Transitions of Care Stroke Disparities Study (TCSD-S)

National Institute on Minority Health and Health Disparities/NIH1R01 MD012467

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Worldwide Stroke Burden

Worldwide Incidence/ Prevalence

1990(‘000)

2013(‘000)

Ischemic Incident 4,310 6,900

Prevalent 10,040 18,310

Hemorrhagic Incident 1,890 3,370

Prevalent 3,890 7,360

Total Incident 6,200 10,270

Prevalent 13,930 25,670

V Feigin, B Norving, GA Mensah. Circ Res. 2017; GBD 2017DO NOT D

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US Stroke Mortality Trends

Age-standardized stroke mortality trends; >35 years, 2000-2015

Q Yang et al. MMWR 2017

• Reversal or stagnation in mortality trend• Worse in South (Florida), Hispanics• 33,000 excess deaths more than expected,

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

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In-hospital care has improved in FL

Defect Free Care - Ischemic OnlyAdjusted Odds Ratio (95% CI)

FL-B vs FL-W FL-H vs FL-W PR-H vs FL-W PR-H vs FL-H

1.03 (0.96, 1.09) 1.03 (0.92, 1.16) 0.62 (0.27, 1.46) 0.60 (0.26, 1.41)

Adjusted for: age, smoker, HTN, diabetes, dyslipidemia, afib/flutter, CAD, PVD, TIA/stroke, prior ambulation, insurance, mode of arrival (EMS), academic status

RL Sacco et al. JAHA 2017; N Asdaghi et al. Stroke 2016.

FL-W

FL-B

FL-H

PR-H

6469

8492 93 93 95 94

6672

8492 94 92 95 94

6067

8592 94 94 94

91

3139

63

77

6166

70 71

0

10

20

30

40

50

60

70

80

90

100

2010 2011 2012 2013 2014 2015 2016 2017

DFC for Women (86%) vs. Men (85%) Adj OR 0.94 (0.91-0.98)

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Stroke recurrence and readmission

• 25% of all strokes are recurrent events1

• 18% of all Medicare readmissions cost $18B2

• After stroke, 25% readmitted within 30 days3

• In GWTG-Stroke, death and readmission after discharge 21% at 30 days4

• The drivers of readmissions are not well understood• Disparities in readmission exist and reasons for these

disparities are not well studied

1 Mozzafarian et al. Circulations 2016; 2 Medicare Payment Policy Report to Congress 2017; 3 Bravata et al. Stroke 2007; 4 Fonarow et al. Stroke 2011 DO N

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Readmissions after acute strokehospitalization in FSR & CMS linked data

• All-cause 30-day readmission was 15% (n=16,952)– 14.4% for Whites (reference*)– 17.2% for Blacks: HR 1.19 (95% CI 0.99-1.44)– 16.7% for Hispanics: HR 1.02 (95% CI 0.87-1.20)– 14.7% for Others: HR 1.03 (95% CI 0.72-1.46)

• Median time d/c to readmission: 11 d• 23.9% readmissions due to stroke

– 16.6% IS or TIA– 1.5% ICH– 5.2% CEA/A&S

• 6.0% NHW, 1.8% NHB, 3.8% H, 7.5% other• 8.2% readmission due pneumonia or UTI

*Adjusted for demographics, comorbities, NIHSS, LOS, d/c destination

H Gardener et al. ISC 2017DO NOT D

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Disparities in Lifestyle Education for AISin FL-PR Stroke Registry

MA Ciliberti et al. ISC 2017 DO NOT D

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Adjusted Odds Ratio (95% CI)(NH-W in FL as reference) FL-NHB FL-H

Physical Activity/Weight Counseling (BMI > 25)

0.97 (0.91-1.04)

0.94 (0.83-1.05)

Diet Recommendation 0.97 (0.92-1.02)

1.01 (0.90-1.13)

Low Sodium Diet Recommendation

0.95 (0.92-0.99)

0.89 (0.74-1.06)

Diabetes Teaching 1.26 (1.12-1.42)

1.11 (0.91-1.36)

Smoking Cessation Counseling 0.73 (0.61-0.87)

1.05 (0.61-1.81)

Data 2010-2016Adjusted for: Age, Race-Ethnicity, Sex, Aphasia and NIHSSBold p<0.05

Disparities in Lifestyle Education for AISin FL-PR Stroke Registry

MA Ciliberti et al. ISC 2017 DO NOT D

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Transitions of Care Stroke Disparity Study

Goal: Improve stroke outcomes and reduce readmissions

• Identify race-ethnic and sex disparities in hospital-to-hometransition of care and outcomes after stroke.

• Identify the key stroke-related and social health-relateddeterminants in hospital-to-home TOSC and stroke outcomes.

