The SH 1999-2001 Stroke Cohort: Flow Chart
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Transcript of The SH 1999-2001 Stroke Cohort: Flow Chart
The SPHIS Project(Southern Population Health Information System)
Stroke Admissions 1999-2001
A Data Model to inform Health Policy and Prevention in a Regional Area
Fabrizio CarinciDirector, Centre for Health Systems Research
Paul TalmanDirector, Stroke Unit
Stroke Admissions 1st July 1998 –30th June 2001 - N=4,032 (1.1%)
Stroke Patients N=3,356
FirstAdmission
Stroke readmissionsN=676 (17%)
Yes No
X
X
X Deaths at First Admission: 316/3356 (9%)
Survivors Died at Readmission: 141/3040 (5%)
Survivors Readmitted: 1194/3040 (39%)
Survivors Never Readmitted: 1705/3040 (56%)
COHORT HISTORYSelect all admissions (any diagnosis) with same UR_NO and date of admission>date of discharge first stroke admission (N=8,287)
Admissions
30/06/2001 TIME1/06/1998
The SH 1999-2001 Stroke Cohort: Flow Chart
3-Year Overall LOS per SubjectDandenong Hospital
0
20
40
60
80
Sum
LO
S p
er S
ubje
ct
Postcodes
Geographical Variability
Stroke Patientsx 1.000(N=3324)
00-11.1-2.93-4.95.1-6.26.9-7.5
Practice Variability
LOS>26 No Yes
FREQUENCY
LOS>26 (75%) by Discharge Unit
MSGP
MDGG
SJVS
MCGA
SDVS
NCUN
SCVS
MSED
NCBS
MSGA
MDED
NJUN
MCED
MDGA
NCST
OVERALL
0 10 20 30 40 50 60 70 80 90 100
1036
716
281
262
197
121
115
91
91
63
62
50
37
31
29
3356
SH 1999-2001 - Event Rates by Department of Discharge(Mortality, Readmissions and LOS observed anywhere)
Mortality Readmission
Overall 1ST Adm. Readm. Overall 7 days
ALL PATIENTS LOS> 26
Emergency Clayton 2.9 1.9 0.6 1.3 28.4 8.5Emergency Dandenong 3.0 2.0 0.9 1.1 26.9 6.1Medicine Clayton 31.0 16.9 8.1 8.8 51.5 4.4Medicine Dandenong 18.4 13.1 6.0 7.1 44.9 3.3Neurosciences (incl. NCST) 15.1 6.1 4.3 1.8 32.7 3.5NCST only 9.6 10.5 9.9 0.6 3.5 0.5Surgery Clayton 15.8 8.4 3.9 4.5 43.8 2.5Surgery Dandenong 16.4 7.6 3.8 4.8 38.2 2.8Other 6.3 1.9 0.8 1.1 27.2 3.2
Mortality Readmission
Overall 1st Adm. Readm. Overall 7 days
STROKE PATIENTS LOS> 26
Emergency Clayton 7.7 9.0 4.4 4.6 35.511.6
Emergency Dandenong 8.2 4.2 3.1 1.1 30.52.1
Medicine Clayton 41.3 40.5 21.3 18.6 59.35.1
Medicine Dandenong 31.7 18.2 6.4 11.8 56.85.0
Neurosciences 27.3 14.3 10.8 3.5 43.54.4
Surgery Clayton 14.2 4.4 - 4.4 39.63.3
Surgery Dandenong 3.2 3.2 - 3.2 25.84.8
Other 24.7 12.9 7.5 5.4 36.74.6
Outcomes= Subject-Level Adjustments +Practice-Level Adjustments +Subject Level Covariates +Practice-Level Risk Covariates +Population-Level Factors
Modelling
SH Stroke Patients 1999-2001Outcome: Overall LOS26
Cox Regression Results (Events / N = 829 / 3,321)
