Stroke Outcomes in Australia - five years of AROC data- Tara Stevermuer AROC Data Manager

Stroke Outcomes in Australia - five years of AROC data- Tara Stevermuer AROC Data Manager

Background on Overview AROC FIM & AN-SNAP Rehabilitation outcome measures Profile of stroke rehabilitation episodes Stroke outcomes over five years stroke AN-SNAP classes sector (public v private) body involvement (left v right)

Background on the Australasian Rehabilitation Outcomes Centre (AROC)

What is AROC? AROC is a joint initiative of the Australian rehabilitation sector (providers, payers, regulators and consumers) The Australasian Faculty of Rehabilitation Medicine (AFRM) is the auspice body and data custodian The Centre for Health Service Development (CHSD is the data manager and responsible for everyday running of AROC AROC commenced 1 July 2002

AROC has five roles... 1. A national data bureau that receives and manages data on the performance of rehabilitation services in Australia. 2. The national benchmarking centre for medical rehabilitation.

3. The national certification centre for the Functional Independence Measures (FIM). 4. An education and training centre for the FIM and other rehabilitation outcome measures. 5. A research and development centre that develops research and development proposals and seeks external funding for its research agenda.

Background on the unctional Independence Measure and the AN-SNAP classification

unctional Independence Measure (FIM Adopted by the AFRM as the standard national measure of function functional status and outcomes in overnight setting functional status only in ambulatory setting Composed of 18 items 13 form the FIM motor sub-scale 5 form the FIM cognition sub-scale FIM is measured at both episode begin and episode end FIM scores range from 18 to 126 the higher the FIM score the greater the functionality of the patien

FIM motor sub-scale 13 items Eating Grooming Bathing Dressing Upper Body Dressing Lower Body Toileting Bladder Management Bowel Management Transfer - Bed/chair/wheelchair Transfer toilet Transfer tub/shower Walk/Wheelchair Stairs

FIM cognition sub-scale 5 items Comprehension Expression Social interaction Problem solving Memory

Scoring the FIM NO HELPER Score of 7 - Complete Independence Score of 6 - Modified Independence HELPER Score of 5 - Supervision or setup Score of 4 - Minimal assistance Score of 3 - Moderate assistance Score of 2 - Maximal assistance Score of 1 - Total assistance

What is AN-SNAP? AN-SNAP stands for: Australian National Sub-Acute and Non-Acute Patient Casemix Classification Similar to DRG used in acute care

Stroke AN-SNAP classes Stroke impairment group + 204 Admission FIM motor score 63-91 + Admission FIM cognition score 20-35 205 Admission FIM motor score 63-91 + Admission FIM cognition score 5-19 206 Admission FIM motor score 47-62 207 Admission FIM motor score 14-46 + aged >= 75 years 208 Admission FIM motor score 14-46 + aged < 75 years

Background on rehabilitation outcome measures

Definition of rehabilitation Provided in a specialist rehabilitation unit; AND Provided by a multidisciplinary team under the clinical management of a consultant in rehabilitation medicine or equivalent; AND Provided for a person with an impairment and a disability and for whom there is reasonable expectation of functional gain; AND For whom the primary treatment goal is improvement in functional status

Rehabilitation Outcome Measures SHORT HIGH HIGH HIGH Length of stay (LOS) FIM change change in functional status per episode FIM end score minus FIM begin score FIM efficiency change in functional status per day FIM change / LOS Discharge destination proportion going home (private residence)

AROC data This presentation uses the established AROC data set, specifically focusing on all overnight episodes in the five years from 2000 to 2004 Version 2 data set implemented July 1 st 2004 data set available at www.uow.edu.au/commerce/aroc Episodes were grouped into quarters, creating 20 time periods based on episode end date's year and quarter

12,000 10,000 Overnight episodes of rehabilitation by sector January 2000 to December 2004 Number of episodes 8,000 6,000 4,000 2,000 0 2000-Q1 2000-Q2 2000-Q3 2000-Q4 2001-Q1 2001-Q2 2001-Q3 2001-Q4 2002-Q1 2002-Q2 2002-Q3 2002-Q4 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 Quarter Total episodes Private Public 2004-Q4

Frequency of impairments Ortho 43.4 Stroke 12.8 Debility 10.3 Other 7.1 Cardiac 4.9 Neuro 4.7 4,500 18 Impairment group Pain Brain Amputee Pulmonary Spine Arthritits 3.6 3.4 2.7 2.7 2.2 1.1 Number of episodes 4,000 3,500 3,000 2,500 2,000 1,500 1,000 16 14 12 10 8 6 4 Percentage MultTrauma 0.9 500 2 Burns Developmental Congenital 0.1 0.0 0.0 0 2000 2001 2002 2003 2004 Stroke Year %Total 0 0 5 10 15 20 25 30 35 40 45 50 Percentage

