Regional Advisory Council (RAC) · Regional Advisory Councils (RACs) play a key role in data...

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Regional Advisory Council (RAC)

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TABLE OF CONTENTS

EXECUTIVE SUMMARY ................................................................................................................................................... 3

INTRODUCTION ............................................................................................................................................................. 4

BACKGROUND ............................................................................................................................................................... 4

STROKE IN TEXAS ........................................................................................................................................................... 4

METHODOLOGY ............................................................................................................................................................. 5

Figure 1. The method of collection and analysis process of the regional stroke data reported. .......................... 6

EVALUATING THE REGIONAL STROKE SYSTEM OF CARE ............................................................................................... 7

Table 1. Number of hospitals reporting per data collection period and participation type. ................................ 7

STROKE CASES REPORTED ......................................................................................................................................... 8

Figure 2. Percentage of stroke cases reported by data collection method. ......................................................... 8

Figure 3. Total number of stroke cases reported by participation type, July 2015-June 2016. ............................ 8

Table 2. Total number of stroke cases reported by participation type, July 2015-June 2016. RAC Data Survey;

Item 14. ................................................................................................................................................................. 9

Figure 4. Total number of stroke cases by RAC, Texas, July 2015-June 2016. .................................................... 10

CLASSIFICATION OF STROKE CASES ......................................................................................................................... 11

Figure 5a. Classification of stroke cases, July 2015-June 2016. ........................................................................... 11

Table 3a. Classification of stroke cases, July 2015-June 2016. RAC Data Survey, Item 15. ................................. 12

Table 3b. Classification of stroke cases, July 2015-June 2016. RAC Data Survey, Item 15. ................................. 13

Figure 5b. Total number of ischemic stroke cases by RAC, Texas, July 2015-June 2016..................................... 14

ARRIVAL METHOD OF STROKE CASES...................................................................................................................... 15

Figure 6a. Percent of EMS from home or scene, July 2015-June 2016. .............................................................. 16

Figure 6b. Percent of private transportation from home or scene, July 2015-June 2016. ................................. 16

Figure 6c. Percent of transfer from other hospital, July 2015-June 2016. .......................................................... 16

Figure 6d. Percent of arrival via EMS from home or scene by RAC, Texas, July 2015-June 2016. ...................... 17

Table 4. Arrival method of stroke cases, July 2015-June 2016. RAC Data Survey; Item 16................................. 18

NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS) PERFORMED ............................................................... 19

Figure 7. Percent of ischemic stroke cases with an NIH Stroke Scale (NIHSS) performed, July 2015-June 2016.

............................................................................................................................................................................. 20

Table 5. Ischemic stroke cases with an NIH Stroke Scale (NIHSS) performed, July 2015-June 2016. RAC Data

Survey, Item 17. .................................................................................................................................................. 20

INTRAVENOUS THROMBOLYTIC THERAPY (IV t-PA) ................................................................................................ 21

Figure 8. Percent of ischemic stroke cases that received IV t-PA, July 2015-June 2016. .................................... 21

Table 6. Ischemic stroke cases that received IV t-PA, July 2015-June 2016. RAC Data Survey, Item 18. ............ 22

IV t-PA WITHIN 60 MINUTES OF ARRIVAL ............................................................................................................... 23

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Figure 9. Percent of ischemic stroke cases that received IV t-PA within 60 minutes or less from time of hospital

arrival, July 2015-June 2016. ............................................................................................................................... 23

Table 7. Ischemic stroke cases that received IV t-PA within 60 minutes or less from time of hospital arrival, July

2015-June 2016. RAC Data Survey, Item 19. ....................................................................................................... 24

ENDOVASCULAR THERAPY ...................................................................................................................................... 25

Figure 10. Percent of ischemic stroke cases that received endovascular therapy (IA catheter-based reperfusion),

July 2015-June 2016. ........................................................................................................................................... 25

Table 8. Ischemic stroke cases that received endovascular therapy (IA catheter-based reperfusion), July 2015-

June 2016. RAC Data Survey, Item 21. ................................................................................................................ 26

PICTURE-TO-PUNCTURE WITHIN 60 MINUTES ........................................................................................................ 27

Figure 11. Percent of ischemic stroke cases that received endovascular therapy (IA catheter-based reperfusion)

within 60 minutes or less of time of initial brain imaging, July 2015-June 2016. ............................................... 27

Table 9. Ischemic stroke cases that received endovascular therapy (IA catheter-based reperfusion) within 60

minutes or less of time of initial brain imaging, July 2015-June 2016. RAC Data Survey, Item 22. .................... 28

DISCHARGE DISPOSITION OF ISCHEMIC STROKE CASES .......................................................................................... 29

Figure 12. Discharge disposition of ischemic stroke cases, July 2015-June 2016. .............................................. 29

Table 10a. Discharge disposition of ischemic stroke cases, July 2015-June 2016. RAC Data Survey, Item 23. ... 30

Table 10b. Discharge disposition of ischemic stroke cases, July 2015-June 2016. RAC Data Survey, Item 23.... 31

HEALTH INSURANCE STATUS OF ISCHEMIC STROKE CASES .................................................................................... 32

Figure 13. Health insurance status of ischemic stroke cases, July 2015-June 2016. ........................................... 32

Table 11. Health insurance status of ischemic stroke cases, July 2015-June 2016. RAC Data Survey, Item 20. . 33

Figure 14. Percent of ischemic stroke cases with any health insurance by RAC, Texas, July 2015-June2016. ... 34

LIMITATIONS ................................................................................................................................................................ 35

REFERENCES ................................................................................................................................................................. 36

APPENDICES ................................................................................................................................................................. 37

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EXECUTIVE SUMMARY

This report describes the findings from the regional data collection effort and reflects the care of stroke

patients reported from July 1, 2015 to June 30, 2016 for the 22 regions in Texas.

Regional stroke care findings, July 2015 – June 2016:

220 hospitals provided stroke data for the first collection period (July - December 2015) and 235

hospitals provided data for the second (January - June 2016) (Table 1).

Strokes cases occurred in all 22 regions (Figure 4).

44,044 stroke cases were reported; 83.2% of which was collected through the RAC Data Surveys and

16.8% GWTG-Stroke (Table 2).

Emergency Medical Service (EMS) was the most common arrival method for 13 out of the 20 regions

included (Figure 6d). Private transportation was the most common for the remaining seven regions

(Figure 6b).

42.4% (n=18,655) reported were classified as ischemic (Figure 5b).

Nearly half, seven of the 15 regions included, reported more than 90% of ischemic stroke patients had

a NIHSS performed (Figure 7).

12.8% of the ischemic stroke patients received intravenous thrombolytic therapy (IV t-PA) (Figure 8).

The average percent of patients that received IV t-PA within 60 minutes of arrival was 59.5%.

4.0% of ischemic stroke patients received endovascular therapy (Figure 10). More than half, six of the

11 regions included, reported 0.0% receiving therapy within 60 minutes of imaging (Figure 11).

Home was the most common discharge disposition for eight of the reporting regions (Figure 12).

21.2% of ischemic patients had some form of health insurance documented (Figure 14).

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INTRODUCTION

Heart disease and stroke are the number one and number three leading causes of death in Texas in 2014.1

In order to reduce heart disease and stroke related death and disability, it is important to evaluate the

current state of systems of care in the state for both conditions by collecting and analyzing data.

During the 83rd Regular Texas Legislative Session, the Legislature appropriated funds to advance heart

attack and stroke reduction efforts throughout Texas. To inform such efforts, the Texas Department of

State Health Services (DSHS) has launched a heart attack and stroke data collection initiative. The initiative

focuses on pre-hospital and hospital heart attack and stroke measures. The data elements are collected

from multiple sources for the comprehensive assessment of the systems of care.

Regional Advisory Councils (RACs) play a key role in data collection by enhancing the surveillance of the

heart attack, with a particular focus on ST-segment elevation myocardial infarction (STEMI), and stroke

systems of care in Texas. This report describes the findings for the regional stroke system of care measures

in Texas. Survey findings will be used to assess practices regarding delivery of heart attack and stroke care

across the state and identify areas of opportunity for quality improvement.

BACKGROUND

With guidance from the Texas Council on Cardiovascular Disease and Stroke, Governor’s EMS and Trauma

Advisory Council (GETAC), and DSHS Office of Surveillance, Evaluation and Research (OSER), the Texas

Heart Disease and Stroke Program developed an online survey using Survey Monkey

(https://www.surveymonkey.com) to gather regional pre-hospital and hospital STEMI and stroke data.

The 22 Regional Advisory Councils (RACs) were surveyed and asked to report STEMI and stroke data

elements for their regions, also known as Trauma Service Areas (TSA), that occurred between July 1, 2015

and June 30, 2016. RACs collected and reported data to the Health Promotion and Chronic Disease

Prevention Section (HPCDPS) of DSHS. OSER analyzed the data and created this report to inform RACs and

the Texas Council on Cardiovascular Disease and Stroke, as well as other stakeholders.