HAZARD RATIODecreased Risk Increased Risk
History ofComorbidityAt First Stroke Admission
Stroke Diagnosis
DischargeUnit
DischargeDestination
DischargeHospital
Springvale (3171) (1.543;1.088-2.188)
CT Scan (1.217;1.034-1.432)
Carotid Endarterectomy (0.245;0.132-0.454)
Hampton (5.111;4.038-6.469)
Kingston (3.657;3.099-4.315)
Separated/Divorced/Widow (1.238;1.06-1.446)
Emergency Dandenong (0.586;0.346-0.989)
Emergency Clayton (0.436;0.268-0.711)
Neurosciences (0.77;0.614-0.965)
Dandenong (1.448;1.134-1.85)
Clayton (1.5;1.188-1.893)
Cerebral Infarction (0.86;0.71-1.043)
Hemorragic (1.355;1.106-1.661)
TIA (0.422;0.323-0.55)
Renal (1.476;1.024-2.128)
Diabetes (1.202;0.932-1.549)
Circulatory (1.115;0.889-1.398)
Heart Disease (1.258;0.998-1.585)
Cancer (1.116;0.741-1.683)
Respiratory (1.13;0.864-1.477)
Male (0.902;0.779-1.045)
Age > 65 (1.443;1.198-1.738)
0.01 0.25 0.5 1 2 5 10
Variable (HR;95% CI)
Procedures
Postcodes
Predictive at Subject level
SH Stroke Patients 1999-2001Outcome: Overall Mortality
HAZARD RATIO
Decreased Risk Increased Risk
Discharge Unit
History ofComorbidityAt First Stroke Admission
Stroke Diagnosis
Procedures
DischargeHospital
Cox Regression Results (Events / N = 435 / 3,321)Variable (HR;95% CI)
Magnetic Resonance (0.49 ; 0.32 - 0.73)
Carotid Endarterectomy (0.19 ; 0.07 - 0.49)
Hospital Transfer (0.24 ; 0.18 - 0.31)
Planned Admission (0.38 ; 0.23 - 0.63)
Carer Unknown or NA (3.81 ; 1.42 -10.25)
Emergency Clayton (0.57 ; 0.34 - 0.94)
Neurosciences (0.57 ; 0.41 - 0.78)
Dandenong (1.36 ; 0.96 - 1.93)
Clayton (2.39 ; 1.67 - 3.41)
Cerebral Infarction (0.94 ; 0.72 - 1.22)
Hemorragic (2.67 ; 2.11 - 3.37)
TIA (0.17 ; 0.11 - 0.25)
Renal (1.56 ; 0.98 - 2.47)
Diabetes (0.96 ; 0.66 - 1.39)
Circulatory (1.18 ; 0.83 - 1.67)
Heart Disease (0.98 ; 0.69 - 1.39)
Cancer (1.44 ; 0.82 - 2.55)
Respiratory (1.29 ; 0.90 - 1.86)
Male (0.96 ; 0.79 - 1.16)
Age > 65 (2.59 ; 1.96 - 3.44)
0.01 0.25 0.5 1 2 5 10
SH Stroke Patients 1999-2001Outcome: In-hospital Mortality at First Admission
DischargeUnit
Logistic Regression Results (Events / N=316 / 3,356)
ODDS RATIODecreased Risk Increased Risk
History ofComorbidityAt First Stroke Admission
Stroke Diagnosis
Procedures
DischargeHospital
Variable (OR;95% CI)
Magnetic Resonance (0.26 ; 0.15 - 0.46)
CT Scan Intrav. (0.38 ; 0.23 - 0.64)
CT Scan (0.68 ; 0.48 - 0.95)
Carotid Endarterectomy (0.09 ; 0.01 - 0.68)
Planned Admission (0.28 ; 0.14 - 0.56)
NE Asian / N American (1.57 ; 1.05 - 2.33)
Medicine Clayton (1.95 ; 1.02 - 3.70)
Emergency Clayton (0.36 ; 0.19 - 0.68)
Dandenong (1.54 ;1.01 -2.35)
Clayton (1.87 ; 1.25 - 2.78)
Cerebral Infarction (0.84 ; 0.59 - 1.17)
Hemorragic (3.59 ;2.65 - 4.87)
