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The Experience of the
Canadian Stroke Network:
Bringing Knowledge to Practice
Quebec Summit to Conquer Stroke
October 7, 2008
Montreal, Quebec
Antoine M. Hakim
CEO & Scientific Director
Canadian Stroke Network
A Canadian Hospital’s Experience with t-PA
(2000)
“29 stroke patients received t-PA from 1996-
1999. This represents approximately 1.8% of
all ischemic strokes seen at our institution”
KM Chapman.......P Teal.
Stroke 2000;31:2920
Risk Factor Management: Control of BP
Hypertensive
100%
Aware
Unaware
58%
Treated
42%
Not treated
39%
Controlled
16%
19%
Not controlled
23%
Clin Invest Med 2003;26:78-86
1999: The Canadian Stroke Network was created
To reduce the impact of stroke through:
Focused,
Collaborative
Research
Capacity
Knowledge
Building
Application
Canadian Stroke Network Goals
To reduce the impact of stroke through:
Focused,
Collaborative
Research
Capacity
Knowledge
Building
Application
CSN Research Covers the Stroke Spectrum
Theme 1: Prevention
Theme 2: Treatment
• 10 projects underway
Theme 3: Reducing Damage
• Over $8M funded
research from 20082010
Theme 4: Rehabilitation/Recovery
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Registry of the Canadian Stroke Network
• Clinical database of consecutive stroke patients from >20 hospitals
across Canada (Phase I & II)
• Data is collected by full time nurse specialists
– Acute care
– Follow-up data (30d, 6m)
• Custom software package e-data transfer to Toronto
• Linkages of data between administrative databases in progress
• ~30,000 patients registered
Highlights of the CSN Registry
•
•
•
•
It is actively being used to improve quality of care.
The Registry forms an integral part of the Ontario Stroke Network
in evaluating and monitoring delivery of care.
It is one of the world's richest stroke databases and it is producing
valuable research results. For example, recent publications based
on Registry data prove the indisputable value of stroke units in
saving lives and reducing disability (Saposnik et al), issues around
treatment of in-hospital strokes (Silver et al), inadequate treatment
of atrial fibrillation (Gladstone et al)
Web-based data collection began this year.
Prevalence of WMH (white matter hyperintensities)
Prevalence (%) of silent and symptomatic infarcts visible on MRI per 5-year age category
Prevalence (%)
40
30
Covert Infarcts
Symptomatic Infarcts
20
10
0
60-64
65-69
70-74
age (years)
75-79
80-84
85-90
Stroke. 2002 May; 33(5): 1179-80
% of patients with poor cognitive function
(mean age 77 yrs)
Elevated Blood Pressure in Midlife Results in Poor
Cognitive function in Later Life
60
50
40
30
20
10
0
<110 (low)
110 – 139
(normal)
140 – 159
(borderline)
>160 (high)
Midlife systolic BP (mmHg) (mean age 52.7 yrs)
Launer LJ, et al. JAMA 1995;274:1846-1851.
Each 1 mmHg increase in
BP, over time, increases
the risk of poor late-life
cognitive function by
approximately 1%.
Launer LJ, et al. JAMA 1995; 274:1846-1851.
Canada’s Population is Sick!
24% adults and 52% of seniors have hypertension*
Is getting Sicker!
1995-2005 Prevalence increased by 60%*
*2005 Ontario data. CMAJ 2008 178:1458
And is expected to get Worse!
Further 60% increase in prevalence projected by 2025
Lancet 2005 365:217
Risk of Dementia with Brain Small
Vessel Disease (SVD)
• In population-based studies (not including imaging),
cerebrovascular risk factors alone (Age, gender, BP, DM, smoking,
heart disease) are associated with worse cognitive function
BMC Neurol 2008; 8:12
• Presence of WMH increases risk of dementia 4-fold
Ann. Neurol 2007; 62:59-66
• Cognitive decline is worse in presence of thalamic lacunes
• WMH affects executive cognitive (frontal lobe) functions, produce
more perseverative errors, and have less effect on attention and
working memory
Canadian Stroke Network Goals
To reduce the impact of stroke through:
Focused,
Collaborative
Research
Capacity
Knowledge
Building
Application
Training Health Professionals
• CSN co-sponsored with the Canadian Stroke Consortium and
industry partners the ANNUAL NATIONAL STROKE
CONFERENCE, bringing together emergency room (ER) physicians,
internists and neurologists to hear about the latest research in stroke
care and find out about best practices.
• CSN co-sponsored an ANNUAL REVIEW COURSE for neurology
residents and a conference on aphasia.
• CSN co-sponsored the National Stroke Rehabilitation Conference to
bring together rehab specialists for an intensive course on the latest
stroke research.
• CSN sponsored the NATIONAL STROKE NURSING COUNCIL,
which promotes research and education.
Developing the Next Generation of Stroke
Researchers
• Summer studentships every year in stroke research labs across
Canada. Since 2001, more than $350,000 has been invested.
• Focus on Stroke training program has funded 116 doctoral, postdoctoral and new-investigator awards with a total investment of
$9.5 million.
• Canadian Stroke Network Trainee Association (CSNTA) is
sponsoring learning events; providing representation at CSN
meetings; encouraging collaboration; and developing core
competencies.
