please refer to Appendix
2 for case definitions.

3.3         Additional Notes
      i.      Thresholds and Benchmarks: Given the complexity of developing benchmarks
              for stroke care, this task was deferred until the Canadian Stroke Report 2010 is
              completed. Data from the first-ever Canadian stroke audit will be used to
              determine valid relevant benchmarks for some aspects of stroke care delivery.
              Thresholds for a subset of the 2010 core indicators, which are included in the
              Accreditation Canada Stroke Distinction Program, are currently under review by
              a sub-committee of the CSS Information and Evaluation Working Group.

      ii.      During the pre-survey some additional indicators were proposed by panel
               members for consideration. These indicators were discussed during the panel
               meeting and none of them met the criteria for inclusion as a core indicator for
               2010. Where appropriate, some of these indicators will be incorporated into the
               performance measures which are directly linked to best practice
               recommendations.




Report of Proceedings                    February 2010                                   Page 5
Canadian Stroke Strategy                                              Core Indicator Review Panel 2009


Table One: CSS Core Indicators Set 2010

(Based on Consensus Review Panel held December 2009)


                  Canadian Stroke Strategy Core System Indicators 2010
   #     Core Indicator
   1.    Proportion of the population aware of 2 or more signs of stroke.

   2.    The proportion of patients in the population that has any identified risk factors for stroke
         including: hypertension, obesity, smoking history, low physical activity, hyperlipidemia,
         diabetes, atrial fibrillation and carotid artery disease.
   3.    The emergency department admission volumes for patients with ischemic stroke,
         intracerebral hemorrhagic stroke, subarachnoid hemorrhage, and transient ischemic
         attack.

         The hospital inpatient admission volumes for patients with ischemic stroke, intracerebral
         hemorrhagic stroke, subarachnoid hemorrhage, and transient ischemic attack.

   4.    Total acute inpatient hospital length of stay (active LOS + ALC = total).^*

         Total inpatient rehabilitation hospital length of stay (active LOS + days waiting – service
         interruptions = total).

   5.    Stroke death rates for 7-day in-hospital stroke fatality; 30 day all cause mortality; one-
         year all cause mortality, for patients with ischemic stroke, intracerebral hemorrhagic
         stroke, subarachnoid hemorrhage, and transient ischemic attack .*

   6.    Proportion of acute stroke and TIA patients that are discharged alive that are then
         readmitted to hospital with a new stroke or TIA diagnosis within 90 days of index acute
         care discharge. ^*

                  Canadian Stroke Strategy Core Clinical Indicators 2010
   7.    Proportion of acute ischemic stroke patients who arrive at hospital within 3.5 hours of
         stroke symptom onset.

   8.    Proportion of all ischemic stroke patients who receive acute thrombolytic therapy. *

   9.    Proportion of all thrombolysed ischemic stroke patients who receive acute
         thrombolytic therapy within one hour of hospital arrival. *

   10.   The proportion of all acute stroke patients who are managed on a designated
         geographically defined integrated, acute, and/or rehabilitation stroke unit at any
         point during hospitalization. *

         Median total time spent on a stroke unit for each patient during inpatient stay.    ^


   11.   Proportion of stroke patients who receive a brain CT/MRI within 24 hours of hospital
         arrival. +

   12.   Proportion of patients with documentation of an initial dysphagia screening during
         admission to ED or acute inpatient care or inpatient rehabilitation. ^*

Report of Proceedings                     February 2010                                          Page 6
Canadian Stroke Strategy                                                     Core Indicator Review Panel 2009


    13.      Proportion of acute ischemic stroke and TIA patients who receive acute antiplatelet
             therapy within the first 48h hours of hospital arrival. ^+

    14.      Proportion of stroke patients with a rehabilitation assessment within 48 hours of hospital
             admission for acute ischemic stroke and within 5 days of admission for hemorrhagic
             stroke. +

    15.      Proportion of acute ischemic stroke patients discharged on antithrombotic therapy
             unless contraindicated. *

    16.      Proportion of acute ischemic stroke patients with atrial fibrillation who are treated with
             anti-coagulant therapy unless contraindicated. +

    17.      Proportion of patients with TIA who are investigated and discharged from the
             emergency department who are referred to organized secondary stroke prevention
             services. +