TIA (0.04;0.015-0.11)
Renal (2.15 ; 1.11 - 4.17)
Diabetes (1.07 ; 0.64 - 1.81)
Circulatory (0.75 ; 0.46 - 1.23)
Heart Disease (1.06 ; 0.66 - 1.71)
Cancer (1.23 ; 0.53 - 2.89)
Respiratory (1.19 ; 0.70 - 2.01)
Male (1.02 ; 0.79 - 1.31)
Age > 65 (2.40 ; 1.70 - 3.38)
0.01 0.25 0.5 1 2 5 10
Predictive at Subject level
SH Stroke Patients 1999-2001Outcome: Overall Readmissions
HAZARD RATIO
Decreased Risk Increased Risk
Discharge Unit
History ofComorbidityAt First Stroke Admission
Stroke Diagnosis
Procedures
DischargeHospital
Discharge Destination
Postcode
Variable (HR;95% CI)
Springvale (3171) (1.52 ; 1.16 - 1.99)Oakleigh South (3167) (1.65 ; 1.19 - 2.28)Bentleigh East (3165) (1.37 ; 1.04 - 1.80)
CT Scan (1.19 ; 1.05 - 1.35)Carotid Endarter. (0.65 ; 0.46 - 0.92)
Hampton (3.53 ; 2.91 - 4.29)Kingston (2.42 ; 2.09 - 2.80)
NE Asian / N American (0.59 ; 0.46 - 0.76)Surgery Dandenong (0.22 ; 0.06 - 0.76)
Medicine Dandenong (0.31 ; 0.10 - 0.98)Emergency Dandenong (0.23 ; 0.07 - 0.75)
Neurosciences (0.80 ; 0.69 - 0.94)Dandenong (6.54 ; 2.06 -20.75)
Clayton (1.88 ; 1.57 - 2.25)Cerebral Infarction (0.95 ; 0.81 - 1.10)
Hemorragic (1.04 ; 0.86 - 1.26)TIA (0.83 ; 0.71 - 0.98)
Renal (1.27 ; 0.93 - 1.74)Diabetes (1.09 ; 0.88 - 1.34)
Circulatory (1.07 ; 0.89 - 1.30)Heart Disease (1.17 ; 0.97 - 1.42)
Cancer (1.30 ; 0.94 - 1.79)Respiratory (1.22 ; 0.98 - 1.51)
Male (0.96 ; 0.86 - 1.07)Age > 65 (1.26 ; 1.10 - 1.43)
0.01 0.25 0.5 1 2 5 10
Cox Regression Results (Events / N =1,335 / 3,027)
Predictive at Subject level
SH Stroke Patients 1999-2001Outcome: Readmissions within 7 days
ODDS RATIODecreased Risk Increased Risk
Discharge Unit
History ofComorbidityAt First Stroke Admission
Stroke Diagnosis
Procedures
DischargeHospital
Predictive at Subject level
Logistic Regression Results (Events / N = 153 / 3,040)
Dandenong (3175) (2.37 ; 1.34 - 4.20)
CT Scan Intrav. (0.52 ; 0.27 - 0.98)
Hospital Transfer (3.06 ; 2.04 - 4.58)
Hampton (1.86 ; 1.04 - 3.34)
Emergency Clayton (2.25 ; 1.31 - 3.86)
Dandenong (1.07 ; 0.60 - 1.90)
Clayton (1.28 ; 0.74 - 2.19)
Cerebral Infarction (0.88 ; 0.55 -1.41)
Hemorragic (0.85 ; 0.47 - 1.56)
TIA (1.10 ; 0.69 - 1.77)
Renal (1.54 ; 0.58 - 4.10)
Diabetes (0.66 ; 0.31 - 1.40)
Circulatory (0.86 ; 0.45 - 1.64)
Heart Disease (1.62 ; 0.88 - 3.01)
Cancer (1.57 ; 0.59 - 4.15)
Respiratory (0.68 ; 0.31 - 1.46)
Male (1.04 ; 0.74 - 1.46)
Age > 65 (0.92 ; 0.61 – 1.37)
0.01 0.25 0.5 1 2 5 10
Variable (OR;95% CI)
Discharge Destination
Postcode
OutlineStrategies for Stroke Care and Prevention
Targets to reduce the impact of Overall Mortality:•Aged patients•Subjects with Hemorragic diagnoses•Assess presence of Carer at home