Appendix A displays the geographic coverage of the 22 RACs in Texas, all of which are represented in the

report.

STROKE IN TEXAS

In 2015, the prevalence of stroke among Texans, 18 years of age and older, was 3.0% (95% CI: 2.5-3.5).2

In 2014, age-adjusted stroke death rate among Texans of all ages, was 43.3 (95% CI: 42.4-44.1) per 100,000

people.1 When stratified by race/ethnicity, the age-adjusted stroke death rate was significantly higher

among black, (59.2, 95%CI: 56.0-62.5), than white (43.7, 95% CI: 42.7-44.8) and Hispanic (36.4, 95%CI:

34.8-38.0) subgroups.1

In 2014, the age-adjusted hospitalization rate due to stroke among Texans of all ages, was 20.3 (95% CI:

20.1-20.4) per 10,000 people.3

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METHODOLOGY

This report includes the de-identified, aggregate RAC-level data collected from hospitals who agreed to

share hospital-level data through 1.) Semi-annual Surveys and 2.) Get With The Guidelines® (GWTG)-

Stroke data with DSHS. All data is protected under Health Insurance Portability Accountability Act (HIPAA)

guidelines. No hospital-level data will be distributed, nor will any hospital name be identified in the report.

There were a total of 24 questions in the survey, consisting of the following elements:

RAC leadership and contact information, and pre-hospital and hospital elements of STEMI and

stroke (Appendix B).

RAC Data Survey 1, collected data on cases that occurred between July 1, 2015 and December 31,

2015.

RAC Data Survey 2, collected data on cases that occurred between January 1, 2016 and June 30,

2016.

The surveys’ RAC-level data submitted to OSER was subsequently combined for analysis and includes data

reported from July 1, 2015 through June 30, 2016.

OSER identified hospitals participating in the GWTG-Stroke registry that did not provide hospital-level data

through the RAC Data Surveys. These hospitals’ data from July 1, 2015 to June 30, 2016 were analyzed at

the regional level and aggregate data were added to the RAC-level data collected through the RAC Data

Surveys.

Figure 1 on the following page explains the data collection method and analysis process used for the

evaluation of the stroke system of care at the regional level.

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Figure 1. The method of collection and analysis process of the regional stroke data reported.

DATA ANALYSIS

OSER removed duplicate entries before analyzing the data. OSER followed up with the RACs when

clarification was needed. Data from the RAC Data Surveys was analyzed using Microsoft Excel 2010, and

GWTG-stroke data was analyzed using SAS 9.4.

RAC Data Collection (via semi-annual survey)

Hospitals participating in GWTG-stroke

and DSHS

Hospitals participating in GWTG-stroke but not with

DSHS

Hospitals NOT participating in either GWTG-stroke or DSHS

Aggregate data from the hospitals will be collected by each RAC. The list of hospitals that submitted data to RACs will be available

along with the aggregate data.

RACs submit aggregate data to DSHS

2016 Texas Regional Stroke System of Care Report

Identify hospitals from GWTG-stroke registry that are not included in the RAC Data

Surveys by each RAC

Pull data for these hospitals at the RAC-level

Analyze data from the above subset for the measures included in the RAC Data Survey

following the same definitions given to RACs

Add aggregate data to the data submitted by the RACs

Regional Data Reports

Method and Process

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EVALUATING THE REGIONAL STROKE SYSTEM OF CARE

Overall, there were 220 hospitals that provided data on stroke cases that occurred between July 1, 2015

and December 31, 2015, and 235 hospitals provided data on stroke cases that occurred between January

1, 2016 and June 30, 2016 (Table 1).

21 RACs reported regional hospital stroke data for RAC Data Survey 1 (Table 1).

22 RACs reported regional hospital stroke data for RAC Data Survey 2 (Table 1).

The number of hospitals participating through the RAC Data Survey increased from 197 for Survey 1

to 212 for Survey 2 (Table 1).

Data from an additional 31 hospitals that participated through the GWTG-stroke registry was

combined with the regional stroke data submitted through the RAC Data Surveys.

Hospitals participating through the GWTG-stroke registry for Survey 1 are located in eight regions

(RACs C, E, G, H, K, L, O, and P).

Hospitals participating through the GWTG-stroke registry for Survey 2 are located in five regions (RACs

E, H, O, P, and V).

Table 1 displays the hospital participation totals for each participation type by RAC for July-December

2015 and January-June 2016.

Table 1. Number of hospitals reporting per data collection period and participation type.

TOTAL NUMBER OF REPORTING HOSPITALS

RAC

July - December 2015 January - June 2016

RAC Data Survey GWTG-stroke RAC Data Survey GWTG-stroke

Total 197 23 212 23 A 12 0 11 0 B 17 0 16 0 C 2 1 6 0 D 16 0 8 0 E 20 13 26 15 F 3 0 6 0 G 8 1 11 0 H 5 1 5 2 I 6 0 6 0 J 13 0 11 0 K 10 1 10 0 L 0 1 7 0

M 7 0 8 0 N 8 0 8 0 O 10 2 1 3 P 2 3 9 2 Q 33 0 32 0 R 8 0 10 0 S 5 0 7 0 T 2 0 2 0 U 3 0 4 0 V 7 0 8 1

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STROKE CASES REPORTED Guidance on inclusion and exclusion criteria was provided to the RACs in the RAC Data Surveys for each

question (Appendix B). For July 1, 2015 through June 30, 2016, a total of 44,044 stroke cases were

reported (Table 2); 83.2% was collected from the RAC Data Surveys and 16.8% collected from the GWTG-

stroke registry participating hospitals (Figure 2).

All 22 regions have reported stroke cases (Figure 4).

A total of 36,652 stroke cases were reported from the RAC Data Surveys (Table 2).

A total of 7,392 stroke cases were reported from GWTG-stroke (Table 2).

Nine regions (RACs C, E, G, H, K, L, O, P, and V) include data from both GWTG-stroke and the RAC Data

Surveys (Table 2).

For the majority of regions, the total number of reporting hospitals varied between the July-December

2015 and January-June 2016 collection periods (Table 2).

Figure 2. Percentage of stroke cases reported by data collection method.

Figure 3 and Table 2 display the number of stroke cases reported by participation type and the total number of stroke cases from July 2015 to June 2016 by RAC.

Figure 3. Total number of stroke cases reported by participation type, July 2015-June 2016.

83.2%

16.8%

RAC Data Surveys

GWTG-stroke registry

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

STR

OK

E C

ASE

S (N

)

RAC

TOTAL NUMBER OF STROKE CASES REPORTED BY DATA COLLECTION METHOD

RAC Data Surveys

GWTG-stroke registry

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Table 2. Total number of stroke cases reported by participation type, July 2015-June 2016. RAC Data Survey; Item 14.

TOTAL STROKE CASES REPORTED

RAC

RAC Data Survey (n)

GWTG-stroke (n)

Total stroke cases reported (N)

Total number of reporting hospitals

Total number of eligible hospitals July-Dec 2015 Jan-June 2016

Total 36,652 7,392 44,044 220 235 412 A 608 -- 608 12 11 18 B 1,134 -- 1,134 17 16 18 C 36 192 228 3 6 13 D 391 -- 391 16 8 17 E 6,853 3,712 10,565 33 41 83 F 490 -- 490 3 6 6 G 2,065 93 2,158 9 11 21 H 230 400 630 6 7 8 I 1,430 -- 1,430 6 6 9 J 949 -- 949 13 11 17 K 345 115 460 11 10 10 L 596 373 969 1 7 10

M 1,395 -- 1,395 7 8 7 N 1,000 -- 1,000 8 8 8 O 3,049 645 3,694 12 4 26 P 1,072 1,624 2,696 5 11 36 Q 9,304 -- 9,304 33 32 54 R 1,250 -- 1,250 8 10 18 S 397 -- 397 5 7 7 T 580 -- 580 2 2 2 U 1,430 -- 1,430 3 4 11 V 2,048 238 2,286 7 9 13

(--) missing; no additional data from GWTG-stroke participating hospitals.

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Figure 4. Total number of stroke cases by RAC, Texas, July 2015-June 2016.

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CLASSIFICATION OF STROKE CASES The stroke classification was reported as follows; 18,655 (42.4%) ischemic stroke, 4,082 (9.3%) transient

ischemic attack <24 hours (TIA), 3,180 (7.2%) intracerebral hemorrhage, 1,046 (2.4%) subarachnoid

hemorrhage, and 755 (1.7%) stroke not otherwise specified (Figure 5a).

▪ 17 regions reported stroke classification data.

▪ Stroke classification data was missing for five regions (RACs A, E, J, P, and T).

▪ Seven regions (RACs C, G, H, K, L, O, and V) included stroke classifications data from GWTG-stroke and

the RAC Data Surveys.

Figures 5a below and Tables 3a-b on the following pages display the classification of the stroke cases

reported from July 1, 2015 through June 30, 2016 by RAC.

Figure 5a. Classification of stroke cases, July 2015-June 2016.

