From Tupelo Neurology Clinic (S.D.N.), North Mississippi Health System
(J.E., K.M.D.), and North Mississippi Medical Center (A.B.-T., K.E.K.),
Tupelo, Miss.
Correspondence to Janet Englert, RN, Clinical Efficiency Department, North Mississippi Medical Center, 830 S Gloster St, Tupelo, MS 38801. E-mail jenglert{at}nmhs.net
Methods—A retrospective analysis of medical record
and financial databases of 356 patients with ischemic stroke
was performed. The medical record data were adjusted for severity,
and outliers were eliminated. The resources utilized by each physician
were determined. Comparative graphs were prepared, presented,
and discussed. The physicians implemented two types of changes: (1)
alteration of resource utilization and consultation patterns and (2)
support of clinical process improvement. In 1997, a follow-up
analysis of 399 patients was performed.
Results—The initial comparison of internists' to neurologists'
patient populations found the following: patient age (75 versus 65
years), patient severity ratings (2.8 versus 2.5), length of stay (10.7
versus 8.8 days), costs ($7360 versus $6862), mortality rates (12.5%
versus 8.9%), and aspiration pneumonia rate (8.5% versus 3.8%). A
comparison of the 1995 analysis to the 1997 analysis
revealed the following per patient resource utilization decreases (all
P<0.05): chemistry laboratory, 2.65 to 1.95 studies;
intravenous fluids, 2.85 to 1.85 L; oxygen use, 6.06 to
2.75 U; and nifedipine use, 1.62 to 0.33 capsules. The
clinical process improvements resulted in the following overall
outcomes (all P<0.05 except mortality): length of stay
(7.2 days), nonadjusted costs ($6246), mortality (6.5%), and rates of
pneumonia (2.7%).
Conclusions—Objective analysis of resource utilization
resulted in physicians changing their individual management of stroke
and collectively supporting clinical process changes that improved
clinical and financial outcomes.
Our facility was in the PRO's initial survey. In concert with the
qualitative care indicators that the PRO was measuring, our facility's
internal evaluation found that stroke (DRG 014), specifically
ischemic stroke, was its most financially draining diagnosis
(loss of more than one million dollars in 1993). Stroke is a
large-volume diagnosis at our facility, with an average of 400 cases
per year. The volume, along with the financial loss, provided
significant motivation for improving stroke management. Several
factors, however, predicted that making improvements would be
challenging, namely, (1) a wide variation in current stroke management;
(2) a sense of complacency regarding the stroke population (ie, the
myth that "not much could be done"); and (3) the requirement of
multidisciplinary management.
Stroke units, protocols, care guides, team care, and case management
have helped other facilities to improve their management of
stroke.3 4 5 6 7 8 9 10 11 12 13 These clinical management tools are
usually more effective when the medical staff has participated in their
development and supports their use. This article describes the use of
clinical efficiency tools to determine each physician's resource
utilization and clinical outcomes as well as the resulting stroke
management changes that the medical staff personally implemented and
collectively supported.
At the time of the initial PRO evaluation, our facility had four
neurologists on staff and a neurological nursing unit, but no stroke
case manager and no dedicated stroke unit. Our facility also had two
physiatrists on staff and an inpatient acute rehabilitation unit.
The Mississippi PRO stroke project's goal was to improve patient
care by increasing adherence to nationally accepted stroke management
guidelines.14 During their first visit, the PRO
team described the program and reviewed the six evaluation process
criteria (Table 1
Clinical Practice Analysis of Stroke
The goal of this CPA was to improve the clinical efficiency (ie, good
outcomes with optimal resource utilization), and therefore it went
beyond the PRO study parameters, which were rooted solely
in improving outcomes. To achieve clinical efficiency, the CPA also
examined internal processes such as the timing of consultations and
patients' discharge placement.