Targets to reduce the impact of Mortality at First Admission:•Aged patients•Subjects with Hemorragic diagnoses•Patients born in North-East Asia or North America•Discharges from Medicine Clayton
Targets to reduce the impact of Overall Readmissions:•Aged patients•Subjects with Hemorragic diagnoses•Residents in Springvale, Bentleigh East, Oakleigh
Targets to reduce the impact of Readmissions within 7 days after first discharge:•Discharges from Emergency Clayton•Residents in Dandenong
Targets to reduce the impact of Long Stay:•Patients Separated, divorced or widowed•Aged patients•Subjects with Hemorragic diagnoses•Residents in Springvale
SH All Patients 1999-2001Outcome:Overall LOS>26 (75% Stroke)
History ofComorbidityAt First Stroke Admission
Stroke Diagnosis
DischargeUnit
DischargeDestination
Procedures
Postcodes
Predictive at Subject level
Variable (HR;95% CI)
Separated/Divorced/Widow (1.44 ; 1.38 - 1.51)
Cox Regression Results (Events / N = 11,719 / 174,614)
HAZARD RATIO
Decreased Risk Increased Risk
DischargeHospital
Dandenong (3175) (1.38 ; 1.29 - 1.49)Noble Park (3174) (1.21 ; 1.11 - 1.31)Springvale (3171) (1.19 ; 1.07 - 1.31)
Carnegie (3163) (0.79 ; 0.69 - 0.91)Glen Waverley (3150) (0.76 ; 0.67 - 0.86)
Mount Waverley (3149) (0.81 ; 0.70 - 0.94)CT Scan Intrav. (1.33 ; 1.17 - 1.45)
CT Scan (1.37 ; 1.27 - 1.47)Carotid Endarter. (0.33 ; 0.17 - 0.63)
Surgery Dandenong (2.42 ; 1.90 - 3.09)Surgery Clayton (0.78 ; 0.63 - 0.96)
Medicine Dandenong (1.59 ; 1.45 - 1.74)Medicine Clayton (1.09 ; 1.01 - 1.19)
Emerg. Dandenong (0.80 ; 0.72 - 0.90)Emergency Clayton (0.36 ; 0.33 - 0.39)
Neurosciences (0.58 ; 0.53 - 0.63)Hospital Transfer (2.24 ; 2.12 - 2.38)
Waiting List (0.29 ; 0.27 - 0.31)Hampton (6.30 ; 5.58 - 7.10)Kingston (2.39 ; 2.20 - 2.59)
Planned Admission (1.52 ; 1.45 - 1.60)Cerebral Infarction (0.73 ; 0.60 - 0.89)
TIA (1.65 ; 1.50 - 1.81)Carer Unknown or NA (1.16 ; 1.06 - 1.27)
NE Asian / N American (0.65 ; 0.59 - 0.71)Dandenong (0.53 ; 0.49 - 0.57)
Clayton (1.12 ; 1.06 - 1.17)Renal (2.07 ; 1.97 - 2.18)
Diabetes (1.10 ; 1.05 - 1.16)Cerebrovascular (1.58 ; 1.49 - 1.68)
Circulatory (1.63 ; 1.55 - 1.71)Heart Disease (1.27 ; 1.21 - 1.33)
Cancer (2.16 ; 2.06 - 2.27)Respiratory (1.84 ; 1.76 - 1.91)
Male (1.09 ; 1.05 - 1.13)Age > 65 (1.65 ; 1.57 - 1.73)
0.01 0.25 0.5 1 2 5 10
SH All Patients 1999-2001Outcome: Overall In-hospital Mortality
History ofComorbidityAt First Stroke Admission
Stroke Diagnosis
DischargeUnit
DischargeHospital
Procedures
Postcodes
Predictive at Subject level
Variable (HR;95% CI)Cox Regression Results (Events / N = 4,314 / 174,614)
HAZARD RATIO