0

20

40

60

80

100

Total B C D F G H I K L M N O Q R S U V

TO

TAL P

ERCEN

T (

%)

RAC

CLASSIFICATION OF STROKE CASES

Ischemic Stroke Transient Ischemic Attack (TIA) Intracerebral Hemorrhage

Subarachnoid Hemorrhage Stroke Not Otherwise Specified

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Table 3a. Classification of stroke cases, July 2015-June 2016. RAC Data Survey, Item 15.

RAC

Total stroke cases (N)

Ischemic Stroke Transient Ischemic Attack (<24 hours) (TIA) Intracerebral Hemorrhage

RAC Survey (n)

GWTG-Stroke (n)

Total (n)

Total %

RAC Survey (n)

GWTG-Stroke (n)

Total (n)

Total %

RAC Survey (n)

GWTG-Stroke (n)

Total (n)

Total %

Total 44,044 17,398 1,257 18,655 42.4 3,607 475 4,082 9.3 3,010 170 3,180 7.2 A 608 -- -- -- -- -- -- -- -- -- -- -- -- B 1,134 638 -- 638 56.2 247 -- 247 21.8 137 -- 137 12.1 C 228 11 138 149 65.4 5 30 35 15.4 2 21 23 10.1 D 391 204 -- 204 52.2 86 -- 86 22.0 27 -- 27 6.9 E 10,565 -- -- -- -- -- -- -- -- -- -- -- -- F 490 276 -- 276 56.3 75 -- 75 15.3 84 -- 84 17.1 G 2,158 1,087 47 1,134 52.5 429 47 476 22.1 197 10 207 9.6 H 630 65 211 276 43.8 81 104 185 29.4 19 29 48 7.6 I 1,430 910 -- 910 63.6 258 -- 258 18.0 185 -- 185 12.9 J 949 -- -- -- -- -- -- -- -- -- -- -- -- K 460 212 99 311 67.6 61 0 61 13.3 42 11 53 11.5 L 969 333 224 557 57.5 118 70 188 19.4 61 44 105 10.8

M 1,395 793 -- 793 56.8 461 -- 461 33.0 134* -- 134* 9.6* N 1,000 523 -- 523 52.3 310 -- 310 31.0 82 -- 82 8.2 O 3,694 1,939 383 2,322 62.9 675 159 834 22.6 296 42 338 9.1 P 2,696 -- -- -- -- -- -- -- -- -- -- -- -- Q 9,304 7,465 -- 7,465 80.2 0 -- 0 0.0 1,404 -- 1,404 15.1 R 1,250 1,031 -- 1,031 82.5 0 -- 0 0.0 177 -- 177 14.2 S 397 230 -- 230 57.9 106 -- 106 26.7 34 -- 34 8.6 T 580 -- -- -- -- -- -- -- -- -- -- -- -- U 1,430 630 -- 630 44.1 302 -- 302 21.1 147 -- 147 10.3 V 2,286 1,051 155 1,206 52.8 393 65 458 20.0 116 13 129 5.6

(--) missing; data is missing as a result of values submitted for RAC Data Survey; Item 15a-e that are invalid. *RAC M for RAC Data Survey 2 reported Intracerebral Hemorrhage (n=75) as a combined total including both Intracerebral and Subarachnoid Hemorrhages. The total number (n) and total percent (%) reported as Intracerebral Hemorrhage (n=134, 9.6%) includes both Intracerebral Hemorrhage and Subarachnoid Hemorrhage classifications.

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Table 3b. Classification of stroke cases, July 2015-June 2016. RAC Data Survey, Item 15.

RAC


Subarachnoid Hemorrhage Stroke Not Otherwise Specified Total number of

reporting hospitals Total

number of eligible

hospitals RAC Survey (n)

GWTG-Stroke (n)

Total (n)

Total %

RAC Survey (n)

GWTG-Stroke (n)

Total (n)

Total %

July-Dec 2015

Jan-June 2016

Total 44,044 983 63 1,046 2.4 644 111 755 1.7 155 159 256 A 608 -- -- -- -- -- -- -- -- -- -- -- B 1,134 80 -- 80 7.1 25 -- 25 2.2 17 16 18 C 228 1 3 4 1.8 17 0 17 7.5 3 6 13 D 391 11 -- 11 2.8 34 -- 34 8.7 16 8 17 E 10,565 -- -- -- -- -- -- -- -- -- -- -- F 490 22 -- 22 4.5 0 -- 0 0.0 3 6 6 G 2,158 51 2 53 2.5 39 8 47 2.2 9 11 21 H 630 2 3 5 0.8 63 53 116 18.4 6 7 8 I 1,430 77 -- 77 5.4 0 -- 0 0.0 6 6 9 J 949 -- -- -- -- -- -- -- -- -- -- -- K 460 11 5 16 3.5 19 0 19 4.1 11 10 10 L 969 46 29 75 7.7 22 6 28 2.9 1 7 10

M 1,395 --* -- -- -- 0 -- 0 0.0 7 8 7 N 1,000 19 -- 19 1.9 66 -- 66 6.6 8 8 8 O 3,694 123 16 139 3.8 16 44 60 1.6 12 4 26 P 2,696 -- -- -- -- -- -- -- -- -- -- -- Q 9,304 435 -- 435 4.7 0 -- 0 0.0 33 32 54 R 1,250 42 -- 42 3.4 0 -- 0 0.0 8 10 18 S 397 9 -- 9 2.3 18 -- 18 4.5 5 7 7 T 580 -- -- -- -- -- -- -- -- -- -- -- U 1,430 28 -- 28 2.0 323 -- 323 22.6 3 4 11 V 2,286 26 5 31 1.4 2 0 2 0.1 7 9 13

(--) missing; data is missing as a result of values submitted for RAC Data Survey; Item 15a-e that are invalid. *RAC M for RAC Data Survey 2 reported Intracerebral Hemorrhage (n=75) as a combined total including both Intracerebral and Subarachnoid Hemorrhages. The total number (n) and total percent (%) reported as Intracerebral Hemorrhage (n=134, 9.6%) includes both Intracerebral Hemorrhage and Subarachnoid Hemorrhage classifications.

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Figure 5b below displays the total number of cases classified as ischemic stroke for each region.

Figure 5b. Total number of ischemic stroke cases by RAC, Texas, July 2015-June 2016. RACs MISSING STROKE CLASSIFICATION DATA In the RAC Data Survey, guidance was provided that the sum of Item 15; Ischemic Stroke, Intracerebral Hemorrhage, Subarachnoid Hemorrhage, Transient Ischemic Attack (<24 hours), and Stroke Not Otherwise Specified, must be less than or equal to the number reported for Item 14.

▪ RAC J, Survey 1; the sum of stroke classifications reported for Item 15 was greater than the total number of stroke cases, Item 14.

▪ RACs E, P, and T, Survey 2; the sum of stroke classifications reported for Item 15 was greater than the total number of stroke cases, Item 14.

▪ RAC A, Survey 1 and 2; the sum of stroke classifications reported for Item 15 was greater than the total number of stroke cases, Item 14.

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ARRIVAL METHOD OF STROKE CASES

According to the 2013 Texas Behavioral Risk Factor Surveillance System (BRFSS) survey, an estimated

86.9% of adults in Texas said they would call 911 if they thought someone was having a heart attack or

stroke. The remaining 13.1% of adults said they would take other action, such as take the person to the

hospital, tell the person to call their doctor, call a spouse or family member, or do something else.

The arrival method of stroke cases was reported as follows; 12,841 (29.2%) EMS from home or scene,

11,554 (26.2%) private transport/taxi/other from home or scene, 4,732 (10.7%) transferred from other

hospital, and 1,030 (2.3%) mode of arrival was not documented or unknown (Table 4).

▪ 20 regions reported arrival method data.

▪ Arrival method data was missing for two regions (RACs A and Q).

▪ Nine regions (RACs C, E, G, H, K, L, O, P, and V) included data from GWTG-stroke and the RAC Data

Surveys.

▪ EMS from home or scene was the most common arrival method in 13 regions (RACs B, E, F, G, I, J, L,

N, O, P, R, T, and U) (Figure 6a).

▪ RAC F reported the highest regional percentage of stroke cases arriving via EMS from home or scene;

51.8% (n=254).

▪ Private transport from home or scene was the most common arrival method in seven regions (RACs

C, D, H, K, M, S, and V) (Figure 6b).

▪ RAC I reported the highest regional percentage of stroke cases arriving via private transportation from

home or scene; 41.8% (n=598).

▪ Transferred from a hospital was the least common arrival method among stroke cases in all 20 regions

(Figure 6c).

Figures 6a-d and Table 4 on the following pages display the arrival methods of the reported stroke cases

from July 1, 2015 through June 30, 2016 by RAC.

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Figure 6a. Percent of EMS from home or scene, July 2015-June 2016.

Figure 6b. Percent of private transportation from home or scene, July 2015-June 2016.

Figure 6c. Percent of transfer from other hospital, July 2015-June 2016.