The majority (88%) of our patients experienced ischemic
stroke, which therefore became the focus of the CPA. Patients with
hemorrhagic strokes or transient ischemic attacks were not
included in this analysis. Since the patient population was
identified by ICD-9 codes for ischemia, patients who underwent
carotid endarterectomy procedures were excluded
from this study population because the procedure places them in a
surgical DRG.
The CPA process used proprietary severity-adjusting software (3 M-APR
DRG) to determine each stroke patient's severity on a scale of 1 to 4,
with 4 being the worst.16 The patients' severity
level was based on their coded comorbidities, complications, risk of
mortality, age, sex, and discharge status.17 To
determine each physician's patient population's average severity
level, the clinical efficiency provider defined the patient population
(time frame, financial status for inpatients, facility, DRG 014, and
ICD-9 codes for ischemia); identified each physician's
ischemic stroke patients; and finally used the medical
record database to produce an average severity index for each
physician's stroke patients in the defined population. Patients whose
cost of care or LOS was more than twice the population average were
identified as outliers. They were noted in the CPA but were excluded
from the comparative database.
The resource utilization of each physician managing ischemic
stroke was then examined. The clinical efficiency provider used an
internally developed financial database, cost-information decision
support (CIDS), which is housed in Oracle and is electronically
accessed through Powersoft's Infomaker, a query and reporting tool.
This information was combined with the severity-adjusted data to
provide a database of more than 100 elements. The clinical efficiency
provider and one of the neurologists reviewed the initial findings,
then selected the elements that would be analyzed and
presented. The criteria for their selection included
evidence-based diagnostic and treatment recommendations as
well as observed internal variations in resource utilization. Two CPAs
were performed: one for the neurologists and one for the internists,
which was compared with the neurologists' CPA.
The clinical efficiency provider prepared graphs that compared each
physician's ischemic stroke management with that of his or her
colleagues as well as with internal and external benchmarks. Bar graphs
and scattergrams depicted each physician's patient population's
severity, LOS, overall costs, and resource utilization. The physicians
were each identified by a letter.
CPA Presentation and Improvement Plans
The neurologists' CPA was presented in January 1996. Although
their outcomes were generally good, they agreed that they could reduce
the incidence of aspiration pneumonia and improve several
inefficiencies in their overall management (ie, lag time in orders,
rehabilitation evaluations, and discharge placement). The neurologists
developed a process improvement plan that included hiring a stroke case
manager, enhancing the stroke care team, creating a stroke unit, and
developing a stroke care guide. The internists' CPA was
presented in November 1996, and these physicians were
encouraged to take advantage of the process improvements that the
neurologists had implemented.
Data Analysis
The CPA analyzed the physicians' utilization of over 20
resources and reviewed three common patient comorbidities (diabetes,
congestive heart failure, and COPD). The analyses of
internists' use of oxygen and patients with COPD are provided as
examples of the individualized data analysis (Figures 2
The key outcome parameters for the internists and the
neurologists during FY 1995 through 1997 are depicted in Table 2
The collective use of individual resources for the internists and the
neurologists during FY 1995 and 1997 is depicted in Table 3
The only resource of potentially considerable impact that was not
compared between the two time periods was tissue
plasminogen activator. During FY 1997, two
patients received tissue plasminogen activator,
and they are included in the 1997 patient data. This usage could not be
compared with usage in 1995, and it was too low to evaluate its
potential impact on overall costs or mortality.
It is difficult to quantify process data from the financial database.
One process parameter, however, was determined: the mean
number of days from patient admission to the consultation of the stroke
team. In 1995 the internists consulted the stroke team on day 3 of the
patients' admission. This consultation pattern changed to day 1 in
1997.
Clinical efficiency tools were used for three purposes: (1) to
objectively determine the baseline practice and outcomes; (2) to create
a forum for reviewing evidence-based literature, resource utilization,
and clinical processes; and (3) to measure the outcome of the practice
changes. The CPA relies on medical record coding and a financial
database. Although these databases have limitations, the CPA identified
inconsistent and excessive resource utilization. The physicians
became engaged in resource utilization because it was individualized.
