TENNESSEE STROKE REGISTRY QUARTERLY REPORT Volume 1, Issue 3 September 2018

This report is published quarterly using data from the Tennessee Stroke Registry.

Inside this report

Data on diagnosis, gender distributions, age distribution, arrival modes, insurance

status, last known well to arrival, and medical history

Data from January 2018 to March 2018

Contact information for the Tennessee Stroke Registry

Background

The Tennessee Stroke Registry (TSR) was created in 2009 through the Tennessee Stroke

Registry Act of 2008. In July 2017, the legislation was updated with Tennessee House Bill 123, requiring

all certified comprehensive and primary stroke centers in Tennessee to share their data with the TSR in

order to improve stroke care in the state. The bill requires data to be provided from hospitals on a

quarterly basis. The data are uploaded to the American Heart/American Stroke Association’s Get With

the Guidelines (GWTG) data system, Quintiles. This report provides a summary of the TSR data for the

third quarter of the fiscal year, January to March 2018. The data are aggregate data from the 30

hospitals currently reporting to Quintiles. In this report, illustrations are made on similarities and

differences between Quarter 1, 2, and 3 data. Quarter 1 contains data from July to September 2017, and

Quarter 2 contains data from October through December 2017.

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Data and Distributions

Diagnosis

78%

8% 4%

14%

70%

6% 5%

14%

69.7%

7.0% 4.7%

13.9%

Ischemic stroke Transient ischemic attack (<24 hours)

Subarachnoid Hemorrhage Intracerebral Hemorrhage

Stroke diagnosis Quarters 1, 2, and 3

Quarter 1 Quarter 2 Quarter 3

Overall, the patterns and distributions for the second quarter are similar to what was shown in past TSR

reports. The total number of stroke cases for the quarter was 2,888. The most common cases were

ischemic strokes at 69.7% of strokes reported to the registry. In Quarter 1, there was a greater proportion

of ischemic strokes than in Quarters 2 and 3. The difference was significant between Quarter 1 and 2,

with 77.9% ischemic strokes in Quarter 1, and Quarter 2 having 70% (z=7.068, p<.01). The difference

was also significant between Quarter 1 and Quarter 3 (z=4.559, p <.01).

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43%

57%

40%

60%

37%

63%

Male Female

Gender distribution SAH Quarters 1, 2, and 3

Quarter 1 Quarter 2 Quarter 3

Gender Distributions

There were similar percentages of male and female cases for ischemic strokes and intracerebral

hemorrhages for the first, second, and third quarters. The proportion of female cases for transient

ischemic attack (TIA) tend to be

higher than male cases. The

gender differences in strokes were

more pronounced for

subarachnoid hemorrhage (SAH)

in the third and second quarters

than in the first. In the second

quarter, 60% of SAH cases were

female compared to 57% in the

first (z= -2.049, p= .04). The

difference was not significant

between the third and first

quarters, but the difference

between male and female SAH

cases in Quarter 3 was significant

(z=-2.954, p=.003).

Male 49%

Female 51%

Ischemic Stroke Quarter 3 n = 2013

Male 47%Female

53%

TIA (<24 hours) Quarter 3 n = 202

Male 40%

Female 60%

Male

Subarachnoid Hemorrhage Quarter 3

Intracerebral Hemorrhage

n = 135

50%

Female 50%

Quarter 3 n = 400

Ischemic Stroke Quarter 2 n = 2187

Female Male 49% 51%

TIA (<24 hours) Quarter 2 n = 195

Male 45%

Female 55%

Subarachnoid Hemorrhage Quarter 2 n = 165

Male 37%

Female 63%

Intracerebral Hemorrhage Quarter 2 n = 425

Male Female

48%52%

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Age distributions

67 68 70 58 6768 70 59 67 0

10

20

30

40

50

60

70

80

90

All stroke Ischemic TIA SAH ICH

Average Ages of Stroke Subtypes Quarter 2 and 3 +/- 1 Standard Deviation

Quarter 2 Mean Quarter 3 Mean

The most common age

group experiencing strokes

were those from ages 66-85,

with 49% of all cases in this

bracket. The prevalence of

stroke overall increased by

age, with only 8.2% of cases

occurring from in those aged 18-45. This pattern was similar for all stroke types except subarachnoid

hemorrhage (SAH), where 47% of cases occurred in those ages 46-65. There was an increase for SAH

in the 18-45 age group in the second quarter compared to the first quarter of 2017. In the third quarter,

we saw the proportion of cases in the 18-45 age bracket decrease to 19%, a significant decrease from

Quarter 2 (z=2.077, p=.038).