26.2 26.8

43.0 40.2

31.6 32.7 33.5

43.8 41.837.0

49.8

36.2 38.334.0 34.9

31.3 31.938.0

6.4

34.938.3

0

20

40

60

80

Total B C D E F G H I J K L M N O P R S T U V

TOTA

L P

ERC

ENT

(%)

RAC

PRIVATE TRANSPORTATION

10.7

26.3

17.5 19.9 17.1

5.912.8 16.0 14.1

10.2 10.0

17.6

1.1

16.0 16.0 18.811.0 10.3

0.05.3 2.5

0

20

40

60

80


TOTA

L P

ERC

ENT

(%)

RAC

HOSPITAL TRANSFER

29.2

43.638.2 37.1 35.6

51.8

36.5 38.442.2

46.7

37.442.8

32.3

41.438.1

46.442.2

36.8

12.6

36.1

28.3

0

20

40

60

80


TOTA

L P

ERC

ENT

(%)

RAC

EMS FROM HOME OR SCENE

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Figure 6d below displays the percentage of stroke patients that arrive at the hospital by EMS from home

or scene for each region.

Figure 6d. Percent of arrival via EMS from home or scene by RAC, Texas, July 2015-June 2016.

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Table 4. Arrival method of stroke cases, July 2015-June 2016. RAC Data Survey; Item 16.

RAC


EMS from Home/Scene Private Transport/taxi/other Transfer from other hospital Not documented or Unknown Total number of reported

hospitals Total

number of

eligible hospitals

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total %

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total %

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total %

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total %

July-Dec 2015

Jan-June 2016

Total 44,044 9,582 3,259 12,841 29.2 8,841

2,713 11,554 26.2 3,355 1,377 4,732 10.7 989 41 1,030 2.3 175 192 340

A 608 -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

B 1,134 494 -- 494 43.6 304 -- 304 26.8 298 -- 298 26.3 31 -- 31 2.7 17 16 18

C 228 14 73 87 38.2 22 76 98 43.0 0 40 40 17.5 0 3 3 1.3 3 6 13

D 391 145 -- 145 37.1 157 -- 157 40.2 78 -- 78 19.9 3 -- 3 0.8 16 8 17

E 10,565 2,119 1,647 3,766 35.6 1,924 1,414 3,338 31.6 1,169 640 1,809 17.1 75 9 84 0.8 33 41 83

F 490 254 -- 254 51.8 160 -- 160 32.7 29 -- 29 5.9 0 -- 0 0.0 3 6 6

G 2,158 752 36 788 36.5 666 57 723 33.5 276 0 276 12.8 122 0 122 5.7 9 11 21

H 630 101 141 242 38.4 119 157 276 43.8 0 101 101 16.0 3 1 4 0.6 6 7 8

I 1,430 603 -- 603 42.2 598 -- 598 41.8 202 -- 202 14.1 27 -- 27 1.9 6 6 9

J 949 443 -- 443 46.7 351 -- 351 37.0 97 -- 97 10.2 34 -- 34 3.6 13 11 17

K 460 128 44 172 37.4 182 47 229 49.8 22 24 46 10.0 13 0 13 2.8 11 10 10

L 969 253 162 415 42.8 228 123 351 36.2 84 87 171 17.6 1 1 2 0.2 1 7 10

M 1,395 450 -- 450 32.3 534 -- 534 38.3 16 -- 16 1.1 395 -- 395 28.3 7 8 7

N 1,000 414 -- 414 41.4 340 -- 340 34.0 160 -- 160 16.0 5 -- 5 0.5 8 8 8

O 3,694 1,149 259 1,408 38.1 1,035 254 1,289 34.9 483 107 590 16.0 19 25 44 1.2 12 4 26

P 2,696 463 789 1,252 46.4 387 457 844 31.3 130 377 507 18.8 22 1 23 0.9 5 11 36

Q 9,304 -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

R 1,250 527 -- 527 42.2 399 -- 399 31.9 137 -- 137 11.0 5 -- 5 0.4 8 10 18

S 397 146 -- 146 36.8 151 -- 151 38.0 41 -- 41 10.3 8 -- 8 2.0 5 7 7

T 580 73 -- 73 12.6 37 -- 37 6.4 0 -- 0 0.0 0 -- 0 0.0 2 2 2

U 1,430 516 -- 516 36.1 499 -- 499 34.9 76 -- 76 5.3 218 -- 218 15.2 3 4 11

V 2,286 538 108 646 28.3 748 128 876 38.3 57 1 58 2.5 8 1 9 0.4 7 9 13

(--) missing; data is missing as a result of values submitted for RAC Data Survey; Item 16a-d that are invalid.

19

RACs MISSING ARRIVAL METHOD DATA In the RAC Data Survey, guidance was provided that the sum of Item 16; EMS from home/scene, Private transport/taxi/other from home/scene, Transfer from other hospital, and Mode not documented or unknown, must be less than or equal to the number reported for Item 14. ▪ RAC Q, Survey 1; the sum of arrival modes reported for Item 16a-d was greater than the total number

of stroke cases, Item 14. ▪ RAC A, Survey 2; the sum of arrival modes reported for Item 16a-d was greater than the total number

of stroke cases, Item 14.

NATIONAL INSTITUTES OF HEALTH STROKE SCALE (NIHSS) PERFORMED

When a potential stroke patient arrives at a hospital, an initial neurological examination should be

conducted as a component for determining diagnosis of stroke and further care. The NIHSS is a

standardized neurologic examination tool commonly used to evaluate and document the patient’s status.

The NIHSS allows healthcare providers to easily quantify the degree of neurological deficits and severity,

and identify the most appropriate treatment and level of care.

Of the total number of ischemic stroke cases reported (n=18,655), 7,798 (41.8%) had a NIHSS performed

(Figure 7).

▪ 15 regions reported NIHSS data.

▪ NIHSS data was missing for seven regions (RACs A, E, G, J, P, S, and T).

▪ Six regions (RACs C, H, K, L, O, and V) included data from GWTG-stroke and the RAC Data Surveys.

▪ The median percent of NIHSS performed among the 15 regions is 86.1%.

▪ RAC D reported the highest regional percentage; 100% (n=204) of ischemic stroke cases had a NIHSS

performed.

▪ Nearly half, seven out of the 15 regions, reported that more than 90% of ischemic stroke cases had a

NIHSS performed.

▪ RAC R reported the lowest regional percentage; 30.8% (n=318) of ischemic stroke cases had a NIHSS

performed.

Figure 7 and Table 5 on the following page display the number and percent of Ischemic stroke cases with

a NIHSS reported from July 1, 2015 through June 30, 2016 by RAC.

20

Figure 7. Percent of ischemic stroke cases with an NIH Stroke Scale (NIHSS) performed, July 2015-June 2016.

Table 5. Ischemic stroke cases with an NIH Stroke Scale (NIHSS) performed, July 2015-June 2016. RAC Data Survey, Item 17.

ISCHEMIC STROKE CASES WITH NIHSS PERFORMED

RAC

Total ischemic stroke cases (n)

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)

Total number of reporting hospitals Total

number of eligible hospitals

July-Dec 2015

Jan-June 2016

Total 18,655 6,685 1,113 7,798 41.8 141 140 228

A -- -- -- -- -- -- -- --

B 638 438 -- 438 68.7 17 16 18

C 149 0 136 136 91.3 3 6 13

D 204 204 -- 204 100.0 16 8 17

E -- -- -- -- -- -- -- --

F 276 253 -- 253 91.7 3 6 6

G 1,134 -- -- -- -- -- -- --

H 276 55 184 239 86.6 6 7 8

I 910 748 -- 748 82.2 6 6 9

J -- -- -- -- -- -- -- --

K 311 170 94 264 84.9 11 10 10

L 557 307 206 513 92.1 1 7 10

M 793 734 -- 734 92.6 7 8 7

N 523 516 -- 516 98.7 8 8 8

O 2,322 1,633 357 1,990 85.7 12 4 26

P -- -- -- -- -- -- -- --

Q 7,465 0 -- 0 0.0 33 32 54

R 1,031 318 -- 318 30.8 8 10 18

S 230 -- -- -- -- -- -- --

T -- -- -- -- -- -- -- --

U 630 621 -- 621 98.6 3 4 11

V 1,206 688 136 824 68.3 7 8 13

(--) missing; data is missing as a result of values submitted for RAC Data Survey; Item 17 that are invalid.

41.8

68.7

91.3100

91.786.6

82.2 84.992.1 92.6

98.7

85.7

0.0

30.8

98.6

68.3

0

20

40

60

80

100

Total B C D F H I K L M N O Q R U V

TOTA

L P

ERC

ENT

(%)

RAC

ISCHEMIC STROKE CASES WITH NIHSS PERFORMED

21

RACs MISSING NIHSS PERFORMED DATA

In the RAC Data Survey, guidance was provided that the number of ischemic stroke cases with NIHSS performed reported for Item 17, must be less than or equal to the total number of ischemic stroke cases reported for Item 15a. ▪ RACs A, E, J, P, and T; missing Item 15a, number of ischemic stroke cases. ▪ RACs G and T, Survey 1; the ischemic stroke cases with NIHSS performed, Item 17 was greater than

the total number of ischemic stroke cases, Item 15a.