Decreased Risk Increased Risk
Dandenong (3175) (1.18 ; 1.06 - 1.32)Noble Park (3174) (1.23 ; 1.09 - 1.40)Springvale (3171) (1.21 ; 1.04 - 1.41)
Magnetic Resonance (0.66 ; 0.50 - 0.88)CT Scan Intrav. (1.34 ; 1.14 - 1.59)
CT Scan (1.647;1.482-1.83)Carotid Endarter. (0.19 ; 0.07 - 0.51)
Surgery Dandenong (2.59 ; 1.84 - 3.65)Surgery Clayton (1.64 ; 1.21 - 2.21)
Medicine Dandenong (1.60 ; 1.40 - 1.83)Medicine Clayton (1.17 ; 1.04 - 1.33)
Emergency Dandenong (1.24 ; 1.06 - 1.45)Emergency Clayton (0.68 ; 0.60 - 0.77)
Hospital Transfer (0.67 ; 0.61 - 0.74)Waiting List (0.31 ; 0.27 - 0.36)
Kingston (0.50 ; 0.26 - 0.93)Planned Admission (1.13 ; 1.03 - 1.23)
Hemorragic (3.94 ; 3.15 - 4.93)TIA (0.72 ; 0.58 - 0.89)
Carer Unknown or NA (2.83 ; 2.28 - 3.52)Separated, Widowed, Divorced (1.43 ; 1.29 - 1.58)
Married (1.19 ; 1.09 - 1.31)NE Asian / N American (1.46 ; 1.31 - 1.63)
Dandenong (0.99 ; 0.87 - 1.13)Clayton (1.47 ; 1.35 - 1.61)
Renal (2.40 ; 2.23 - 2.58)Diabetes (0.85 ; 0.79 - 0.91)
Cerebrovascular (1.72 ; 1.58 - 1.88)Circulatory (1.23 ; 1.14 - 1.32)
Heart Disease (2.12 ; 1.96 - 2.28)Cancer (3.52;3.28 - 3.77)
Respiratory (2.09 ; 1.95 - 2.23)Male (1.19 ; 1.12 - 1.27)
Age > 65 (3.77 ; 3.45 - 4.12)
0.01 0.25 0.5 1 2 5 10
Discharge Destination
SH All Patients 1999-2001Outcome: In-hospital Mortality at First Admission
History ofComorbidityAt First Stroke Admission
Stroke Diagnosis
DischargeUnit
DischargeHospital
Procedures
Variable (OR;95% CI) Logistic Regression Results (Events / N = 1,938 / 176,148)
ODDS RATIO
Decreased Risk Increased Risk
Magnetic Resonance (0.47 ; 0.31 - 0.72)CT Scan Intrav. (1.48 ; 1.13 - 1.92)
CT Scan (2.33 ; 2.01 - 2.71)Surgery Dadenong (4.30 ; 2.49 - 7.43)
Surgery Clayton (2.00 ; 1.26 - 3.17)Medicine Dandenong (2.53 ; 2.02 - 3.16)
Medicine Clayton (1.35 ; 1.12 - 1.63)Emergency Dandenong (1.28 ; 1.00 - 1.65)
Emergency Clayton (0.31 ; 0.25 - 0.39)Neurosciences (1.63 ; 1.32 - 2.02)
Waiting List (0.11 ; 0.08 - 0.16)Hemorragic (5.70 ; 4.15 - 7.82)
TIA (0.48 ; 0.35 - 0.68)Separated/Divorced/Widow (1.17 ; 1.05 - 1.31)
NE Asian / N American (2.23 ; 1.94 - 2.57)Dandenong (0.91 ; 0.74 - 1.13)
Clayton (1.76 ; 1.53 - 2.03)Renal (1.72 ; 1.51 - 1.96)
Diabetes (0.67 ; 0.59 - 0.76)Cerebrovascular (1.30 ; 1.11 - 1.51)
Circulatory (0.88 ; 0.79 - 0.98)Heart Disease (2.22 ; 1.98 - 2.48)
Cancer (2.03 ; 1.78 - 2.32)Respiratory (1.44 ; 1.30 - 1.60)
Male (1.29 ; 1.16 - 1.42)Age > 65 (5.78 ; 5.07 - 6.60)
0.01 0.25 0.5 1 2 5 10
Predictive at Subject level
SH All Patients 1999-2001Outcome:Overall Readmissions
History ofComorbidityAt First Stroke Admission
Stroke Diagnosis
DischargeUnit
DischargeHospital
Procedures