For example, oxygen use was reviewed, and one physician (physician F)
was using an average of 21.9 U of oxygen therapy per patient. However,
when the comorbidities were analyzed, none of physician F's
patients had a pulmonary comorbidity (Figures 2
The CPA could not address clinical processes or appropriateness of
care, but it provided the stimulus for the medical staff to pursue
these issues and make the necessary changes. For example, the
internists were unaware that a rehabilitation evaluation should be
ordered during the acute phase management. With this realization, the
paradigm shifted, and they fully endorsed an automatic evaluation on
day 3. During their CPA presentation, the neurologists
discussed several general "coordination of care" problems. They
recommended the hiring of an SCM to identify and solve specific process
problems. The SCM coordinated the efforts that resulted in the
significant decrease in overall LOS (9.9 to 7.2 days;
P=0.049).
The SCM worked with the SITF to efficiently move patients through the
evaluation and management processes. The first efficiency step was an
obvious one: identify the etiology of the stroke as early as possible
(within 24 to 48 hours) and plan the patient's course of care within
48 to 72 hours. The neurologists expedited the diagnostic
process by creating a standard list of diagnostic tests and
defining when and why they are performed. CT scan of the head within 24
hours was one of the criteria of the PRO, and it is now routinely
performed on admission (Tables 1
Early diagnosis enables the neurologist to determine and implement the
patient's course of therapy. For example, if the patient had a
correctable condition such as an internal carotid artery
stenosis, then carotid endarterectomy could
be considered. Early recognition of atrial fibrillation also stimulates
specific treatment. In contrast, if the patient has a hopeless
condition, such as a massive intracranial hemorrhage, then it
may be more appropriate to implement social work and pastoral care
consultations while exploring patient placement options. The majority
of patients do not fit into either of these categories and benefit from
early assessments of their rehabilitative abilities.
The second efficiency step improved patient care management processes
through a proactive stroke team. Although a stroke team had been in
place since 1988, the new emphasis on efficiency changed the
composition of the team and its dynamics (ie, from passive to active).
The SCM, an RCM, a social worker, and a psychological associate were
added to the team, which already consisted of a neurologist, nurse,
occupational therapist, speech therapist, physical therapist,
pharmacist, dietician, and discharge planner. The stroke team meets
weekly and is coordinated by the SCM.
Instead of waiting for individual consultations, the team members now
automatically review patients as soon as a stroke team consultation is
ordered. The occupational therapist, speech therapist, and physical
therapist are required to complete their evaluations within 24 hours
and will remove themselves from a case if they cannot offer the patient
any benefits. The RCM reviews the therapists' consultations and
discusses the potential rehabilitation options with the patient's
family. This social worker also reviews the patient's insurance
coverage and coordinates this information for the rehabilitation
physician, who determines the patient's rehabilitation course (ie,
acute, subacute, or outpatient). For example, if the patient's
family plans to care for him or her at home, the RCM provides them with
a realistic picture of how to meet the patient's needs. In this way
the family can evaluate their ability to care for the patient, and, if
necessary, nursing home placement plans can be made accordingly. Once
the rehabilitation physician orders the patient's course, the RCM then
arranges specific bed location and other rehabilitation services for
the patient.
The SCM optimizes the physicians' rounds by making all the laboratory
and study results available for their timely evaluation and ensuring
that the physicians' decisions and actions are carried out. If a
patient care issue is not addressed during rounds, the SCM and other
team members highlight the patient's specific needs on a standard list
of day 2 or day 4 patient care reminders and place it on the patient's
chart. These reminder lists were approved by the stroke team as a means
for the nonphysicians to prompt the physicians about the patients'
nutrition, medication, activity level, and intravenous
access status.