▪ RAC J, Survey 2; the ischemic stroke cases with NIHSS performed, Item 17 was greater than the total number of ischemic stroke cases, Item 15a.

INTRAVENOUS THROMBOLYTIC THERAPY (IV t-PA)

Of the total number of ischemic stroke cases reported (n=18,655), 12.8% (n=2,392) received intravenous

thrombolytic therapy (IV t-PA) (Figure 8).

17 regions reported IV t-PA data.

IV t-PA data was missing for five regions (RACs A, E, J, P, and T).

Seven regions (RACs C, G, H, K, L, O, and V) included data from GWTG-stroke and the RAC Data Surveys.

RAC F reported the highest regional IV t-PA percentage; 26.1% (n=72) of ischemic stroke cases (n=276)

received IV t-PA.

RAC M reported the lowest regional IV t-PA percentage; 5.8% (n=46) of ischemic stroke cases (n=793)

received IV t-PA.

Figure 8 and Table 6 display the number and percent of ischemic stroke cases that received IV t-PA from

July 1, 2015 through June 30, 2016 by RAC.

Figure 8. Percent of ischemic stroke cases that received IV t-PA, July 2015-June 2016.

12.8

7.212.1 11.8

26.1

13.0

7.611.1 9.3

13.1

5.89.6 11.0 12.8

17.7

25.222.4

14.7

0

20

40

60


TOTA

L P

ERC

ENT

(%)

RAC

ISCHEMIC STROKE CASES THAT RECEIVED IV T-PA

22

Table 6. Ischemic stroke cases that received IV t-PA, July 2015-June 2016. RAC Data Survey, Item 18.

ISCHEMIC STROKE CASES THAT RECEIVED IV t-PA

RAC


RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)

Total number of reporting hospitals

Total number

of eligible hospitals

July-Dec 2015

Jan-June 2016

Total 18,655 2,285 107 2,392 12.8 153 159 256 A -- -- -- -- -- -- -- -- B 638 46 -- 46 7.2 17 16 18 C 149 1 17 18 12.1 3 6 13 D 204 24 -- 24 11.8 16 8 17 E -- -- -- -- -- -- -- -- F 276 72 -- 72 26.1 3 6 6 G 1,134 144 3 147 13.0 9 11 21 H 276 4 17 21 7.6 6 7 8 I 910 101 -- 101 11.1 6 6 9 J -- -- -- -- -- -- -- -- K 311 18 11 29 9.3 11 10 10 L 557 55 18 73 13.1 1 7 10

M 793 46 -- 46 5.8 7 8 7 N 523 50 -- 50 9.6 8 8 8 O 2,322 235 20 255 11.0 10 4 26 P -- -- -- -- -- -- -- -- Q 7,465 952 -- 952 12.8 33 32 54 R 1,031 182 -- 182 17.7 8 10 18 S 230 58 -- 58 25.2 5 7 7 T -- -- -- -- -- -- -- -- U 630 141 -- 141 22.4 3 4 11 V 1,206 156 21 177 14.7 7 9 13

(--) missing; data is missing as a result of values submitted for RAC Data Survey; Item 18 that are invalid. RACs MISSING INTRAVENOUS THROMBOLYTIC THERAPY (IV t-PA) DATA In the RAC Data Survey, guidance was provided that the number of ischemic stroke cases that received IV t-PA reported for Item 18, must be less than or equal to the total number of ischemic stroke cases reported for Item 15a. ▪ RACs A, E, J, P, and T; missing Item 15a, number of ischemic stroke cases.

23

IV t-PA WITHIN 60 MINUTES OF ARRIVAL

Of the total number of ischemic stroke cases treated with intravenous thrombolytic therapy (IV t-PA) reported (n=2,392), 64.0% (n=1,532) received IV t-PA within 60 minutes or less from time of hospital arrival (Figure 9).

17 regions reported IV t-PA ≤ 60 minutes of arrival data.

IV t-PA within 60 minutes data was missing for five regions (RACs A, E, J, P, and T).

Seven regions (RACs C, G, H, K, L, O, and V) included data from GWTG-stroke and the RAC Data Surveys.

RAC F reported the highest regional IV t-PA ≤ 60 minutes percentage; 26.1% (n=72) of ischemic stroke

cases that received IV t-PA (n=276).

RAC M reported the lowest regional IV t-PA ≤ 60 minutes percentage; 5.8% (n=46) of ischemic stroke

cases that received IV t-PA (n=793).

The average among the 17 regional percentages reported was 59.5%.

The total number and percent of ischemic stroke cases that received IV t-PA within 60 minutes or less

from time of hospital arrival is displayed in Figure 9 and Table 7.

Figure 9. Percent of ischemic stroke cases that received IV t-PA within 60 minutes or less from time of hospital arrival, July 2015-June 2016.

64.0

28.3

66.7

58.3

66.760.5

57.1

48.5

31.0

61.6

69.666.0

71.866.0

62.6 63.8

56.7

75.7

0

20

40

60

80

100


TOTA

L P

ERC

ENT

(%)

RAC

IV t-PA ≤ 60 MINUTES OF ARRIVAL

24

Table 7. Ischemic stroke cases that received IV t-PA within 60 minutes or less from time of hospital arrival, July 2015-June 2016. RAC Data Survey, Item 19.

IV t-PA ≤ 60 MINUTES OF ARRIVAL

RAC

Ischemic stroke cases that received IV t-PA (n)

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)



July-Dec 2015

Jan-June 2016

Total 2,392 1,449 83 1,532 64.0 153 159 256

A -- -- -- -- -- -- -- --

B 46 13 -- 13 28.3 17 16 18

C 18 0 12 12 66.7 3 6 13

D 24 14 -- 14 58.3 16 8 17

E -- -- -- -- -- -- -- --

F 72 48 -- 48 66.7 3 6 6

G 147 87 2 89 60.5 9 11 21

H 21 1 11 12 57.1 6 7 8

I 101 49 -- 49 48.5 6 6 9

J -- -- -- -- -- -- -- --

K 29 5 4 9 31.0 11 10 10

L 73 31 14 45 61.6 1 7 10

M 46 32 -- 32 69.6 7 8 7

N 50 33 -- 33 66.0 8 8 8

O 255 164 19 183 71.8 10 4 26

P -- -- -- -- -- -- -- --

Q 952 628 -- 628 66.0 33 32 54

R 182 114 -- 114 62.6 8 10 18

S 58 37 -- 37 63.8 5 7 7

T -- -- -- -- -- -- -- --

U 141 80 -- 80 56.7 3 4 11

V 177 113 21 134 75.7 7 9 13


RACs MISSING IV t-PA WITHIN 60 MINUTES OF ARRIVAL DATA

In the RAC Data Survey, guidance was provided that the number of ischemic stroke cases that received IV t-PA within 60 minutes of less of hospital arrival reported for Item 19, must be less than or equal to the total number of ischemic stroke cases treated with IV t-PA reported for Item 18.

▪ RACs A, E, J, P, and T; missing Item 18, number of ischemic stroke cases treated with IV t-PA.

25

ENDOVASCULAR THERAPY

Of the total number of ischemic stroke cases reported (n=18,655), 4.0% (n=748) received endovascular

therapy (IA catheter-based reperfusion) (Figure 10).

17 regions reported endovascular therapy data.

Endovascular therapy data was missing for five regions (RACs A, E, J, P, and T).

Two regions (RACs L and O) included data from GWTG-stroke and the RAC Data Surveys.

Six regions (RACs C, D, H, K, S, and U) reported 0 (0.0%) ischemic stroke cases treated with

endovascular therapy.

RAC F reported the highest regional IA catheter-based reperfusion percentage; 11.2% (n=31) of

ischemic stroke cases (n=276).

The total number and percent of ischemic stroke cases that received IA catheter-based reperfusion

therapy from July 1, 2015 through June 30, 2016 by RAC is displayed in Figure 10 and Table 8.

Figure 10. Percent of ischemic stroke cases that received endovascular therapy (IA catheter-based reperfusion), July 2015-June 2016.

4.0

1.40.0 0.0

11.2

2.3

0.0

5.5

0.0 0.4 0.6 0.2

3.75.3

6.5

0.0 0.0

6.6

0

5

10

15

20


TOTA

L P

ERC

ENT

(%)

RAC

ISCHEMIC STROKE CASES THAT RECEIVED ENDOVASCULAR THERAPY

26

Table 8. Ischemic stroke cases that received endovascular therapy (IA catheter-based reperfusion), July 2015-June 2016. RAC Data Survey, Item 21.