Postcodes
Discharge Destination
Predictive at Subject level
Variable (HR;95% CI) Cox Regression Results (Events / N = 49,461 / 172,755)
HAZARD RATIO
Decreased Risk Increased Risk
Bentleigh (3204) (1.10 ; 1.03 - 1.17)Mordialloc (3195) (1.10 ; 1.04 - 1.16)
Dandenong (3175) (1.21 ; 1.16 - 1.25)Noble Park (3174) (1.16 ; 1.11 - 1.21)Springvale (3171) (1.18 ; 1.13 - 1.25)
Clayton (3168) (1.10 ; 1.05 - 1.16)Oakleigh (3166) (1.11 ; 1.05 - 1.17)
Carotid Endarterectomy (0.53 ; 0.38 - 0.75)Medicine Clayton (0.90 ; 0.85 - 0.96)
Emergency Clayton (0.92 ; 0.89 - 0.95)Neurosciences (0.71 ; 0.67 - 0.75)
Hospital Transfer (1.64 ; 1.59 - 1.70)Waiting List (0.79 ; 0.76 - 0.81)
Hampton (3.03 ; 2.76 - 3.32)Kingston (1.76 ; 1.65 - 1.88)
Planned Admission (1.13 ; 1.10 - 1.16)Cerebral Infarction (0.80 ; 0.69 - 0.93)
TIA (1.31 ; 1.24 - 1.39)Carer Unknown or NA (1.04 ; 1.01 - 1.08)
Separated/Divorced/Widow (1.37 ; 1.33 - 1.41)Married (1.35 ; 1.32 - 1.38)
NE Asian / N American (0.66 ; 0.63 - 0.69)Dandenong (1.15 ; 1.12 - 1.18)
Clayton (1.36 ; 1.32 - 1.39)Renal (1.31 ; 1.27 - 1.36)
Diabetes (1.13 ; 1.10 - 1.16)Stroke (1.24 ; 1.19 - 1.30)
Circulatory (1.27 ; 1.24 - 1.30)Heart Disease (1.29 ; 1.26 - 1.32)
Cancer (1.97 ; 1.91 - 2.02)Respiratory (1.56 ; 1.52 - 1.59)
Male (0.92 ; 0.91 - 0.94)Age > 65 (0.94 ; 0.92 - 0.97)
0.01 0.25 0.5 1 2 5 10
SH All Patients 1999-2001Outcome: Readmission within 7 days
History ofComorbidityAt First Stroke Admission
DischargeUnit
DischargeHospital
Procedures
Postcodes
Discharge Destination
Predictive at Subject level
Variable (OR;95% CI)Logistic Regression Results (Events / N = 7,076 / 174,210)
ODDS RATIO
Decreased Risk Increased Risk
Dandenong (3175) (1.17 ; 1.05 - 1.29)Noble Park (3174) (1.19 ; 1.06 - 1.33)Springvale (3171) (1.16 ; 1.01 - 1.34)
Mount Waverley (3149) (0.79 ; 0.66 - 0.96)CT Scan (0.84 ; 0.73 - 0.96)
Medicine Dandenong (0.69 ; 0.58 - 0.82)Emergency Dandenong (1.55 ; 1.41 - 1.71)
Emergency Clayton (1.99 ; 1.85 - 2.16)Neurosciences (0.64 ; 0.54 - 0.76)
Hospital Transfer (6.76 ; 6.35 - 7.19)Waiting List (0.46 ; 0.41 - 0.51)
Kingston (0.55 ; 0.44 - 0.67)Planned (1.20 ; 1.10 - 1.31)
Carer Unknown or NA (1.32 ; 1.18 - 1.47)Separated/Divorced/Widow (1.20 ; 1.10 - 1.31)
Married (1.32 ; 1.25 - 1.40)NE Asian / N American (0.57 ; 0.51 - 0.64)
Dandenong (0.96 ; 0.88 - 1.05)Clayton (0.94 ; 0.87 - 1.01)
Renal (1.81 ; 1.62 - 2.02)Diabetes (1.06 ; 0.98 - 1.16)
Cerebrovascular (1.06 ; 0.93 - 1.22)Circulatory (1.23 ; 1.14 - 1.32)
Heart Disease (0.93 ; 0.87-1.01)Cancer (1.97 ; 1.81 - 2.15)
Respiratory (1.26 ; 1.18 - 1.34)Male (0.94 ; 0.89 - 0.99)
Age > 65 (0.54 ; 0.50 - 0.58)
0.01 0.25 0.5 1 2 5 10