Home

Referring Site

47.2%of patients transferred to an EVT centre for EVT received EVT

EQUITY

3.8%of Ischemic Stroke patients received EVT

EVT CentreONTARIO*

CTA, CTP orMRA

IVTPA

Arterial Puncture

EVT Procedure

Reperfusion Achieved

Critical Step-down Unit

EVT Centre Stroke Unit

TIMELINESSMedian time from ED

arrival (at EVT site)to :

qualifying CTA, CTP or MRA

arterial puncture

time of first reperfusion

EFFECTIVENESS

99.4%of EVT patients received CTA, CTP or MRA prior to the EVT procedure

75.3%of EVT patients were successfully reperfused

47Median number of days EVT patients spent at home in first 90 days post procedure

Next Level ofCare

20.4%30-day all-cause mortality rates for patients who received EVT

17 min

78 min

112.5 min

The EVT Dashboard landing page (Figure 2) provides users with a visual representation of the EVT patient journey:

Users have the option to view either provincial orhospital-specificresults Each indicator is linked to a more detailed pagewhichfocusesononeofthequality domains/questionsandprovidesrelated indicatorresults

The detailed pages (Figure 2) present results graphically and allow for cross-hospital comparison: Whereavailable,targetsareincluded Denominatorandnumeratorvalues,and25th, 75thand50th percentiles are available for each hospital in the province Outcomeindicatorsarestratifiedtoinclude/ excludein-hospitalstrokes

CorHealthOntariotodevelopaprovincialqualityimprovementprocessforEVTthatwillleveragetheseresultsPerformanceofindividualhospitals,basedonkeyperformanceindicators,maybeusedtoinformfuturefundingrecommendationsIntegratetheEVTKPIintootherstrokereportingtoillustratethecompletepictureofstrokecareinOntarioExploretheopportunitytoobtainadditionalinformationfromthereferralhospitalstobetterunderstandpatientoutcomes

RegionalStrokeCentre&EVTCentre (9)

RegionalStrokeCentre&Telestroke (2)

DistrictStrokeCentre&EVTCentre (1)

DistrictStrokeCentre (2)

DistrictStrokeCentre&Telestroke (14)

Telestroke (13)

OntarioLHIN (14)

EVT INDICATOR SELECTIONThetaskgroupidentified22indicatorsandprioritizedtheseforreportingbasedonthefollowingconsiderations:

Level of Reporting:patientoutcomes,access,systemperformanceandkeyprocesses Data Availability: abilitytocalculatetheindicatorusingexistingdatasources Redundancy: whethertheindicatoriscapturedinotherprovincialreports Distribution of Indicators: wheretheindicatorfitsinthepatientjourney–preEVT,duringEVTandpostEVT Quality Domain: capturesvariousaspectsofqualityincludingtimeliness,equity,andeffectiveness

Ofthe22proposedindicators,12couldbecalculatedusingexistingdataheldbytheCanadianInstituteforHealthInformation(CIHI).Afterfactoringinthelevelofreporting,redundancy,distributionandqualityoftheseindicators,3wereexcluded,resultinginatotalof9keyperformanceindicators.

DEFINING THE COHORT AND DEVELOPMENT OF TECHNICAL SPECIFICIATIONS IterativelydevelopedbyCorHealthOntario’sanalyticsteamincollaborationwiththeEVTPMMGroup ICES,asanindependentandexperiencedentityinhealthservicesresearch,reviewedindicatortechnicalspecificationsandprovided recommendationsforfurtherrefinement CorHealthOntario’sanalyticsteamcalculatedallindicatorsandvettedresultsthroughtheRegionalStrokeProgramManagers/Directorsatthe EVThospitalstoensurealignmentbetweenresultsandindividualtracking/clinicalexperience

DEVELOPMENT OF A REPORTING TOOL Internalblue-skythinkingsessiontodevelopavisionforthereport Keytakeaways:reportshould“tellastory” “Thestory”istoldthroughfourquestions(Table1) Eachindicatorisalignedwithaquestion Mock-upofdashboardcreated,andfeedbackobtainedfromkeystakeholder(e.g.RegionalStrokeProgramManagers/Directors) IntegratedDecisionSupport(IDS),atechnologyinfrastructurehostedanddeliveredbyHamiltonHealthSciences,createdandimplementedaninteractive dashboardofindicatorresultsandmadeitavailabletoallEVTsites(Figure2)

Developing and Implementing Key Performance Indicators (KPI) for Endovascular Thrombectomy in OntarioAuthors: Kathryn Yearwood, Dr. Richard H. Swartz, Anar Pardhan, Phongsack Manivong, Julie Tang, Leah Justason, Shelley A. Sharp, Dr. Mark Bayley, Dr. Leanne K. Casaubon, Kathy Godfrey, Dr. Moira K. Kapral, Elizabeth Linkewich, Rhonda McNicoll-Whiteman, Joan Porter, Dr. Grant Stotts, Dr. Amy Y. X. Yu, Mirna Rahal

Background

2. REPORTING TOOL: EVT DASHBOARDConclusionThekeyperformanceindicators(KPIs)andreportingprocessmarkacriticalmilestoneinpromotingsuccessfulimplementationofEVTinOntario.Theseindica-torsareintendedtodrivequalitypracticeimprovementandinformsystemplanningatinstitutionandpopulationlevels.