             Percentage of patients referred to organized secondary stroke prevention services
             who are seen within 72 hours

    18.      Wait time from ischemic stroke or TIA symptom onset to carotid revascularization. +

    19.      Distribution of discharge locations (dispositions) for acute stroke patients from acute
             inpatient care to: home (with and without services); inpatient rehabilitation (General
             or specialized); long term care; and to palliative care (each stratified by stroke type
             and severity). *
    20.      Wait times for inpatient stroke rehabilitation services from stroke onset to rehabilitation
             admission. +

             Wait times for outpatient stroke rehabilitation services from stroke onset to outpatient
             rehabilitation admission.

    21.      Distribution of discharge locations (dispositions) from inpatient rehabilitation to: home
             (with and without services); acute care (for acute medical issues or as repatriation to
             home community); and to long term care (each stratified by stroke type and severity).


    i        Proportion of all stroke patients with documentation of education provided for patient,
             family and/or caregivers during acute inpatient care or inpatient rehabilitation stay. !+


^       New core indicator – previously part of larger set of CSS best practice indicators, and/or part of
        Accreditation indicator set and elevated to core indicator for 2010
*       CSS core indicators that are also mandatory indicators for the Accreditation Canada Stroke Distinction
        Program
+       CSS core indicators that are also optional indicators for the Accreditation Canada Stroke Distinction
        Program
!       Indicator on documentation of patient education is considered a developmental indicator that will be
        monitored closely for data quality and validity prior to being considered as a part of the CSS core
        indicator set.

    For additional indicators associated with each stroke best practice recommendation,
             please refer to the CSS Performance Measurement Manual, found at
                                www.canadianstrokestrategy.ca



Report of Proceedings                           February 2010                                          Page 7
Canadian Stroke Strategy                                   Core Indicator Review Panel 2009



Appendix One: Members of the CSS Core Indicator Update 2010 Consensus Panel

Dr. Michael Hill                Director, Stroke Unit
Chair                           Calgary Stroke Program, Foothills Medical Centre
Dr. Patrice Lindsay             Information & Evaluation Specialist
Staff Lead                      Canadian Stroke Network
Dr. Robert Cote                 Stroke Neurologist
                                Division of Neurology, Montreal General Hospital
Dr. Andrew Demchuk              Calgary Stroke Program
                                Foothills Medical Centre
Dr. Teri Green                  Assistant Professor, University of Calgary
                                Foothills Medical Centre
Dr. Gord Gubitz                 Stroke Neurologist
                                QEII Health Sciences Centre
Mary Elizabeth Harriman         Associate Executive Director
                                Heart and Stroke Foundation of Canada
Jennifer Jelley                 Health Information Specialist
                                Government of PEI Department of Health and Wellness
Dr. Moira Kapral                Associate Professor of Medicine, Division of General
                                Internal Medicine, University of Toronto
                                Co-Principal Investigator Registry of the Canadian
                                Stroke Network
Dr. Hans Krueger                Evaluation Lead, British Columbia Stroke Strategy
                                Adjunct Professor, School of Population and Public
                                Health, UBC Faculty of Medicine
Katie Lafferty                  Executive Director
                                Canadian Stroke Network
Dr. Sylvain Lanthier            Stroke Neurologist
                                CHUM , University of Montreal
Kathryn LeBlanc                 Regional Stroke Manager Central South Stroke Region
                                Regional Stroke Centre , Hamilton General Hospital
Dr. Gary Teare                  Director of Quality Management & Analysis
                                Saskatchewan Health Quality Council
                                Co-chair Saskatchewan Evaluation Working Group

Samantha Singh                  Research Coordinator
                                Canadian Stroke Strategy
Elizabeth Woodbury              Executive Director
                                Canadian Stroke Strategy
Dr. Sharon Wood-Dauphinee       Professor, School of Physical & Occupational Therapy
                                McGill University




Report of Proceedings            February 2010                                      Page 8
Canadian Stroke Strategy                                           Core Indicator Review Panel 2009


Appendix Two: CSS Stroke Case Definitions 2010


The following stroke code groupings should be applied when identifying stroke cases for
performance measurement and monitoring. Activities related to this may include quality
improvement, surveillance and research in stroke.