ISCHEMIC STROKE CASES THAT RECEIVED ENDOVASCULAR THERAPY

RAC


RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)



July-Dec 2015

Jan-June 2016

Total 18,655 739 9 748 4.0 149 153 256

A -- -- -- -- -- -- -- --

B 638 9 -- 9 1.4 17 16 18

C 149 0 -- 0 0.0 2 6 13

D 204 0 -- 0 0.0 16 8 17

E -- -- -- -- -- -- -- --

F 276 31 -- 31 11.2 3 6 6

G 1,134 26 -- 26 2.3 8 11 21

H 276 0 -- 0 0.0 5 5 8

I 910 50 -- 50 5.5 6 6 9

J -- -- -- -- -- -- -- --

K 311 0 -- 0 0.0 10 10 10

L 557 1 1 2 0.4 1 7 10

M 793 5 -- 5 0.6 7 8 7

N 523 1 -- 1 0.2 8 8 8

O 2,322 77 8 85 3.7 10 2 26

P -- -- -- -- -- -- -- --

Q 7,465 392 -- 392 5.3 33 31 54

R 1,031 67 -- 67 6.5 8 10 18

S 230 0 -- 0 0.0 5 7 7

T -- -- -- -- -- -- -- --

U 630 0 -- 0 0.0 3 4 11

V 1,206 80 -- 80 6.6 7 8 13


RACs MISSING ENDOVASCULAR THERAPY DATA In the RAC Data Survey, guidance was provided that the number of ischemic stroke cases that received endovascular therapy reported for Item 21, must be less than or equal to the total number of ischemic stroke cases reported for Item 15a. ▪ RACs A, E, J, P, and T; missing Item 15a, number of ischemic stroke cases.

27

PICTURE-TO-PUNCTURE WITHIN 60 MINUTES

Of the total number of ischemic stroke cases that received endovascular therapy (IA catheter-based

reperfusion) reported (n=748), 6.6% (n=49) received IA catheter-based reperfusion within 60 minutes or

less from time of initial brain imaging (Figure 11).

11 regions reported picture-to-puncture time ≤ 60 minutes’ data.

Picture-to-puncture data was missing for five regions (RACs A, E, J, P, and T).

No GWTG-stroke data was included.

Six regions (RACs C, D, H, K, S, and U) reported no endovascular therapy.

More than half of the regions (RACs B, L, M, N, Q, and R) reported 0.0% picture-to-puncture time ≤60

minutes.

RAC G reported the highest regional picture-to-puncture time ≤60 minutes percentage; 69.2% (n=18)

of endovascular treatments (n=26).

The total number and percent of ischemic stroke cases that received IA catheter-based reperfusion within

60 minutes or less from time of initial brain imaging is displayed in Figure 11 and Table 9.

Figure 11. Percent of ischemic stroke cases that received endovascular therapy (IA catheter-based reperfusion) within 60 minutes or less of time of initial brain imaging, July 2015-June 2016.

6.6

0 NA NA

9.7

69.2

NA

18.0

NA 0 0 0

21.2

0 0 NA NA 1.3

0

20

40

60

80


TOTA

L P

ERC

ENT

(%)

RAC

PICTURE-TO-PUNCTURE ≤ 60 MINUTES OF INITIAL BRAIN IMAGING

28

Table 9. Ischemic stroke cases that received endovascular therapy (IA catheter-based reperfusion) within 60 minutes or less of time of initial brain imaging, July 2015-June 2016. RAC Data Survey, Item 22.

PICTURE-TO-PUNCTURE ≤ 60 MINUTES OF INITIAL BRAIN IMAGING

RAC

Ischemic stroke cases that received endo-vascular therapy (n)

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)


number of eligible

hospitals July-Dec

2015 Jan-June

2016 Total 748 49 0 49 6.6 149 153 156

A -- -- -- -- -- -- -- --

B 9 0 -- 0 0.0 17 16 18

C 0 NA NA NA NA 2 6 13

D 0 NA NA NA NA 16 8 17

E -- -- -- -- -- -- -- --

F 31 3 -- 3 9.7 3 6 6

G 26 18 -- 18 69.2 8 11 21

H 0 NA NA NA NA 5 5 8

I 50 9 . 9 18.0 6 6 9

J -- -- -- -- -- -- -- --

K 0 NA NA NA NA 10 10 10

L 2 0 0 0 0.0 1 7 10

M 5 0 -- 0 0.0 7 8 7

N 1 0 -- 0 0.0 8 8 8

O 85 18 0 18 21.2 10 2 26

P -- -- -- -- -- -- -- --

Q 392 0 -- 0 0.0 33 31 54

R 67 0 -- 0 0.0 8 10 18

S 0 NA NA NA NA 5 7 7

T -- -- -- -- -- -- -- --

U 0 NA NA NA NA 3 4 11

V 80 1 -- 1 1.3 7 8 13 (--) missing; data is missing as a result of values submitted for RAC Data Survey; Item 22 that are invalid. (NA) not applicable to report a value.

RACs MISSING PICTURE-TO-PUNCTURE WITHIN 60 MINUTES DATA In the RAC Data Survey, guidance was provided that the number of ischemic stroke cases that received endovascular therapy within 60 minutes of initial brain imaging reported for Item 22, must be less than or equal to the total number reported for Item 21. ▪ RACs A, E, J, P, and T; missing Item 15a, number of ischemic stroke cases.

29

DISCHARGE DISPOSITION OF ISCHEMIC STROKE CASES

The discharge disposition of ischemic stroke cases was reported as follows; 3,176 (17.0%) home, 1,353

(7.3%) inpatient rehabilitation facility, 867 (4.6%) skilled nursing facility, 222 (1.2%) hospice, 307 (1.6%)

expired, and 4,881 (26.2%) other or not documented or unknown (Table 10a-b).

10 regions reported discharge disposition data.

Discharge disposition data was missing for 12 regions (RACs A, C, D, E, F, G, J, K, M, P, R, and T).

Four regions (RACs H, L, O, and V) included discharge disposition data from GWTG-stroke and the RAC

Data Surveys.

Discharged home was the most common disposition among eight regions (RACs B, H, L, N, O, S, U, and

V).

RAC L reported the highest regional percentage of ischemic stroke patients (n=557) discharged home;

53.7% (n=299).

The discharge disposition of ischemic stroke cases by RAC is displayed in Figure 12 and Tables 10a-b.

Figure 12. Discharge disposition of ischemic stroke cases, July 2015-June 2016.

0

20

40

60

Total B H I L N O Q S U V

TOTA

L P

ERC

ENT

(%)

RAC

DISCHARGE DISPOSITION OF ISCHEMIC STROKE CASES

Home Inpatient Rehabilitation Facility Skilled Nursing Facility

Hospice Expired Not Documented

30

Table 10a. Discharge disposition of ischemic stroke cases, July 2015-June 2016. RAC Data Survey, Item 23.

RAC


Home Inpatient Rehabilitation Facility Skilled Nursing Facility

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)

Total 18,655 2,691 485 3,176 17.0 1,116 237 1,353 7.3 743 114 867 4.6 A -- -- -- -- -- -- -- -- -- -- -- -- -- B 638 259 -- 259 40.6 74 -- 74 11.6 57 -- 57 8.9 C 149 -- -- -- -- -- -- -- -- -- -- -- -- D 204 -- -- -- -- -- -- -- -- -- -- -- -- E -- -- -- -- -- -- -- -- -- -- -- -- -- F 276 -- -- -- -- -- -- -- -- -- -- -- -- G 1,134 -- -- -- -- -- -- -- -- -- -- -- -- H 276 27 86 113 40.9 3 63 66 23.9 14 28 42 15.2 I 910 234 -- 234 25.7 88 -- 88 9.7 55 -- 55 6.0 J -- -- -- -- -- -- -- -- -- -- -- -- -- K 311 -- -- -- -- -- -- -- -- -- -- -- -- L 557 185 114 299 53.7 40 35 75 13.5 56 47 103 18.5

M 793 -- -- -- -- -- -- -- -- -- -- -- -- N 523 246 -- 246 47.0 86 -- 86 16.4 88 -- 88 16.8 O 2,322 961 197 1,158 49.9 472 104 576 24.8 198 30 238 10.2 P -- -- -- -- -- -- -- -- -- -- -- -- -- Q 7,465 -- -- -- -- -- -- -- -- -- -- -- -- R 1,031 -- -- -- -- -- -- -- -- -- -- -- -- S 230 94 -- 94 40.9 52 -- 52 22.6 18 -- 18 7.8 T -- -- -- -- -- -- -- -- -- -- -- -- -- U 630 309 -- 309 49.0 130 -- 130 20.6 191 -- 191 30.3

V 1,206 376 88 464 38.5 171 35 206 17.1 66 9 75 6.2

(--) missing; data is missing as a result of values submitted for RAC data survey; item 23a-f that are invalid.

31

Table 10b. Discharge disposition of ischemic stroke cases, July 2015-June 2016. RAC Data Survey, Item 23.