Age Distribution among SAH Patients Quarter 2

>85 2%

18 - 45 66 85 24% 28%

46 - 65 45%

Age Distribution among SAH Patients Quarter 3

>85 4%

18 - 45 19%

66 85 30%

46 - 65 47%

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Co-morbidities

76%

40% 35%

24% 24%

75%

38% 34%

24% 23%

78%

39% 34%

24% 24%

Hypertension Dyslipidemia Diabetes Mellitus Previous Stroke CAD/Prior MI

Top 5 Co-morbidities among Stroke Patients

Quarter 1 Quarter 2 Quarter 3

The top three co-morbidities among stroke patients, as seen in past quarters’ data, were hypertension

with 77.8% of cases, dyslipidemia at 39.1%, and diabetes mellitus at 34.2%.

Arrival mode

Most patients arrived via EMS services,

with 39.7% of patients in the third quarter

using this method of transportation.

Arrival Mode for All Stroke Types Quarter 3

EMS from home/scene

39.7%

Mobile Stroke Unit

0.4%

Private transport/taxi/

other from homes/scene

27.7%

Transfer from other

hospital 32.1%

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Transportation times

Similar transport times

for the various types of

transportation were

reported in the first and

second quarter, with

private transport

experiencing longer

transportation times on

average from

home/scene in

comparison to

Emergency Medical

Services (EMS)

transport. Most patients

arrived at the hospital

in over 300 minutes via

private transportation

(74%) while only 51.1%

of patients via EMS

services arrived in that

time frame (z=9.97, p<.001).

Time from Last Known Well to Arrival Quarter 2 and 3

Quarter 2 Quarter 3

66%64%

11% 10% 11% 10%9% 9%7% 7%

0-60 min. 61-120 min. 121-180 min. 181-300 min. >300

Time from Last Known Well to Arrival Quarter 3

Private transport/taxi/other from home/scene EMS from home/scene

74%

51%

20% 14%

9% 9% 10% 7%5% 5%

0-60 min. 61-120 min. 121-180 min. 181-300 min. >300

Meanwhile, 14.2% of patients arrived to the hospital via EMS services in

less than 60 minutes, compared to 9.5% in private transport (z=2.402, p=.016).

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Insurance status

The majority of stroke

patients had Medicare

(59.4%). This reflects that

the most common age

group experiencing strokes

are those from ages 66-85.

The majority of patients with a diagnosis of

ischemic stroke or stroke not otherwise specified,

94%, had a score reported for the National

Institute of Health Stroke Scale (NIHSS). The

NIHSS is a 15-item examination used to evaluate

the effect of acute cerebral infarction on the

levels of consciousness, language, neglect, Yes 94%

No 6%

Quarter 3 NIHSS Reported

58%

11%

35%

7%

59%

11%

34%

7%

Medicare Medicaid Private Self-pay

Insurance Status of Stroke Patients Quarter 2 and Quarter 3

Quarter 2 Quarter 3

NIHSS Reported

visual-field loss, extraocular movement, motor

strength, ataxia, dysarthria, and sensory loss.

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Time to Intravenous Thrombolytic Therapy

IV t-PA was

initiated within 60

minutes for most

patients in Quarter

3, at 90.5%.

Compared to

transport via EMS

services, private

transport

experience slightly

slower times with

80% of patients

receiving treatment

in an hour versus

92.4% (z=-2.571,

p=.01).

Time to Intravenous Thrombolytic Therapy Quarter 2 and 3

Quarter 2 Quarter 3

64%

51%

38%

26%

8%6% 3% 1% 1% 0% 0% 1%

0-30 min. 31-60 min. 61-90 min. 91-120 min. 121-150 min. >150 min.

Time to Intravenous Thrombolytic Therapy Quarter 3

Private transport/taxi/other from home/scene EMS from home/scene

69% 63%

29%

18% 11%

6% 2%0% 1% 0% 0% 0%

0-30 min. 31-60 min. 61-90 min. 91-120 min. 121-150 min. >150 min.

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Reasons for no IV rt-PA

27%

24%

20%

15%

7% 5% 5% 5%

5%

23%

26%

20%

14%

8% 8% 7%

5%

3%

Reasons for no IV rt-PA Initiation Quarter 2 and 3

Quarter 2 Quarter 3

The top five reasons for no IV rt-PA initiation in Quarter 3, in order of highest proportion of

patients to lowest, were because IV or IA tPA was given outside the hospital, the stroke severity

was too mild, the patient showed rapid improvement, acute bleeding diathesis, and recent IC or

spinal surgery. In Quarter 2, we saw similar proportions for these reasons, except the top

reason in Quarter 2 was that the stroke severity was too mild.