The Canadian Stroke Strategy is working in collaboration with the Public Health Agency of
Canada Surveillance division on several initiatives. The case definitions for stroke
contained in the following table are aligned with codes used in PHAC reports on stroke
care and will be applied to the stroke component of the National Chronic Disease
Surveillance System (NCDSS).

          Stroke subcategory                          ICD-9 codes*             ICD-10 codes*
                                                            430                       I60
                                                            431                       I61
                                                          433.x1 c                  I63 a
   1.     Acute stroke
                                                          434.x1 c                   I64 d
                                                            436                     I67.6
                                                           362.3 b                 H34.1b
                                                          433.x1c                    I63a
          Ischemic stroke (includes acute but
   2.                                                     434.x1 c                   I64d
          ill-defined cerebrovascular)
                                                            436                     H34.1b

   3.     Subarachnoid hemorrhage                           430                       I60

   4.     Intracerebral hemorrhage                          431                       I61
                                                                             G45 (excl. G45.4)
   5.     Transient ischemic attack                         435
                                                                                  H34.0 b
          For paediatric cases:
                                                                                    I63.6 a
          Cerebral Cortical Vein Thrombosis
   6.                                                      437.6                     I67.6
          Intracranial Venous Sinus
                                                                                     G08
          Thrombosis (nonpyogenic)


*Not to be included in Stroke Case Definition:

          Arteriovenous Malformation
                                                       747.6
   7.     (cerebral)                                                             I60.8 (Ruptured) f
                                                       747.81
          Arterial Malformation (cerebral)




Report of Proceedings                 February 2010                                           Page 9
Canadian Stroke Strategy                                           Core Indicator Review Panel 2009


Notes:

*         In all case selections, ICD9 and ICD10 coding should be applied to the 5th digit
          (ICD9) or 4th digit (ICD10) where available. See specific notes below regarding
          exceptions and exclusions to the case codes.

    a.    437.6, I63.6, I67.6 – Cerebral venous thrombosis. This is uncommon in adults (<<1% of
          all stroke) and has a different pathology compared to arterial stroke. In children a
          much greater proportion of strokes are due to venous thrombosis. [Note: codes
          325 and G08 refer to septic intracranial venous thrombo-phlebitis and are excluded
          here.]

    b.    362.3/H34.0/H34.1 - Transient/Central Retinal Artery Occlusion. Impractical to
          include retinal vascular occlusion if 4th digit coding is not available; include where
          information is available. Considerable variation will exist across provinces for this
          code, however. Overall impact of including this code may be small.

    c.    433/434 – Both require 5th digit coding and should not be used if it is not available;
          include where information is available and the fifth digit is coded as a ‘1’ indicating
          infarction present (ie. 433.x1 or 434.x1, where x can be any number)

    d.    I64 – Stroke, not specified as hemorrhage or infarction. Generally included in
          overall acute stroke. Cannot be counted on its own as a separate stroke type.
          Efforts should be made to reduce use of this code as almost all stroke patients
          receive a CT scan and based on the scan they should be able to be categorized
          at ischemic or hemorrhagic. Generally, the issue seems to be that health records
          abstractors are not trained in all the possible terminology that may be used for
          ischemic stroke, and they look for the word ‘infarction’ to classify I-63. This term is
          not used as frequently as the following list: ischaemic stroke, small vessel stroke,
          lacunar stroke, stroke from atrial fibrillation, ischemic cerebrovascular insult
          presumably from an embolic location, right MCA stroke, L MCA distribution
          secondary to small vessel ischemia. Abstractors should be provided with this
          additional list and efforts made to reduce use of I-64 category.

     e. I62, 432 – Codes for non-specific hemorrhage or subdural hemorrhage are
        excluded. To be consistent with past coding practices for comparison purposes,
        these codes are included in the “all cerebrovascular disease” category. Some
        patients with these codes will have a hemorrhagic stroke syndrome rather than
        simply a subdural hemorrhage.

     f.   Unruptured AV malformations and aneurysms are not considered stroke and are
          therefore not included in acute stroke case definitions. They are coded as Q28 in
          ICD_10, with Q28.2 and Q.28.3 specifically being for the cerebral vessels.




Report of Proceedings                    February 2010                                     Page 10

								
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