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
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)
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
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
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.