During the weekly team meetings, the stroke team discusses each
patient's progress and continues to make process improvements. For
example, the stroke team identified "harmless" sips of water as a
source of aspiration pneumonia and educated everyone with patient
contact about them (Table 2
The stroke team's lead neurologist presented the
ischemic stroke care guide to the internists. This
evidence-based stroke management review complemented the previously
presented CPA and provided solutions to identified clinical and
efficiency problems. The internists individually changed their resource
utilization and collectively incorporated the stroke team process
improvements into their practice. The ischemic stroke care
guide was implemented in May 1997.
The SITF's initial improvement plan included implementing a stroke
unit. The CPA and resulting improvements were the basis of the unit's
proposal. An eight-bed stroke unit utilizing telemetry and dedicated
nursing staff was incorporated into the neurological nursing unit in
November 1997.
With the stroke management improvements in place at the tertiary care
referral center, the stroke team's lead neurologist presented
stroke prevention and management guidelines to the health system's
primary care providers and community hospitals. During this time the
health system implemented blood pressure screening at its 37 primary
care clinics. Although the impact of the stroke team's efficiencies
and resource utilization changes was easily measured, it will be
difficult to measure the long-term impact of system-wide blood pressure
screening and a neurologist's stroke prevention and stabilization
tutorial. The assumption that better screening and prevention will
result in fewer patients experiencing stroke is supported by the
prediction of Pharoah and Sanderson18 of a 17%
reduction in stroke deaths after the implementation of a health
promotion program.
Improving patient assessment and placement processes resulted in a
statistically significant decreased LOS (9.9 to 7.2 days;
P=0.049). One of the concerns about showing a 4-day decrease
in acute care LOS is that it may actually reflect a transfer of costs
to another provider and not a true decrease in the patient's total
healthcare cost. The true impact of the shortened LOS can be assessed
by the patients' discharge status, specifically the percentage of
patients who are discharged to their homes. During FY 1995, 52% of all
stroke patients were discharged to their homes, whereas in FY 1997,
56% of stroke patients went directly to their homes. Since the number
of patients discharged to home did not decrease, it would appear that
the 4-day decrease in acute care LOS is a true decrease in overall
healthcare expense. The discharge status of patients to nursing homes
(7.4% in 1995 and 6.4% in 1997) and rehabilitation facilities (23.6%
in 1995 and 23.7% in 1997) also remained constant.
The lasting process improvements can be attributed to the efforts of
the SCM and the stroke team. The CPA process, however, is responsible
for measuring outcomes and resource utilization and most importantly
for stimulating the desire to make improvements. By providing detailed,
line-item review of clinical practice, the CPA allowed the physicians
to see how they were performing relative to each other and encouraged
them to question their management. Alberts et
al19 also found that educating physicians on the
utilization and charges of specific diagnostic tests was an
effective means of optimizing their utilization.
The CPA process cost-efficiently examines and manipulates large numbers
of variables. The two 1995 CPAs each took approximately 40 hours
for the clinical efficiency provider to collect and analyze the
data. In contrast, the PRO chart review took at least 100 hours just to
abstract the 196 patient medical records. The CPA, however, cannot
provide the same qualitative data as the PRO's chart review and may
result in information gaps that require focused chart review or
educated assumptions. For example, the PRO determined that in 1993,
92.4% of patients had a CT scan ordered, 89.6% of which were
performed in the first 24 hours. The 1995 CPA found that 376 CT scans
were ordered for 356 patients; however, the financial database does not
discern when the test was ordered. All that is definitely known is that
more than one test was ordered per patient. The assumption is that the
1994 PRO presentation, which encouraged routine and early
CT scans, was effective and resulted in 100% of patients receiving at
least one CT scan.
Coding limitations also complicate the CPA data interpretation. For
example, all nifedipine 10 mg is one code, regardless of
the administration route. The PRO's chart review found that sublingual
nifedipine was ordered for 43.9% of patients. The 1995 and
1997 CPAs, however, reported all of the administered
nifedipine doses (577 and 66 doses, respectively). Although
it is not specific for sublingual nifedipine used to manage
acute hypertension, this dramatic decline can be interpreted as a
positive sign.
