The Florida Stroke Registry: the view from the University of Miami

Jose G. Romano, MD, FAHA, FANA, FAAN Professor of Clinical Neurology

Director, Cerebrovascular Division University of Miami, Miller School of Medicine

Boca Raton, FL May 17, 2019

Support: NIH/NINDS U54 NS081763, NIH/NIMH R01 MD012467

Burden of Stroke

• 5th cause of death in US (170 K); 2nd worldwide (5.8 M).

• 795,000 new strokes each year; ¼ are recurrent events; worldwide 16.9 M incident strokes.

• 3.2% adult US population has had a stroke (3.4 M by 2030).

• 6-28% have silent strokes.

• Main cause of disability: 24% inpatient rehab, 31% SNF/NH, 45% return directly home; 70% unable to return to usual activities.

• Annual costs: Direct: $71.6 B $184.1 B by 2030 Lost Productivity: $33.7 B $56.5B by 2030

Kochanek et al. NCHS. 2014;178; 2013. Lancet 2015; 385:117-171; V Roger et al. Circulation. 2012; 125: e2-e220; B Ovbiagele et al. Stroke. 2013; 44: 2361-2375

US Stroke Mortality Trends

Age-standardized stroke mortality trends; >35 years, 200-2015

Q Yang et al. MMWR 2017;66:933

• Reversal or stagnation in mortality trend

• Worse in South (Florida), Hispanics

• 33,000 excess death compared to expected,

1/3 in young adults (age 35-64)

South Florida Stroke Systems of Care

South Florida

Area 5,100 mi2

Population 6 M

EMS 911 Private

37 26

Transport/yr 639 K

PSC 2017 24

CSC 2017 19 (4 JC)

FL DOH, EMS Report, Sep 2014 FL AHCA PSC & CSC, May 1, 2017 US Census, July 2016

• 2004 Florida passes Stroke Act • Miami-Dade: transport to CSC based on time

& severity 2012 (enforced 2016) • Broward y Palm Beach transport all to CSC

since 2015

Palm Beach Broward Miami-Dade

10

12

11

9

8

15

15

15

15

15.2

12

17.3

11.6

13

8.8

0 5 10 15 20 25 30 35 40 45 50

Florida

North/PH

WestCentral

Eastcentral

South

Median meinminutes

EMS mesinAISinFloridaFL-PRStrokeRegistry2010-2015linkedtoEMSTARS,N=21,562

911-scene

Inscene

Scene-hospital

10

12

11

9

8

15

15

15

15

15.2

12

17.3

11.6

13

8.8

0 5 10 15 20 25 30 35 40 45 50

Florida

North/PH

WestCentral

Eastcentral

South

Median meinminutes

EMS mesinAISinFloridaFL-PRStrokeRegistry2010-2015linkedtoEMSTARS,N=21,562

911-scene

Inscene

Scene-hospital

10

12

11

9

8

15

15

15

15

15.2

12

17.3

11.6

13

8.8

0 5 10 15 20 25 30 35 40 45 50

Florida

North/PH

WestCentral

Eastcentral

South

Median meinminutes

EMS mesinAISinFloridaFL-PRStrokeRegistry2010-2015linkedtoEMSTARS,N=21,562

911-scene

Inscene

Scene-hospital

EMS times in AIS in Florida FL-PR Stroke Registry 2010-2015 linked to EMSTARS, N=21,562

Florida Stroke Registry Collaboration to Reduce Stroke Disparities

Dianne Foster Kathy Fenelon Kay Johnson Rhoda Saunders Jeffrey Walker Mark Landreth

Scott Rivkees Shamarial Roberson Melissa Jordan Tara Hylton Laura Schofield

FSR Advisory Committee Peter Antevy, MD EMS Med. Director Davie/Coral Springs Scott Burgin, MD Tampa General Hospital Antonio Gandia, MD Mount Sinai Medical Center Ricardo Hanel, MD, PhD Baptist Medical Center (JAX) Jonathan Harris, MD Broward Health North Wayne Hodges, RN, PMD UF Health Hospital (JAX) Nils Mueller-Kronast, MD Tenet Regional Brijesh Mehta, MD Memorial Regional Hospital Max Mokin, MD PhD Tampa General Hospital Terry Neill, MD Sacred Heart Hospital Joe Nelson, MD FL Department of Health Paul E. Pepe, MD, MPH UTSW Medical Center, Dallas David Rose, MD Tampa General Hospital Charles Sand, MD St. Joseph's Hospital Kenneth A Scheppke, MD Palm Beach County Fire Rescue Dileep Yavagal, MD UM Miller School of Medicine

Background: Funding Timeline

2012-2017 2018 2019 ~$700,000 (annually)

NIH- NINDS 5 year grant

$200,000 Florida State Appropriations

July 1 2017- June 30 2018 (1 year)

$500,000 Florida State Appropriations

July 1 2018- June 30 2019 (1 year)