– Develop a Transitions of Stroke Care Performance Index

• Develop effective hospital-initiated system level initiatives toreduce disparities

Transition of Care Stroke Disparities Study, NIMHHD R01 MD-012467 DO NOT D

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Conceptual Design

StrokeHospitalization

Stroke-Related Factors

Transition of Stroke Care

Hospital to home

Stroke OutcomesReadmission and stroke outcomes

Socio-Economic & Environmental DisparitiesRace-Ethnic & Sex SDH

Multi-Modal Systems of Care InitiativesHealth System Feedback (Disparities Dashboard)

Health Care Provider Education

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Home Care Transition

Medication adherence• Filled stroke meds• Taking stroke medsLifestyle & behavior• Exercise as indicated• Diet modification• Tobacco/alcohol/drug

cessation treatmentRehabilitation• Attended therapy• Using DMEMedical attention• Scheduled follow-up• Seen by provider

Outcomes (30, 90 days)

• Readmission• Stroke/TIA recurrence• Other CV events and

revascularization• Death

Disparities

Individual Characteristics• Demographics• Risk Factors & PMH• Premorbid status• Baseline meds• Arival mode, on/off time• NIHSS, symptoms• Treatment type & times• Disability (mRS) at DC• Education/counsellingHospital characteristics• Region• Volume: Beds, stroke, tPA • Status: JC/DNV/HFAP

Social Determinants• Community

characteristics• Household

characteristics

TOSC PI

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Acute Hospital

GWTG/FSR

• Demographics• Risk Factors & PMH• Premorbid status• Baseline meds• Arival mode, on/off time• NIHSS, symptoms• Treatment type & times• Disability (mRS) at DC• Education/counselling

Care Transitions

Interview at 30 days

Medication adherence• Filled stroke meds• Taking stroke medsLifestyle & behavior• Exercise, Diet• Tobacco/alcohol/drug

cessation treatmentRehabilitation• Attended therapy• Using DMEMedical attention• Scheduled follow-up• Seen by provider

Outcomes

Interview at 30, 90 days

• Hospital Readmission• Disability (mRS)• Stroke/TIA recurrence• Other CV events and

revascularization

Hospital charateristics• Region• Volume: Beds, stroke, tPA • Status: JC/DNV/HFAP

Public Sources/Sciera

Social Determinants• Community

characteristics• Household

characteristics

Data source for TOSC-PI

AHCA/JC/DNV/survey

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Planned enrollment

• 2400 patients /5 years– 1200 to develop TOSC-PI– 1200 to validate TOSC-PI, evaluate disparities, develop

initiatives to reduce disparities in TOSC• 400 participants per site Baptist Jacksonville Baptist Miami Jackson Memorial Sarasota Memorial UF/Shands USF/Tampa

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Initiatives for TOSC Disparities

• TOSC Index will be developed in first 1,200 participants after which initiatives will be implemented to assess their effect on the TOSC-I and on outcomes.

• Feedback to sites on TOSC metrics, disparities, TOSC-I– Dashboard benchmarked against group

• Educational programs for hospital personnel involved in discharge and TOSC to improve outcomes– Creating multidisciplinary advisory group: patients,

caregivers, therapists, pharmacist, nutritionist, nurses, physicians

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Eligibility

• Acute ischemic stroke or intracerebral hemorrhage, age >18 • Discharge directly home• mRS 1 or greater at discharge• Patient or LAR signs informed consent-willing to take 2 f/u calls

Exclusion: • mRS = 0 (no residual symptoms, able to carry all activities)• TIA, SAH, Stroke NOS, elective admission for procedure• Children, prisoners

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Schedule of Assessments

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Transitions of Care Stroke Disparities Study TeamUniversity of Miami• Ralph Sacco, PI• Tanja Rundek, PI• Jose Romano, PI• Carolina Gutierrez, project manager• Iszet Campo-Bustillo, regulatory &

training liaison• Hannah Gardener, epidemiologist• Chuanhui Dong, biostatistician• Kefeng Wang, data manager• Erika Marulanda-Londono, co-I• Adina Zekki Al Hazzouri, co-I

Participating Sites• Baptist Jacksonville

– Ricardo Hanel, PI– Mark Fafard, Coord

• Baptist Miami– Felipe de los Rios, PI– Josette Elysee, Coord

• Jackson Memorial– Jose Romano, PI– Digna Cabral, Coord

• Sarasota Memorial– Mauricio Concha, PI– Jeanette Wilson, Coord

• UF/Shands– Anna Khana, PI– Stephen Ruggles, Coord

• USF/Tampa– Scott Burgin, PI– Corbin Hilker, CoordDO N

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