The noted limitations of the CPA data are discussed during the
presentations, and they have not hindered the process,
which relies on physicians' desire to do their best for their patients
as well as their nature to compete with their colleagues. Whereas the
CPA process depends on these motivations for the physicians to change
their practice patterns, it also incorporates evidence-based standards
of care into these changes. In our experience, the CPA process has
resulted in numerous clinical efficiency changes that physicians made
on their own, many of which were later incorporated into clinical care
guides.15 17 20
This ischemic stoke CPA project resulted in a narrowing of
the gap between the internists' and the neurologists' management of
stroke as well as an overall improvement in clinical and financial
outcomes. Internists can and do manage their own patients; however,
through the CPA process they now utilize the expertise of the
neurologists and the efficiency of the stroke team.
The management of stroke is complex and requires multidisciplinary
involvement. CPA is a clinical efficiency tool that examines each step
of stroke care management and creates a forum for multidisciplinary
involvement. Healthcare facilities can use CPA to improve the
efficiency of their acute care management and develop stroke units.
Received January 22, 1998;
revision received March 18, 1998;
accepted March 18, 1998.
2.
Gordon DL, Cobb AB, McIlwain JS, Keller C, Roach CA,
Miller D, Sanchez N, Guy B, Meydrech EF. Cooperative stroke management
project by a peer-review organization. J Stroke Cerebrovasc
Dis. 1996;6:45–53.
3.
Crawley WD. Case management: improving outcomes of
care for ischemic stroke patients. Med Surg Nursing. 1996;5:239–244.
4.
Hinkle JL. Development of an acute stroke unit.
J Neurosci Nursing. 1992;24:113–116.[Medline]
[Order article via Infotrieve]
5.
Hydo B. Designing an effective clinical pathway for
stroke. Am J Nursing. March 1995:44–51.
6.
Bowen J, Yaste C. Effect of a stroke protocol on
hospital costs of stroke patients. Neurology. 1994;44:1961–1964.
7.
Falconer JA, Roth EJ, Sutin JA, Strasser DC, Chang RW.
The critical path method in stroke rehabilitation: lessons from an
experiment in cost containment and outcome improvement. Qual Rev
Bull (Chicago). January 1993:8–16.
8.
Romito D. A critical path for CVA patients.
Rehabil Nursing. 1990;15:153–156.
9.
Indredavik B, Bakke F, Solberg R, Rokseth R, Haaheim
LL, Holme I. Benefit of a stroke unit: a randomized controlled trial.
Stroke. 1991;22:1026–1031.
10.
Indredavik B, Slordahl SA, Bakke F, Rokseth R, Haheim
LL. Stroke unit treatment: long-term effects. Stroke. 1997;28:1861–1866.
11.
Webb DJ, Fayad PB, Wilbur C, Thomas A, Brass LM.
Effects of a specialized team on stroke care: the first two years of
the Yale Stroke Program. Stroke. 1995;26:1353–1357.
12.
Pasquarello MA. Measuring the impact of an acute stroke
program on patient outcomes. J Neurosci Nursing. 1990;22:76–82.[Medline]
[Order article via Infotrieve]
13.
Wood-Dauphinee S, Shapiro S, Bass E, Fletcher C,
Georges P, Hensby V, Mendelsohn B. A randomized trial of team care
following stroke. Stroke. 1984;15:764–872.
14.
Adams HP Jr, Brott TG, Crowell RM, Furlan AJ, Gomez CR,
Grotta J, Helgason CM, Marler JR, Woolson RF, Zivin JA, Feinberg W,
Mayberg M. Guidelines for the management of patients with acute
ischemic stroke: a statement for healthcare professionals from
a special writing group of the Stroke Council, American Heart
Association. Stroke.. 1994;25:1901–1914.[Medline]
[Order article via Infotrieve]
15.
Carlisle M, Englert J, Davis KM, Koch KE. Clinical
practice analysis: a means and an end. J Clin
Outcomes Manage. In press.
16.