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Reasons for delay, IV rt-PA beyond 60 minutes

54%

22%

12% 9%

4%

45%

30%

4%

15% 11%

Care-team unable to determine patient

eligibility

Hypertension Refusal Further diagnostic evaluation

Management of concomitant emergent

conditions

Reasons for no IV rt-PA Initiation Beyond 60 mins Quarter 2 and 3

Quarter 2 Quarter 3

The most common reason for delay in IV rt-PA beyond 60 minutes was that care-team was

unable to determine eligibility of patient, composing 44.7% of cases. The difference between

Quarter 2 and Quarter 3 was not significant.

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Modified Rankin Scale at discharge

10% 11% 10% 10%

17%

5% 11%

27%

73%

10% 10% 10% 9%

19%

5% 10%

28%

72%

0 1 2 3 4 5 6 ND/Missing Documented mRS at

discharge

Modified Rankin Scale at Discharge Quarter 2 and Quarter 3

Quarter 2 Quarter 3

72% of patients had their Modified Rankin Scale at discharge documented in Quarter 3. The

Modified Rankin Scale ranges from 0-6, with the following designations for values:

0 - No symptoms at all

1 - No significant disability despite symptoms: Able to carry out all usual activities

2 - Slight disability

3 - Moderate disability: Requiring some help but able to walk without assistance

4 - Moderate to severe disability: Unable to walk without assistance and unable to attend to own bodily needs without assistance

5 - Severe disability: Bedridden, incontinent and requiring constant nursing care and attention

6 - Death

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Complication types

41%

59%

11% 11%

46%

73%

0%

12%

IV t-PA & Symptomatic Intracranial Hemorrhage

Intra-arterial & Symptomatic Intracranial Hemorrhage

IV t-PA & Life-threatening, serious systemic hem

Intra-arterial & Life-threatening

Co-morbidities among Stroke Patients

Quarter 2 Quarter 3

The most common type of complication for thrombolytic therapy in Quarter 3 was Intra-arterial

and Symptomatic Intracranial Hemorrhage at 73.1%. This was an increase from Quarter 2, but

the difference was not significant, with a sample size in Quarter 2 of 27 and a sample size in

Quarter 3 of 26.

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Initial exam findings

Quarter 2 and Quarter 3 Initial Exam Findings

Quarter 2 Quarter 3

66%63%

24%

39% 45%

4% 0%

7%

24%

44% 47%

3% 0%

6%

The most common findings in initial exam of patients were weakness/paresis (65.5%), language

disturbance (43.6%), and other neurological symptoms (45.1%).

• •

Length of stay (LOS)

The type of stroke with the longest length of hospital stay was SAH at about 11 days, and the

type of stroke with the shortest LOS was TIA at about 3 days.

GWTG/PAA Defect Free

93% of patients received defect free care

according to GWTG standards.

Defect Free 93%

Not Defect Free 7%

Quarter 3 Percentage GWTG/PAA Defect Free

n = 2421

5.9 5.3

2.4

12.2

8.0

4.8 5.5

1.8

6.0 5.6

2.8

11.3

7.7

5.2

3.3 1.8

All Patients Ischemic Stroke

Transient Ischemic

Attack

Subarachnoid Hemorrhage

Intracerebral Hemorrhage

Stroke of Uncertain

Type

No stroke related

diagnosis

Elective Carotid

Intervention only

Average Length of Stay Quarter 2 and 3

Quarter 2 Average Quarter 3 Average

CDC/COV Defect Free

84% of patients received defect free care Quarter 3 Percentage CDC/COV

Defect Free according to the Center for Disease Control n = 2531

Not (CDC) standards. Defect

Free 16%

Defect Free 84%

Contact Information

For more information about the Tennessee Stroke Registry and how to participate, contact:

Megan Quinn, TSR manager, or Natalie Stanley, TSR graduate assistant. Email (preferred): strokeregistry@etsu.edu or stanleyn1@etsu.edu Phone: (423) 439-4427

Local GWTG Representative: Angel Paylings Director, Quality & Systems Improvement, Tennessee Angel.Paylings@heart.org

We look forward to working with you to improve stroke care in Tennessee.