RAC


Hospice (home or facility) Expired Other or Not Documented



RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)

July-Dec

2015

Jan-June 2016

Total 18,655 184 37 222 1.2 235 44 307 1.6 4,852 41 4,881 26.2 98 100 164

A -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

B 638 12 -- 12 1.9 21 -- 21 3.3 58 -- 58 9.1 17 16 18

C 149 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

D 204 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

E -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

F 276 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

G 1,134 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

H 276 3 15 18 6.5 2 5 7 2.5 16 9 25 9.1 6 7 8

I 910 28 -- 28 3.1 29 -- 29 3.2 476 14 490 53.8 6 6 9

J -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

K 311 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

L 557 8 5 13 2.3 16 14 30 5.4 28 5 33 5.9 1 7 10

M 793 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

N 523 23 -- 23 4.4 9 -- 9 1.7 51 -- 51 9.8 8 8 8

O 2,322 64 15 80 3.4 90 17 135 5.8 120 -- 108 4.7 12 4 26

P -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

Q 7,465 -- -- -- -- -- -- -- -- 4,001 -- 4,001 53.6 33 32 54

R 1,031 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

S 230 2 -- 2 0.9 9 -- 9 3.9 49 -- 49 21.3 5 7 7

T -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

U 630 23 -- 23 3.7 24 -- 24 3.8 22 -- 22 3.5 3 4 11

V 1,206 21 2 23 1.9 35 8 43 3.6 31 13 44 3.6 7 9 13

(--) missing; data is missing as a result of values submitted for RAC data survey; item 23a-f that are invalid.

32

RACs MISSING DISCHARGE DISPOSITION DATA In the RAC Data Surveys, guidance was provided that the discharge disposition of ischemic stroke cases reported in Item 23, must be less than or equal to the number of ischemic stroke cases reported. RACs A, E, J, P, and T; missing Item 15a, number of ischemic stroke cases. RACs K, P, and T, Survey 1; the sum of discharge dispositions reported for Item 23a-f was greater than

the number of ischemic stroke cases, Item 15a. RACs A, C, and J, Survey 2; the sum of discharge dispositions reported for Item 23a-f was greater than

the number of ischemic stroke cases, Item 15a. RACs E, F, G, and M, Survey 1 and Survey 2; the sum of discharge dispositions reported for Item 23a-f

was greater than the number of ischemic stroke cases, Item 15a. RAC R, Survey 1 and Survey 2; did not report data for Item 23.

HEALTH INSURANCE STATUS OF ISCHEMIC STROKE CASES

Of the total number of ischemic stroke cases (n=18,655), 21.2% (n=3,960) had a form of health insurance

documented, 3.4% (n=634) did not have health insurance, and 22.3% (n=4,163) health insurance status

was not documented or unknown (Figure 13).

Nine regions reported health insurance data.

Health insurance status was missing for 13 regions (RACs A, C, E, F, G, I, J, K, M, P, R, T, and U).

Four regions (RACs H, L, O, and V) included data from GWTG-stroke and the RAC Data Surveys.

RAC N reported the highest regional percentage of any health insurance; 88.3% (n=462) of ischemic

stroke cases (n=523).

RAC B reported the highest regional percentage of no health insurance; 18.2% (n=116) of ischemic

stroke cases (n=638).

The health insurance status of ischemic stroke cases by RAC is displayed in Figure 13-14 and Table 11.

Figure 13. Health insurance status of ischemic stroke cases, July 2015-June 2016.

21.2

67.1

11.3

71.0

50.1

88.3

78.3 80.4

47.3

3.4

18.211.8 12.7

6.611.7 10.4

15.2

7.0

22.3

4.21.0

8.32.3 0.0 3.5

53.6

4.3 0.40

20

40

60

80

100

Total B D H L N O Q S V

TOTA

L P

ERC

ENT

(%)

RAC

HEALTH INSURANCE STATUS OF ISCHEMIC STROKE CASES

Any Health Insurance No Health Insurance Not Documented

33

Table 11. Health insurance status of ischemic stroke cases, July 2015-June 2016. RAC Data Survey, Item 20.

RAC


Any Health Insurance No Health Insurance Not Documented or Unknown Total number of reporting hospitals

Total number

of eligible

hospitals

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)

RAC Survey (n)

GWTG-stroke (n)

Total (n)

Total Percent (%)

July-Dec 2015

Jan-June 2016

Total 18,655 3,165 795 3,960 21.2 543 91 634 3.4 4,076 87 4,163 22.3 105 98 161

A -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

B 638 428 -- 428 67.1 116 -- 116 18.2 27 -- 27 4.2 17 16 18

C 149 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

D 204 23 -- 23 11.3 24 -- 24 11.8 2 -- 2 1.0 16 8 17

E -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

F 276 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

G 1,134 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

H 276 38 158 196 71.0 5 30 35 12.7 0 23 23 8.3 6 7 8

I 910 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

J -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

K 311 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

L 557 84 195 279 50.1 17 20 37 6.6 4 9 13 2.3 1 7 10

M 793 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

N 523 462 -- 462 88.3 61 -- 61 11.7 0 -- 0 0.0 8 8 8

O 2,322 1,518 299 1,817 78.3 213 29 242 10.4 27 55 82 3.5 12 4 26

P -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

Q 7,465 -- -- -- -- -- -- -- -- 4,001 -- 4,001 53.6 33 32 54

R 1,031 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

S 230 185 -- 185 80.4 35 -- 35 15.2 10 -- 10 4.3 5 7 7

T -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

U 630 -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

V 1,206 427 143 570 47.3 72 12 84 7.0 5 0 5 0.4 7 9 13

(--) missing; data is missing as a result of values submitted for RAC data survey; item 20 that are invalid.

34

Figure 14. Percent of ischemic stroke cases with any health insurance by RAC, Texas, July 2015-June2016.

RACs MISSING HEALTH INSURANCE STATUS DATA In the RAC Data Surveys, guidance was provided that the health insurance status of ischemic stroke cases reported in Item 20, must be less than or equal to the number of ischemic stroke cases reported. RACs A, E, J, P, and T; missing Item 15a, number of ischemic stroke cases. RACs G and I, Survey 1; the sum of health insurance status reported for Item 20 was greater than the

number of ischemic stroke cases, Item 15a. RACs U and C, Survey 2; the sum of health insurance status reported for Item 20 was greater than the

number of ischemic stroke cases, Item 15a. RACs F, J, K, and P, Survey 1 and Survey 2; the sum of health insurance status reported for Item 20

was greater than the number of ischemic stroke cases, Item 15a. RAC R, Survey 1 and Survey 2; did not report data for Item 20.

35

LIMITATIONS

The measures and values reported represent aggregate RAC-level data and do not represent

individual hospital performance.

Hospitals participation was voluntary however RACs were encouraged to gather data as much as

possible.

The accuracy of the hospital-level data collected by the RAC affects the accuracy of the final aggregate

RAC-level data submitted to DSHS. For example, for RACs A, E, J, P, and T the sum of reported stroke

cases by classification was larger than the reported total number of stroke cases. Thus, classification

of stroke for these RACs was set to missing (Table 3a-b).

Only the total number of hospitals reporting stroke data for each RAC is known. It cannot be assumed

that the same hospitals reported data for both data collection periods.

Only the total number of hospitals reporting stroke data for each RAC is known. The data received by

DSHS via the RAC Data Surveys were aggregated at the RAC-level. So it cannot be assumed that all

hospitals reported on all measures asked.

The number of hospitals reporting per region includes the number of hospitals reported for the RAC

Data Survey and hospitals reporting from GWTG-stroke.

36

REFERENCES

1. 2014 Texas Vital Statistics, Mortality Data. Texas Department of State Health Services, Austin, TX.

2. Texas Behavioral Risk Factor Surveillance System Public Use Data File, 2015. Texas Department of State

Health Services, Austin, TX.

3. Texas Hospital Inpatient Discharge Public Use Data File, 2014. Texas Department of State Health

Services, Austin, TX.

37

APPENDICES

APPENDIX A

38

APPENDIX B

Rider 97 RAC Data Survey #1 2016-03-01

Introduction

Stroke and STEMI Data Collection

The purpose of data collection among the Regional Advisory Councils (RACs) is to enhance surveillance

of the stroke and STEMI systems of care in Texas. RACs will collect and report data to the Health

Promotion and Chronic Disease Prevention Section (HPCDPS) of DSHS and HPCDPS will analyze the

data and report results of the analyses to RACs and the Texas Council on Cardiovascular Disease and

Stroke, as well as other stakeholders.

DSHS is asking RAC (leadership, RAC Chairs or RAC Directors and, if applicable, Stroke Committee

Chairs and Cardiac Committee Chairs, or others) to work with key stakeholders in their regions to

complete this survey. Information must be entered into every field to move forward to the next question.

If your response to a question is a zero (0), please enter "0" in the text box. If you are not able to provide

a response or compile the necessary data, please enter "NA" in the text box. Please provide the most

accurate and complete data as possible.

This survey is due March 1, 2016, and should only include data from July 1, 2015, through

December 31, 2015. If you have any questions about taking the survey, please contact Randy

Crutsinger at 512-776-6525 or [email protected].