IntegratedDecisionSupport(IDS)LindsayArscottandLindsaySiurna,DataQuality,CorHealthOntarioRichelleHimaya,Design,CorHealthOntarioICES

PROVINCIAL QUALITY IMPROVEMENT

AccesstoEVTvariesconsiderablybetweenpatientspresentingdirectlytoanEVThospitalandthosewhofirstpresenttoahospitalthatonlyprovidesthrombolysis(i.e.tissueplasminogenactivator(tPA))forstroke.Assuch,theEVTSteeringCommitteehasrequestedtheEMS/PatientTransportTaskGrouptodeveloprecommendationsregardingtheuseoflargevesselocclusion(LVO)screeningtoolswithEmergencyMedicalServiceProviderstostreamlineaccesstoEVThospitalsforthosepatientslikelytobeeligibleforEVT.

LOCAL QUALITY IMPROVEMENT

InSeptember2019,biannualandannualtrendingwillbeincludedforeachindicatortoenableindividualhospitalstotracktheirprogressovertime.

3. QUALITY IMPROVEMENT

TIMELINESS: Are patients being identified and treated in a timely manner?

EQUITY: Do patients have equitable access to EVT throughout the province?

EFFECTIVENESS: Are the appropriate patients being identified, referred, and accepted for EVT?

EFFECTIVENESS: Are the desired outcomes being achieved?

QUALITY DOMAINS/QUESTIONS

Mediantimefromemergencydepartment(ED)arrival(atEVTsite)toqualifyingcomputedtomographyangiograph(CTA),computedtomographyperfusion(CTP),magneticresonanceangiography (MRA)

MediantimefromEDarrival(atEVTsite)toarterialpuncture

MediantimefromEDarrival(atEVTsite)totimeoffirstreperfusion

ProportionandnumberofischemicstrokepatientswhoreceiveanEVTprocedure(cross-regionalcomparisonindetailedpages)

ProportionofpatientstransferredtoanEVTcentreforEVTwhoreceivedEVTprocedurebyLHINand/orfacility

30-dayrisk-adjustedall-causemortalityratesforpatientswhoreceivedEVT

MediannumberofdaysEVTpatientsspendathomeinthefirst90dayspostprocedure

ProportionofEVTpatientssuccessfullyreperfused

INDICATORS

Results

Methods

InOntario,EndovascularThrombectomy(EVT)isperformedat10specializedhospitalsacrosstheprovince(Figure1).In2017,theMinistryofHealthandLong-TermCare(MOHLTC)requestedthatCorHealthOntario1 establish a framework for measuring,monitoringandreportingonEVTperformancetoensurealignmentwithbestpractices,improvesystemplanninganddrivequality/systemimprovements.Tosupportthedevelopmentofthisframework CorHealth Ontario leveraged theexpertiseoftheprovincialEVTPerformanceMeasurementandMonitoring(EVTPMM)TaskGroup.ThisgroupreportstoCorHealthOntario’sEVTSteeringCommitteeaspartofCorHealthOntario’sexternalgovernancestructureandconsistsofagroupofcontentexperts,includingneurologists,clinicalnursespecialists,epidemiologistsandotherkeystakeholderswithexpertiseinstrokesystemevaluationandimplementation.

Figure 1. MapofhospitalsinOntariothatofferhyperacutestrokecare.

Figure 2. EVTDashboardlandingpageindicatingtheabilitytoclickonspecificsectionsformore detailedpages,includinghospitallevelresults.

1. QUALITY DOMAINS/QUESTIONS AND KEY PERFORMANCE INDICATORS

TIMELINESS

1. CorHealthOntarioisacentralagencythatadvisestheMinistryofHealthandLong-TermCare(publicfunder),hospitals,andcareproviderstoimprovethe quality,efficiency,accessibilityandequityofcardiac,strokeandvascularservicesforpatientsacrossOntario.

Table 1. Qualitydomains/questionsandkeyperformanceindicators

CorHealthOntariodevelopedadataquality(DQ)managementmodel,theDQandComplianceProgram,toensuredataisofhigh-qualityandfit-for-use,withafocusonimprovingdataatthesource.

TheDQandComplianceProgramwasappliedtoEVTdataandconsistsofthefollowing:

9EVTDQindicatorswhichwereidentifiedandvalidatedbytheEVTPMMTaskGroup Areportshowingtheindicatorscomparedagainstthresholds/acceptablevalues Aquarterlyprocessforreviewandfeedback

Hospitalsusethereporttoinvestigate,correctissues,providefeedbacktoCorHealthOntario,andputinplacedataimprovementplanstoresolveissuesandhelppreventthemfromreoccurring.

TheDQandComplianceProgramhasincreasedthequalityoftheEVTdata.Withthisincreasedqualitycomesincreasedconfidenceinreportingandtheabil-itytocreateaccurateactionplans,allwiththegoalofimprovingEVTservicesinOntario.

4. DATA QUALITY (DQ)

EQUITY EFFECTIVENESS EFFECTIVENESS

STROKE SITE CATEGORY

Next Steps

AcknowledgementsCorHealthOntariowouldliketoextendtheirgratitudetothefollowingfortheirinvolvementinthisproject:

Stroke EVT DashboardOverview Page

Facility: ONTARIO* Fiscal Year: FY 17/18 Fiscal Quarters: Q1, Q2, Q3, Q4

References