76 FL hospitals 80 FL hospitals 88 + 19 amendments

NIH/ NINDS U54 NS-081763

Stroke Registry Legislation

2017 Florida State Law says that all Florida Stroke Centers should participate in the

Florida Stroke Registry

Accomplishments

• Collaborations: acute stroke care facilities across FL, Emergency Medical Services, Department of Health, AHA, UM

• Breadth: 90 hospitals in FSR (19 amendments pending)

• Described state of acute stroke care in State with focus on disparities

• Feedback to stakeholders: hospitals, Counties, State of Florida

• Linkage with other datasets

• Education to care providers

• New endeavors: expand regional dashboards, other collaborations (i.e. prehospital severity scale validation, FLiPER, TCSD-S)

• Advocacy

1) Already ENGAGED Your hospital is actively participating in GWTG-S

AND the Florida Stroke Registry

IN Florida Stroke

Registry

IN GWTG

90

2) Easy to become ENGAGED Your hospital is actively participating in GWTG-S

BUT NOT the Florida Stroke Registry

NOT IN Florida Stroke

Registry

IN GWTG

~45

3) To be ENGAGED Your hospital is NOT actively participating in GWTG-S

NOR the Florida Stroke Registry

NOT IN Florida Stroke

Registry

NOT IN GWTG

~30

Engagement: Statewide Hospital Participation

NOT IN FSR IN FSR

25

6

20

As of 5/8/2019

Quality Improvement by Addressing Disparities

23 presentations at national and international meetings

Predefined Performance Measures

1) IV tPA 3 h, arrive 2 Hour

2) Early Antithrombotics (2 days)

3) VTE Prophylaxis

4) Antithrombotics at discharge

5) Anticoagulation for AF at discharge

6) LDL <100 or ND-Statin

7) Smoking Cessation Counseling

Defect-Free Care Measure

Feedback: FSR Measures and Outcomes

Treatment Performance Metrics

1. Overall use of tPA, EVT in CSC

2. Door to CT

3. Door to Needle

4. Door to Puncture

Outcome Metrics

1. In-Hospital Overall Mortality

2. Ambulatory Status at discharge

3. Modified Rankin Score discharge

4. Discharge Disposition

FSR Data Flow GWTG-S

Hospital Data

IQVIA Data Warehouse

UM downloads

de-identified aggregate GWTG-S Hospital Data

Florida Stroke Registry Database

1.Bulk data download 4x’s/year 2.Data analyzed by region and/or

race-ethnicity, sex 3.Develop interventions and REPORTS

Annual Hospital Disparity Dashboards

State Annual Dashboard

Regional Dashboards

FSR Quality Improvement Reports

Annual report of 16 hospital stroke measures by race/ethnicity and sex

2013 2014

2015 2016

2017 2018

FSR secured website

Annual Hospital Dashboard

Annual Statewide Dashboard 2017

2018

Updated 01 2019

Tri-County Hospital Participation CSC, TCC, PSC

BOCA RATON REGIONAL HOSPITAL *DELRAY MC

Good Samaritan MC JFK MC

JFK MC – N. CAMPUS

JUPITER MC Palm Beach Gardens MC

SAINT MARY’S MC West Boca MC

Palm Beach County (9/12 FSR Hospitals):

Broward Health Coral Springs BROWARD HEALTH MC

BROWARD HEALTH NORTH CLEVELAND CLINIC FLORIDA

FMC - A CAMPUS OF NORTH SHORE *HOLY CROSS HOSPITAL

Memorial Hospital Pembroke *MEMORIAL HOSPITAL WEST

MEMORIAL REGIONAL HOSPITAL Northwest Medical Center WESTSIDE REGIONAL MC

Broward County (11/14 FSR Hospitals):

BAPTIST HOSPITAL Coral Gables Hospital

Hialeah Hospital JACKSON MEMORIAL HOSPITAL

Jackson North MC Jackson South Hospital

MOUNT SINAI MC NORTH SHORTE MC

PALMETTO GENERAL HOSPITAL South Miami Hospital

University of Miami Hospital West Kendall Baptist Hospital

Miami-Dade County (12/16 FSR Hospitals):

UM Florida Stroke Registry

IN GWTG-S & NOT IN FSR

NOT IN GWTG-S & NOT IN FSR

MIAMI-DADE 1. Larkin Community

Hospital- Palm Springs Campus

2. Mercy Hospital 3. Kendall Regional Medical

Center

BROWARD 1. Plantation General

Hospital 2. University Hospital and

Medical Center

PALM BEACH 1. Bethesda Hospital East 2. Bethesda Hospital West 3. Wellington Regional

Medical Center

MIAMI-DADE 1. Westchester General

Hospital

BROWARD 1. Broward Health Imperial

Point

Background: Tri-County Hospital Participation Status

12

2

For more information contact: flstrokeregistry@miami.edu