Thank you in advance for your time.

mailto:[email protected]

39


RAC Information

1. RAC Information

RAC Name:

Trauma Service Area:

2. Person entering data

Name:

Email Address:

Phone Number:

3. Your Professional Title:

4. I am the:

RAC Chair

RAC Executive Director

Stroke Committee Chair

Cardiac Committee Chair

Other (please specify)

40


Regional Hospital Stroke Data

Please consult the hospitals in your Trauma Service Area to enter the following data.

INCLUSION CRITERIA (Questions 14-22): Stroke is defined as a case with a final clinical diagnosis

related to stroke regardless of time last known well that presented to the emergency department during

the corresponding months regardless of admission or transfer status. Exclude strokes that occurred

after hospital arrival (ED/observation/inpatient).

14. Total number of stroke cases from July 1, 2015 through December 31, 2015.

15. Classification of stroke cases reported in Item 14.

Logic: 15a + 15b + 15c + 15d + 15e must be less than or equal to Item 14.

15a. Number of ischemic

Strokes

15b. Number of Intracerebral

hemorrhages

15c. Number of

Subarachnoid

Hemorrhages

15d. Number of Transient

Ischemic Attack (< 24

hours) (TIA)

15e. Number of stroke not

otherwise specified

41

16. Arrival method for the stroke cases reported in Item 14.

Logic 16a +16b + 16c + 16d must be less than or equal to Item 14.

16a. Number arriving via

EMS from home/scene

16b. Number arriving via private

transport/taxi/other from

home/scene

16c. Number arriving via

transfer from other hospital

16d. Number with arrival mode

not documented or unknown

17. Of the ischemic stroke cases reported in Item 15a, how many had an NIH stroke scale performed?

Logic: Must be a number less than or equal to Item 15a.

18. Of the ischemic stroke cases reported in Item 15a, how many received t-PA therapy?

Logic: Must be a number less than or equal to Item 15a.

19. Of the cases reported in Item 18, how many received t-PA within 60 minutes or less from the time of

arrival?”

Logic: Must be a number less than or equal to Item 18.

20. Of the ischemic stroke cases reported in Item 15a, indicate the health insurance status for these cases.

Logic: 20a + 20b + 20c must be less than or equal to Item 15a

20a. Number with any health

insurance

20b. Number without health

insurance

20c. Number with health

insurance not documented or

unknown.

42

21. Of the ischemic stroke cases reported in Item 15a, how many received endovascular therapy? Logic:

Must be a number less than or equal to Item 15a.

22. Of the endovascular therapy cases reported in Item 21, how many received endovascular therapy within

60 minutes?

Definition: Number includes all cases that received IA catheter-based treatment within 60 minutes or less from

time of initial brain imaging (“picture to puncture” time ≤ 60 minutes). Time difference between pretreatment

neuroimaging (picture) and receiving IA catheter-based treatment (puncture) is equal or less than 60 minutes.

This is regardless of IV t-PA status.

EXCLUSION CRITERIA: patients where the time of IA catheter-based treatment was earlier than time for brain

imaging and patients where IA catheter-based treatment was done outside your hospital.

Logic: Must be a number less than or equal to item 21.

23. Of the total ischemic stroke cases reported in Item 15a, how many met the following disposition

categories?

Logic: 23a + 23b + 23c + 23d + 23e + 23f = Item 15a.

23a. Number discharged to

home

23b. Number discharged to

inpatient rehabilitation

23c. Number discharged to

skilled nursing facility

23d. Number discharged to

hospice care (home hospice or

facility hospice)

23e. Number expired

23f. Number discharged to

“other” or not known/reported

43

24. Please provide a list of individual hospital names that contributed to the STROKE data.

Please separate individual hospital names with a semicolon (;). If the individual hospital is part of a hospital system

please use the following naming convention: Hospital System name - individual hospital name or location.

44


Thank You For Your Time

Thank you for completing this assessment of the STEMI and stroke systems of care in your Trauma

Service Area. This information will assist Texas organizations in providing leadership, technical

assistance, training, and additional resources to areas where system building is needed.

45


Introduction

Stroke and STEMI Data Collection

The purpose of data collection among the Regional Advisory Councils (RACs) is to enhance surveillance

of the stroke and STEMI systems of care in Texas. RACs will collect and report data to the Health

Promotion and Chronic Disease Prevention Section (HPCDPS) of DSHS and HPCDPS will analyze the

data and report results of the analyses to RACs and the Texas Council on Cardiovascular Disease and

Stroke, as well as other stakeholders.

DSHS is asking RAC (leadership, RAC Chairs or RAC Directors and, if applicable, Stroke Committee

Chairs and Cardiac Committee Chairs, or others) to work with key stakeholders in their regions to

complete this survey. Information must be entered into every field to move forward to the next question.

If your response to a question is a zero (0), please enter "0" in the text box. If you are not able to provide

a response or compile the necessary data, please enter "NA" in the text box. Please provide the most

accurate and complete data as possible.

This survey is due August 31, 2016, and should only include data from January 1, 2016, through June

30, 2016. If you have any questions about taking the survey, please contact Randy Crutsinger at 512-

776-6525 or [email protected].

Thank you in advance for your time.

mailto:[email protected]

46


RAC Information

1. RAC Information

RAC Name:

Trauma Service Area:

2. Person entering data

Name:

Email Address:

Phone Number:

3. Your Professional Title:

4. I am the:

RAC Chair

RAC Executive Director

Stroke Committee Chair

Cardiac Committee Chair

Other (please specify)

47


Regional Hospital Stroke Data

Please consult the hospitals in your Trauma Service Area to enter the following data.

INCLUSION CRITERIA (Questions 14-22): Stroke is defined as a case with a final clinical diagnosis

related to stroke regardless of time last known well that presented to the emergency department during

the corresponding months regardless of admission or transfer status. Exclude strokes that occurred

after hospital arrival (ED/observation/inpatient).

14. Total number of stroke cases from January 1, 2016 through June 30, 2016.

15. Classification of stroke cases reported in Item 14.

Logic: 15a + 15b + 15c + 15d + 15e must be less than or equal to Item 14.

15a. Number of ischemic

Strokes

15b. Number of Intracerebral

hemorrhages

15c. Number of

Subarachnoid

Hemorrhages

15d. Number of Transient

Ischemic Attack (< 24 hours)

(TIA)

15e. Number of stroke not

otherwise specified

48

16. Arrival method for the stroke cases reported in Item 14.

Logic 16a +16b + 16c + 16d must be less than or equal to Item 14

16a. Number arriving via

EMS from home/scene

16b. Number arriving via private

transport/taxi/other from

home/scene

16c. Number arriving via

transfer from other hospital

16d. Number with arrival mode

not documented or unknown

17. Of the ischemic stroke cases reported in Item 15a, how many had an NIH stroke scale performed?

Logic: Must be a number less than or equal to Item 15a

18. Of the ischemic stroke cases reported in Item 15a, how many received t-PA therapy?


19. Of the cases reported in Item 18, how many received t-PA within 60 minutes or less from the time of

arrival?”

Logic: Must be a number less than or equal to Item 18

20. Of the ischemic stroke cases reported in Item 15a, indicate the health insurance status for these cases.

Logic: 20a + 20b + 20c must be less than or equal to Item 15a

20a. Number with any health

insurance

20b. Number without health

insurance

20c. Number with health

insurance not documented or

unknown.

49

21. Of the ischemic stroke cases reported in Item 15a, how many received endovascular therapy?


22. Of the endovascular therapy cases reported in Item 21, how many received endovascular therapy

within 60 minutes?

Definition: Number includes all cases that received IA catheter-based treatment within 60 minutes or

less from time of initial brain imaging (“picture to puncture” time ≤ 60 minutes). Time difference between

pretreatment neuroimaging (picture) and receiving IA catheter-based treatment (puncture) is equal or

less than 60 minutes. This is regardless of IV t-PA status.

EXCLUSION CRITERIA: patients where the time of IA catheter-based treatment was earlier than time for

brain imaging and patients where IA catheter-based treatment was done outside your hospital.

Logic: Must be a number less than or equal to item 21

23. Of the total ischemic stroke cases reported in Item 15a, how many met the following disposition

categories?

Logic: 23a + 23b + 23c + 23d + 23e + 23f = Item 15a

23a. Number discharged to

home

23b. Number discharged to

inpatient rehabilitation

23c. Number discharged to

skilled nursing facility

23d. Number discharged to

hospice care (home hospice or

facility hospice)

23e. Number transferred to

higher level of care

23e. Number expired

23g. Number discharged to

“other” or not known/reported

50

24. Please provide a list of individual hospital names that contributed to the STROKE data.

Please separate individual hospital names with a semicolon (;). If the individual hospital is part of a hospital system

please use the following naming convention: Hospital System name - individual hospital name or location.

51


Thank You For Your Time

Thank you for completing this assessment of the STEMI and stroke systems of care in your Trauma

Service Area. This information will assist Texas organizations in providing leadership, technical

assistance, training, and additional resources to areas where system building is needed.

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