Imler SW. Provider profiling: severity-adjusted versus
severity-based outcomes. J Healthcare Quality. 1997;19:6–11.
17.
Beckham SH, Englert J, Davis KM, Koch KE. Clinical
applications of computer-based health information. Top Health
Inform Manage. 1998;18:50–59.[Medline]
[Order article via Infotrieve]
18.
Pharoah PDP, Sanderson SP. Health promotion in primary
care: modeling the impact of intervention on coronary heart
disease and stroke. J Public Health Med. 1995;17:150–156.
19.
Alberts MJ, Bennett CA, Rutledge VR. Hospital charges
for stroke patients. Stroke. 1996;27:1825–1828.
20.
Saunders R. Lumbar discectomy: practice
analysis and care guide. Hosp Case Manage. October
1997:181–184.
© 1998 American Heart Association, Inc.
Original Contributions
Clinical Efficiency Tools Improve Stroke Management in a Rural Southern Health System
Abstract
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Background and
Purpose—Ischemic stroke is a high-volume and financially
draining diagnosis at this rural health system. The purpose of this
clinical practice analysis was to identify resource utilization
and clinical process inefficiencies and to promote clinically
efficient, evidence-based improvements.
Key Words: cost and cost analysis • quality of health care • stroke management
Introduction
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Mississippi is in the
middle of the "Stroke Belt," a section of the southeast United
States with the highest stroke-related death rates in the United
States.1 In 1994, the Mississippi Foundation for
Medical Care, a PRO, used six basic predetermined criteria and reviewed
427 patients at four facilities.2 The review of
this comparative database became a springboard for each facility to
discuss and improve stroke management.
Subjects and Methods
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Background
Our 647-bed facility is the tertiary-care referral center of an
integrated rural healthcare system that serves more than 600 000
people in a 22-county region in northern Mississippi, Alabama, and
Tennessee. In addition to our facility, our health system consists of
four community hospitals, 32 family medicine clinics, 3 nursing homes,
5 internal medicine clinics, and a home healthcare agency that provides
an average of 500 000 visits per year. The details of system
integration are important because stroke management starts with its
prevention in the primary care settings and often ends in nursing homes
or with assisted home living. 
). Our
facility provided data on 197 stroke patients, which were
differentiated by ICD-9 codes (173 were ischemic stroke
patients). The PRO tabulated the information and presented our
results as a subgroup of the statewide findings to a group of
neurologists, internists, clinical managers, and
administrators.2 In response to the stroke
expert's presentation, the Stroke Initiative Task Force
(SITF), a multidisciplinary group, was formed to evaluate and improve
stroke care.
View this table:
[in a new window]
Table 1. Mississippi Foundation for Medical Care's Key Data
Collection Elements
The SITF's first step was to request a CPA of stroke. CPAs use
severity-adjusted and resource utilization data to provide detailed
reviews of medical and surgical diagnoses. The CPA was managed by a
clinical efficiency provider, an experienced nurse with training in
health information and clinical and financial database
management.15 The SITF worked with the clinical
efficiency provider to determine the parameters of the
CPA.
At the beginning of the CPA presentation, each
physician was given an envelope with his or her identifying letter
inside. This enabled the physicians to privately view and compare their
resource and outcome information. The clinical efficiency provider
described each graph and encouraged questions and discussion.
The impact of these improvements was tracked by both economic
and clinical outcomes: cost of care, LOS, mortality, and complication
rate, specifically aspiration pneumonia. Although outcome data are
available since the initial PRO review (1993 data), statistical
analysis was performed only on the initial CPA data (1995) and
data from the most recent year (1997). The Student's t test
was applied to the parametric data (cost, LOS), whereas the
2 test was applied to the
nonparametric data (mortality, aspiration pneumonia) and to
the resource utilization data in which we compared proportions. A value
of P
0.05 was selected as significant, and correlative
statistics were performed with the use of electronic software, Sigma
Stat (SPSS).
