Quality registries aiming to ensure high quality stroke care in Sweden Katharina Stibrant Sunnerhagen MD, PhD Professor Rehabilitation Medicine Institute of Neuroscience and Physiology Gothenburg Uniervsity SWEDEN
Outlines of the talk - Background - What are quality registers? - Information on Riks-stroke - Information on WebRehab - Summary
9 million inhabitants in Sweden
Quality refers to a value or uniqueness as a subject or object has- applies to artistic works, products (goods, services, person or equity) and more.
Quality registers Quality registers refers to the collection of a limited number of well-defined indicators for the analysis of the quality of care and results of the process of care
Open access Data of the hospitals/units are accessible for the general public, but no data from individuals can be accessed
The basic idea is that no matter who is providing the care there is a need to find out the results and follow them over time. In addition to this, there is also need of knowledge of how to work with to change and improve the process. Quality Registers provides support for this work.
Each quality register draws up the points and the reporting features considered important to demonstrate good and less good results for each patient group The quality and reliability of the results depends on as many people as possible participate in the registration.
Partly tax funded by SALAR in Sweden The Swedish Society for Rehabilitation Medicine The database can be used for CARF accreditation
Open comparison In Open Comparisons information on quality, outcomes and costs in certain sectors such as municipalities, county councils and regions are displayed.
Reason for open comparisons is to stimulate counties and cities to analyze their services, learn from others, improve quality and work more efficient The citizens in a democratic society has the right to obtain full information on tax financed services to see how their money is spent
Year Number Cumulated number 1994 5,584* 5,584* 1995 10,111 15,695 1996 14,304 29,999 1997 16,300 46,299 1998 19,152 65,451 1999 21,042 86,493 2000 19,873 106,366 2001 20,945 127,311 2002 22,489 149,800 2003 23,461 173,261 2004 24 017 197,617 2005 25,175 222,839 2006 24,546 247,472 2007 24,130 271,602 * from April 1, 1994 only Coverage of hospitals. As of 1998, all hospitals in Sweden admitting patients with acute stroke report to Riks-Stroke (79 hospitals in 2008).
Care type at admittance 2013
Care type during the acute phase of stroke 2004-2013
To the hospital within 3 hours
A web-based database since 2007 The aim is to improve quality in the rehabilitation process use limited resources better enhance awareness of the ICF model support the participating units rehabilitation process developing make comparison between units possible to gather knowledge of rare conditions to be used for research
30 medical rehabilitation clinics Stroke, traumatic and other brain damage, neurological disorders, multi-trauma and spinal cord injuries and chronic pain conditions. Medical rehabilitation (16-65 years), geriatric units (65+) http://www.ucr.uu.se/webrehab/
Data are gathered at admittance, at discharge and 1 year after onset of disease/trauma. There is information on demographics, diagnoses, problems within different domains of ICF.
Physical and mental functioning on organ level Reduced functioning leads to an impairment Simple Complex Body Functioning Body Structure Activity A individual performance of a task or an action Difficulty performing activities leads to activity limitations ICF classification Inpatient Webrehab data FIM TM EQ-5D func.limitation Outpatient Webrehab data EQ-5D func.limitation Participation Participation in life situations A limitation of participation arises when a person experience problems in participating i life situations EQ-5D Health Li-Sat IPA EQ-5D Health Li-Sat
Data are entered on-line and immediately you can check to compare the results of the patient with the results from you own hospital as well as with the results from the whole of Sweden. Data on patient level is anonymous for other hospitals than your own hospital From 2009 results are accessible for all
Demographics: Such as number of registrations. Diagnoses, problems according to ICF
3000 2613 2730 2500 2297 2382 2000 1903 1971 1902 1500 1000 500 0 2008 2009 2010 2011 2012 2013 2014
Demographics Hosp N A 204 B 42 C 28 D 78 E 134 Stroke 45% Brain Injury 67% Other 2 % F 225 G 186 H 106 I 73 J 89 K 13 L 59 M 35 29% > 64 years 55% stroke N 32 O 100 P 60 Q 101 R 7 S 51 T 181 X 1804
