2016/17 Ontario Stroke Report Card

CorHealth Ontario is pleased to publish the 2016/17 Stroke Report Card. Click here to view it.

To view the 2016-17 Stroke Care in Ontario Infographic, click here.

Provincial Overview

  • Compared to three-year average rates (2013/14 – 2015/16): 9 indicators significantly improved in 2016/17
  • Compared to benchmarks set for 2015/16: 7 performance thresholds improved in 2016/17

Areas of Progress

This edition of the provincial report card documents significant improvement for nine performance indicators compared to their previous three-year average including carotid imaging, access to and timeliness of thrombolysis (tPA), stroke unit care, referral to secondary prevention services, achievement of target length of stay (LOS) for inpatient rehabilitation, functional outcome of patients receiving inpatient rehabilitation, receipt of outpatient rehabilitation services, and 30-day all-cause readmission to hospital.

A significantly higher rate of tPA observed in 2016/17 may be associated with better functional outcome in patients who, without this treatment, may have required inpatient rehabilitation services. Indeed, the proportion of patients with stroke considered mild and discharged home has increased since 2015/16. Availability of the novel clot retrieval therapy known as Endovascular therapy (EVT) and an increase in access to outpatient rehabilitation services may also account for higher rates of discharge to the community following stroke.

The proportion of stroke patients admitted to inpatient rehabilitation and achieving an active LOS at or less than the target LOS appropriate to their level of disability increased in 2016/17 compared to the three-year average rate (66.4% vs 56.9%). Additionally, patients with moderately severe stroke admitted to inpatient rehabilitation experienced greater improvement in activities of daily living independence at discharge (median FIM efficiency) compared to prior years. Taking these indicators together, greater efficiency in resource use by rehabilitation facilities and better functional outcomes following inpatient rehabilitation care have been observed.

The 30-day readmission rate after acute stroke continues to track lower in 2016/17 (7.0%) and was almost half the readmission rate reported for the general population following a medical (non-surgical) hospitalization (13.8%).

Areas for Improvement

There were five indicators in which the reported values were unchanged or worsened in 2016/17 compared to the three-year average and include the overall rate of admission for stroke and TIA, the ratio of ALC days to total LOS, admission to inpatient rehabilitation from acute care, the time between stroke onset and admission to inpatient rehabilitation, and the admission of patients with severe stroke to inpatient rehabilitation.

The increase in the overall rate of admission for stroke and TIA may be the result of greater awareness by the population of the signs and symptoms of stroke and their likelihood to present to the ED. It could also be an indicator of lack of access to secondary prevention services following discharge from the ED and while referral rates are improving, there is marked variability across the province and most regions still fall well below the provincial benchmark of 95%.

Although not shown in this report, the rate of in-hospital death among patients admitted with acute stroke or TIA has declined in each year since 2007 resulting in an increasing demand for inpatient rehabilitation services over time. This greater proportion of stroke and TIA patients surviving to discharge has implications for almost all of the indicators that did not improve. For example, the time between stroke onset and admission to inpatient rehabilitation is affected by a larger pool of eligible patients attempting to access an inelastic and static rehabilitation infrastructure. Patients unable to progress to rehabilitation from acute care may contribute to higher ALC days as a proportion of LOS. While Ontario’s overall rate of admission to inpatient rehabilitation following stroke of any severity exceeds the national target of 30%, the 2016/17 rate represented a decline from the prior three-year average. The need for additional investment in rehabilitation services should be examined.

Between year variation in performance across LHINs was measured using the Extremal Quotient (EQ) which is the ratio of the highest LHIN value (rate, ratio, proportion or median) to the lowest LHIN value in each of 2015/16 and 2016/17. There were three indicators in which the EQ was 50% or higher in 2016/17 compared to 2015/16 and includes DTN time, 30-day readmission and the proportion of patients discharged to LTC/CCC. Year over year fluctuations may represent random variation or data quality issues. For example, while the DTN median time demonstrated a statistically significant five minute reduction in 2016/17 compared to the previous 3-year average (47 minutes and 52 minutes, respectively), a larger EQ in the most recent year compared to 2015/16 suggests continued effort is needed to ensure that the time variables are accurately recorded. Time to thrombolysis is a critical component for establishing treatment eligibility criteria and for evaluating outcomes; it is essential that this be measured without error.

Current or Planned Activities

CorHealth Ontario will continue its vital collaboration with Ontario’s 11 Regional Stroke Networks to align operating plans, education, knowledge translation approaches and implementation strategies to advance access to best practices with a goal of improving performance measured by the report card indicators.

CorHealth Ontario will continue to coordinate the implementation of best practices. In 2018/19, there will be a greater focus on implementation of QBP recommendations for TIA, community-based rehabilitation and EVT.

CorHealth Ontario will continue to work with the MOHLTC and CIHI to inform a sustainable stroke data collection and data quality strategy. This strategy will aim to inform report card indicators that include EVT, and to support the work of the Rehabilitative Care Alliance in addressing availability of outpatient rehabilitation data.

The CorHealth Ontario Stroke Evaluation Quality Committee will continue to review the report card indicators in the context of stroke best practices and evolving data availability and quality.