Results
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
The 1995 baseline CPA found that the neurologists had both a
shorter LOS (8.8 versus 10.7 days) and a lower cost ($6862 versus
$7360) than the internists managing ischemic stroke. The
internists' patients were older (75 versus 65 years) and had more
comorbidities, which accounted for the slightly higher severity ranking
(2.8 versus 2.5) (Figure 1). These
rankings, however, were considered close enough to perform a valid
practice management comparison. The racial composition of these
populations was comparable: 24% of the 1995 patients were African
American, as were 26% of the 1997 population. The percentages of
patients who were outliers were also similar: 8.3% of internist'
patients and 8.1% of neurologists' patients in 1995, and 6.6% of
internists' patients and 5.2% of neurologists' patients in 1997.
View larger version (7K):
[in a new window]
Figure 1. Internists' and neurologists' patient severity
and age comparisons for 1995 (x axis, average age per
case; y axis, average acuity per case). Internists are
represented by the letters A through V; neurologists are
represented by WW, XX, YY, and ZZ. and 3).
View larger version (16K):
[in a new window]
Figure 2. Internists' use of oxygen for 1995
(x axis, internists; y axis, average
number of units per case).
View larger version (17K):
[in a new window]
Figure 3. Internists' COPD comorbidity for 1995
(x axis, internists; y axis, percentage
of patients with COPD). . Statistical significance
was achieved in the following key parameters: overall
decrease in LOS (9.9 to 7.2 days; P=0.049); overall decrease
in aspiration pneumonia (6.4% to 2.7%; P=0.03); and
overall decrease in nonadjusted costs ($7111 to $6246;
P=0.001) (note that the 1997 costs were not adjusted for
inflation). The overall decrease in mortality (11.1% to 6.5%)
approached statistical significance (P=0.063).
View this table:
[in a new window]
Table 2. Comparison of Financial and Clinical Outcomes for FY
1995 and FY 1997 . Changes in resource
utilization were measured as an average of what each physician group
used per patient. The following changes from 1995 to 1997 achieved
statistical significance: increase in MR angiography usage (0.22 to
0.41 studies per patient; P=0.001); decrease in basic
electrolyte chemistry laboratory tests, "Chem 7" orders (1.94 to
1.43 serum concentrations per patient; P=0.001); decrease in
expanded electrolyte and enzyme chemistry laboratory tests, "Chem
12" and "Chem 18" orders (0.71 to 0.52 serum concentrations per
patient; P=0.011); decrease in prothrombin time orders (2.92
to 2.27 prothrombin time orders per patient; P=0.004);
decrease in liters of intravenous solutions (2.85 to 1.85 L
per patient; P=.001); decrease in increments of oxygen
usage, (6.06 to 2.75 increments per patient; P=0.001) (note
that oxygen is billed for, and therefore measured, in 12-hour
increments); and decrease in nifedipine usage (1.62 to 0.33
capsules per patient; P=0.001).
View this table:
[in a new window]
Table 3. Comparison of Resource Utilization for FY 1995 and
FY 1997
Discussion
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
The significant improvements in ischemic stroke management
started from an external chart review of clinical outcomes and were
completed by an internal database analysis of clinical
efficiency. The SITF responded to the two pharmacotherapy-related PRO
issues by producing a pharmacy newsletter on the dangers of sublingual
nifedipine and posting laminated signs that reminded
physicians to order subcutaneous heparin for immobilized
and/or stroke patients. These passive actions did not ensure positive
changes, and therefore the SITF turned to the CPA process to actively
engage the medical staff in the improvement process. 
and 3). Note
that overall use of oxygen decreased by 55% (Table 3). and 3). ). The stroke team incorporated all of these
improvements into a clinical care guide. The care guide defines the
first 24 hours of patient evaluation, after which the patient
progresses through 48-hour "phases" that depend on the patient's
capabilities. A "decision time" is noted after the 24- to 72-hour
phase and again at 5 days, and the goal is to discharge patients within
the 7- to 9-day phase.