Registration of BMI To measure and monitor the development of BMI during the rehabilitation period is about working knowledge based. We know that it is not uncommon to have difficulty swallowing and eating difficulties after a neurological disorder (such as stroke). We also know that in order to cope train the body must have enough energy. Target is 90% at both admittance and discharge
BMI ifyllnadsgrad in, målinivå 90%, slutenvård Sunderby Mälargården Stockholms sjukhem Sandviken Karolinska Örebro Jönköping Gotland Härnösand Danderyd Västerås Borås Uppsala Umeå Falun Rehabstation Växjö Sahlgrenska Halmstad Skåne Frykcenter Blekinge Linköping Västervik 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
BMI ifyllnadsgrad ut, målinivå 90%, slutenvård Örebro Sunderby Sandviken Mälargården Borås Stockholms sjukhem Uppsala Västerås Danderyd Umeå Blekinge Karolinska Frykcenter Rehabstation Gotland Skåne Falun Jönköping Växjö Halmstad Linköping Härnösand Västervik Sahlgrenska 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Process measures: Such as length of stay, time from referral to admittance, if questions have been asked regarding driving and smoking, if different assessments have been performed or not, if the patient has a rehabilitation plan
length of stay Örebro Danderyd Uppsala Sunderby Linköping Falun Rehabstation Umeå Karolinska Sahlgrenska Skåne Sandviken Västerås Jönköping RIKET Växjö Härnösand Borås Blekinge Gotland Halmstad Västervik Stockholm Frykcenter Mälargården Östersund Uddevalla Skövde Karlstad 0 20 40 60 80 100 2014 2013 2012 2011 2010
time from referral to admittance Hospital
Producing a written rehabilitation plan Having a plan for rehabilitation is required in from the health department. Target is 90%
Har skriftlig rehabplan upprättats?. Slutenvård Karolinska Jönköping Frykcenter Mälargården Sahlgrenska Borås Stockholms sjukhem Skåne Umeå Örebro Sandviken Sunderby Linköping Rehabstation RIKET Blekinge Falun Danderyd Halmstad Gotland Växjö Uppsala Västervik Härnösand Västerås Ja Nej Info saknas 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Outcome: Such as deceased, ADL before and after rehabilitation, complications, medical incidents, household and work before, at discharge and 1 year after, where the person is discharged to, life satisfaction, if the rehabilitation plan has been used
ADL/FIM at admittance and discharge Stroke Minne Problemlösning Socialt samspel Uttrycksförmåg Förståelse Äta/dricka 7 6 5 4 3 2 1 0 Övre toalett Dusch/bad Påklädning Påklädning Nedre toalett In Ut Trappor Blåsskötsel Gång eller Tarmskötsel Badkar/dusch Toalett Säng, stol,
Motor items (13) from FIM Stroke n:907 Admittance Discharge Dependent n: 783 Independent n: 124 Dependent n:557 Independent n: 350 Social/cognitive items (5) from FIM Stroke n:907 Admittance Discharge Dependent n: 648 Independent n: 259 Dependent n:513 Independent n: 394
Complications A safe care is something that is sought. Reducing the number of cases, accidents and pressure sores should be a priority for rehabilitation units to strive for. Falls with fractures target 0 % Pressure sores target 0 %
Complications during rehab Infection other Other complication/illness/injury Deviated from warod DVT Fall with fracture Heterotop ossification Hydrocefalus Contracture Pulmonary emboli MRSA infection Meningitis New brain damage Pressure sore Ulcus 0 10 20 30 40 50 60 70 80 90 100 % No Yes Not known
Assessment of fitness to drive Deciding on suitability/fitness to drive is an important task for the rehabilitation team. There can be motor impairments as well as cognitive problems, and in Sweden the responsibility (under license regulation) rests with the treating physician. It is a matter of safety. Target is 90%
Assessment of fitness to drive Uddevalla Sthlm sjukhem Karlstad Härnösand Danderyd Borås Jönköping Blekinge Falun Örebro Halmstad Östersund Skåne Gotland Sunderby Umeå Västervik Uppsala Sahlgrenska Växjö Riket Sandviken Linköping Rehabstation Västerås Mälargården Karolinska 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
PREM Patient satisfaction with: the staff, the rehabilitation, information about the disease/trauma, information about where to turn to after discharge.
The rehabilitation Not satisfied Satisfied Don t know
Information about the disease/trauma Not satisfied Satisfied Don t know
PROM EQVAS avarage socre per hospital admittance and discharge Västerås Blekinge Mälargården Umeå Jönköping Danderyd Gotland Skåne RIKET Uppsala Sandviken Stockholms sjukhem Växjö Härnösand Halmstad Borås Linköping Västervik Sahlgrenska Rehabstation Falun Frykcenter Örebro Sunderby Karolinska EQVAS Nuvarande hälsotillstånd ut EQVAS Nuvarande hälsotillstånd in 0 10 20 30 40 50 60 70 80
Thank you! Thanks to Qstat, Åsa Lundgren-Nilsson and Guna Berzina Ks.sunnerhagen@neuro.gu.se