• Working with an industry partners to develop a new post-doctoral
training program.
Canadian Stroke Network Goals
To reduce the impact of stroke through:
Focused,
Collaborative
Research
Capacity
Knowledge
Building
Application
“Knowing is not enough;
we must apply.
Willing is not enough;
we must do.”
Johann Wolfgang von Goethe
The Canadian Stroke Strategy Model
“The Canadian Stroke Strategy (CSS) is
a framework to change policy and
practice where health care is
delivered…this is about real health
systems change.”
Canadian Stroke Strategy
Provincial/Regional Implementation of Best Practice
Prevention
Treatment
Rehabilitation
Reengagement
National Pillars to Support Provincial/Regional Strategies
Public Awareness
Best Practice Guidelines/Standards
Professional Development
Information Platform
Coordinated Research
National Pillars: What Needs to Happen
• Large scale public awareness campaign of the signs and
symptoms of stroke
• Making best practices and standards of care in stroke
accessible, reinforced by stroke centre accreditation
• National tracking of key performance indicators
• Novel stroke training programs for health professionals,
including team-based approaches for stroke care
• Coordinated research in stroke, including clinical trials
Canadian Best Practices
Features:
•
Recommendations across the continuum of prevention through to
community reintegration
•
Rationale and summary of the evidence provided
•
Implications to the healthcare system described
•
Performance measures defined
•
Consumer-friendly versions in development
•
Used as the content for hospital accreditation and point-of-care tools
Best Practice Development & Evaluation Cycle
1.
Identify a Clinical Area to
Promote Best Practice
2.
Establish an
Interdisciplinary
Guideline Evaluation
Group
3.
4.
10.
9.
Obtain Official Endorsement
and Adoption of Local
Guideline
8. Finalize Local Guideline
Establish Guideline
Appraisal Process
7.
Search for and
Retrieve Guidelines
5.
(Adapted from
Graham et al, 2005)
Schedule Review and
Revision of Local Guideline
Assess Guidelines
a) Quality
b) Currency
c) Content
6.
Seek External Review –
Practitioner and Policy Maker
Feedback; Expert Peer Review
Adopt or Adapt Guidelines
for Local Use
International Collaboration
• Endorsement of the CSS Best Practices by World Stroke
Organization
• WSO leading international effort to align guidelines and support
less developed countries in organizing stroke care based on
best practice standards
Key Performance Indicators
Arrival time to ED
Stroke
Risk Factors Public
Awareness Incidence
Mortality
Pre
Hospital
Stroke Unit
CT/MRI before D/C
Discharge Location
Hyper
acute
tPA rates
CT Scan
DTN Time
Acute
SPC Referrals Time to CEA
Antiplatelet Rx Anticoags for A-Fib
Rehab
Prevention
Community
Admit rates for inpt rehab LTC admit Rates Home
Wait times Change in FIM care service rates Home
D/C Disposition
care duration/intensity
Organizing Provinces/Regions
Regional Stroke Centre
•Neurosurgeon
•MRI
•Angiography
•Leadership for regional plans
DSC
District Stroke Centre
•Neurologist/ Stroke Expert
•24/7 CT Scanner
•Leadership for district plans
RSC
DSC
DSC
Community Network
•Local Hospital
•CCAC
• Primary Care Practitioner
•LTC/Rehab/CCC
•PHU
•Support groups
Impact of the Canadian Stroke Strategy
• Average tPA rate increased to 11.2% in designated regional stroke
centres (some sites as high as 30%)
• Inpatient admissions for stroke decreased by 11%, mostly attributable
to a decrease in admissions for transient ischemic attacks (TIA) or
small strokes
• 54% increase in patients receiving referrals to stroke prevention
clinics following initial stroke/TIA to prevent more serious event (there
are now 19 prevention clinics in Ontario) and spreading across
Canada
Impact of the Canadian Stroke Strategy
• Number of patients now managed on specialized stroke units
increased from 9% to 42%
• Physiotherapy assessments before hospital discharge have increased
from 47% to 75%, and occupational therapy consults from 38% to 71%
• 85% of patients discharged from regional stroke centres on antiplatelet
medications to help prevent another stroke
• 8.7% of patients require admission to long-term care following stroke a major decrease from 2 years previously
Economic Impact
• Based on current Canadian population, widespread access to
organized stroke care would, over next 20 years:
– Prevent 160,000 strokes
– Prevent disability in 60,000 Canadians
– Achieve net savings of $8 billion
The CSN is Making a Difference
• A leading funder of multi-disciplinary stroke research in Canada
• Moving research to the bedside
• Transforming patient care in all parts of Canada
• Developing critical tools for researchers and the public
• Leading efforts in stroke prevention
• Expanding the world’s richest stroke database
• Training health professionals
• Mentoring and supporting the next generation of researchers
• Forging national and international collaborations
• Getting the message out
What you Need
to Change the Healthcare System
1. Leadership commitment and support
2. Key stakeholder involvement
3. Simple changes in practice should be introduced first.
4. Regular communication must convey the evidence
5. It takes money…and patience.
6. Data gathering, evaluation and monitoring of outcomes.
7. Educate, educate, educate.
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