Selected Abbreviations and Acronyms
COPD
=
chronic obstructive pulmonary disease
CPA
=
clinical practice analysis
DRG
=
diagnosis related group
FY
=
fiscal year
ICD=9
=
International Classification of Diseases, Ninth Revision
LOS
=
length of stay
PRO
=
physician review organization
RCM
=
rehabilitation case manager
SCM
=
stroke case manager
SITF
=
Stroke Initiative Task Force
Acknowledgments
We would like to acknowledge Dorie Crouch for managing the
databases and the stroke team members for their dedication to
their patients.
References
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
1.
Alberts MJ. The stroke belt consortium. J
Stroke Cerebrovasc Dis. 1996;6:54–59.[Medline]
[Order article via Infotrieve]
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 K. A. LaBresh, M. J. Reeves, M. R. Frankel, D. Albright, and L. H. Schwamm Hospital Treatment of Patients With Ischemic Stroke or Transient Ischemic Attack Using the "Get With The Guidelines" Program Arch Intern Med, February 25, 2008; 168(4): 411 - 417. [Abstract] [Full Text] [PDF]
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A. I. Qureshi, M. F. K. Suri, A. Nasar, J. F. Kirmani, M. A. Ezzeddine, A. A. Divani, and W. H. Giles Changes in Cost and Outcome Among US Patients With Stroke Hospitalized in 1990 to 1991 and Those Hospitalized in 2000 to 2001 Stroke, July 1, 2007; 38(7): 2180 - 2184. [Abstract] [Full Text] [PDF]
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 C. A. Smith Hammond and L. B. Goldstein Cough and Aspiration of Food and Liquids Due to Oral-Pharyngeal Dysphagia: ACCP Evidence-Based Clinical Practice Guidelines Chest, January 1, 2006; 129(1_suppl): 154S - 168S. [Abstract] [Full Text] [PDF]
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Task Force Members, L. H. Schwamm, A. Pancioli, J. E. Acker III, L. B. Goldstein, R. D. Zorowitz, T. J. Shephard, P. Moyer, M. Gorman, S. C. Johnston, et al. Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association's Task Force on the Development of Stroke Systems Stroke, March 1, 2005; 36(3): 690 - 703. [Full Text] [PDF]
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 L. H. Schwamm, A. Pancioli, J. E. Acker III, L. B. Goldstein, R. D. Zorowitz, T. J. Shephard, P. Moyer, M. Gorman, S. C. Johnston, P. W. Duncan, et al. Recommendations for the Establishment of Stroke Systems of Care: Recommendations From the American Stroke Association's Task Force on the Development of Stroke Systems Circulation, March 1, 2005; 111(8): 1078 - 1091. [Full Text] [PDF]
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 V. C. Douglas, D. C. Tong, L. A. Gillum, S. Zhao, L. M. Brass, J. Dostal, and S. C. Johnston Do the Brain Attack Coalition's criteria for stroke centers improve care for ischemic stroke? Neurology, February 8, 2005; 64(3): 422 - 427. [Abstract] [Full Text] [PDF]
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 M. T. Forthman, L. D. Wooster, W. C. Hill, J. M. Homa-Lowry, and S. I. DesHarnais Insights Into Successful Change Management: Empirically Supported Techniques for Improving Medical Practice Patterns American Journal of Medical Quality, September 1, 2003; 18(5): 181 - 189. [Abstract] [PDF]
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L. A. Gillum and S. C. Johnston Characteristics of Academic Medical Centers and Ischemic Stroke Outcomes Stroke, September 1, 2001; 32(9): 2137 - 2142. [Abstract] [Full Text] [PDF]
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 M. J. Alberts, G. Hademenos, R. E. Latchaw, A. Jagoda, J. R. Marler, M. R. Mayberg, R. D. Starke, H. W. Todd, K. M. Viste, M. Girgus, et al. Recommendations for the Establishment of Primary Stroke Centers JAMA, June 21, 2000; 283(23): 3102 - 3109. [Abstract] [Full Text] [PDF]
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