The SPHIS Project (Southern Population Health Information System) Stroke Admissions 1999-2001 A Data...

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


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


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)


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


SH Stroke Patients 1999-2001Outcome: Overall Readmissions

HAZARD RATIO


Discharge Unit


Stroke Diagnosis

Procedures

DischargeHospital

Discharge Destination

Postcode


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)


SH Stroke Patients 1999-2001Outcome: Readmissions within 7 days

ODDS RATIODecreased Risk Increased Risk

Discharge Unit


Stroke Diagnosis

Procedures

DischargeHospital


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)


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)


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)


Stroke Diagnosis

DischargeUnit

DischargeDestination

Procedures

Postcodes



Separated/Divorced/Widow (1.44 ; 1.38 - 1.51)

Cox Regression Results (Events / N = 11,719 / 174,614)

HAZARD RATIO


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)



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


Stroke Diagnosis

DischargeUnit

DischargeHospital

Procedures

Postcodes


Variable (HR;95% CI)Cox Regression Results (Events / N = 4,314 / 174,614)

HAZARD RATIO



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


SH All Patients 1999-2001Outcome: In-hospital Mortality at First Admission


Stroke Diagnosis

DischargeUnit

DischargeHospital

Procedures

Variable (OR;95% CI) Logistic Regression Results (Events / N = 1,938 / 176,148)

ODDS RATIO


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)


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)



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


SH All Patients 1999-2001Outcome:Overall Readmissions


Stroke Diagnosis

DischargeUnit

DischargeHospital

Procedures

Postcodes



Variable (HR;95% CI) Cox Regression Results (Events / N = 49,461 / 172,755)

HAZARD RATIO


Bentleigh (3204) (1.10 ; 1.03 - 1.17)Mordialloc (3195) (1.10 ; 1.04 - 1.16)


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)



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)


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)



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


DischargeUnit

DischargeHospital

Procedures

Postcodes



Variable (OR;95% CI)Logistic Regression Results (Events / N = 7,076 / 174,210)

ODDS RATIO



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)



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

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