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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: [email protected]