STROKE vernight rehabilitation episodes Profile and Outcomes

Data criteria for inclusion Inpatient overnight admissions for stroke Episode end date is between 1 January 2000 and 31 December 2004 Episode has valid FIM scores and a valid LOS AN-SNAP class has been assigned to episode

AROC data - overnight episodes Episodes in AROC database about 200,000 Episodes between 2000 to 2004 = 143,926 Valid stroke episodes (2000-2004) = 16,555

1400 1200 Overnight Stroke Rehabilitation Episodes by sector, January 2000 to December 2004 Number of Episodes 1000 800 600 400 200 0 2000-Q1 2000-Q2 2000-Q3 2000-Q4 2001-Q1 2001-Q2 2001-Q3 2001-Q4 2002-Q1 2002-Q2 2002-Q3 2002-Q4 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 2004-Q4 Quarter All Stroke Private Public

Profile of stroke episodes - by year - All Calendar year strokes 2000 2001 2002 2003 2004 Episodes 16,555 2,314 2,849 3,558 3,801 4,033 Female (%) 48.8 48.4 49.0 48.1 49.1 49.1 Age (mean) 73.7 72.4 73.4 73.6 74.2 74.2 Onset < 28 days* (%) 83.6 90.8 89.1 83.9 79.1 82.2 Initial rehabilitation** (%) 96.0 96.8 97.6 97.4 94.8 94.6 Admission FIM score (mean) 77.4 76.8 77.1 76.8 77.3 78.4 Admitted from private residence (%) 94.5 94.1 94.3 94.3 93.9 95.5 The profile of stroke patients has not changed greatly over the last five years, however there does appear to have been a sight increase in age * %Episodes with onset reported has increased (8.9% in 2000-22.3% in 2004); Onset is reported less in the public sector ** %Episodes with initial rehabilitation reported is very low, increasing from 0.5% in 2000 to 1.5% in 2004

Profile of stroke episodes - by class - AN-SNAP class 204 205 206 207 208 Episodes 5,056 482 4,536 3,745 2,736 Female (%) 46.6 41.8 50.0 56.6 41.1 Age (mean) 71.8 71.4 75.1 82.4 63.0 Onset < 28 days* (%) 87.2 80.6 86.6 79.4 72.8 Initial rehabilitation** (%) 97.0 98.0 95.7 93.8 96.6 Admission FIM score (mean) 104.9 88.2 81.1 52.5 52.5 Admitted from private residence (%) 96.7 94.8 94.5 90.7 95.4 As the severity of the stroke increases there appears to be a decline in the proportion admitted from a private residence, otherwise there are no patterns between the AN-SNAP classes in the profile of stroke patients * %Episodes with onset reported has increased (8.9% in 2000-22.3% in 2004); Onset is reported less in the public sector ** %Episodes with initial rehabilitation reported is very low, increasing from 0.5% in 2000 to 1.5% in 2004

Profile of stroke episodes by sector and body involvemen Body involvement Sector Left Right Public Private Episodes 6,888 5,942 11,268 5,287 Female (%) 48.6 47.5 47.9 50.5 Age (mean) 73.6 73.2 72.1 76.9 Onset < 28 days* (%) 83.3 85.1 76.2 86.8 Initial rehabilitation** (%) 95.6 96.7 97.8 95.5 Admission FIM score (mean) 76.6 74.7 75.7 80.9 Admitted from private residence (%) 94.6 94.3 94.0 95.5 There is no difference between left/right body involvement Episodes from the public sector were typically younger, had a lower admission FIM and a greater time since onset * %Episodes with onset reported has increased (8.9% in 2000-22.3% in 2004); Onset is reported less in the public sector ** %Episodes with initial rehabilitation reported is very low, increasing from 0.5% in 2000 to 1.5% in 2004

Stroke Outcomes 2000 to 2004 Outcomes measured: FIM change Length of stay FIM efficiency Discharge destination Measured for: All stroke episodes Stroke episodes by AN-SNAP class sector body involvement

25 Change in FIM score (episode begin to end) 20 FIM change 15 10 5 0 2000-Q1 2000-Q2 2000-Q3 2000-Q4 2001-Q1 2001-Q2 2001-Q3 2001-Q4 2002-Q1 2002-Q2 2002-Q3 Quarter Between 2000 and 2004 FIM Change has increased 2 points 2002-Q4 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 2004-Q4

35 Change in Length of Stay 30 25 LOS 20 15 10 5 0 2000-Q1 2000-Q2 2000-Q3 2000-Q4 2001-Q1 2001-Q2 2001-Q3 2001-Q4 2002-Q1 2002-Q2 2002-Q3 Quarter 2002-Q4 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 2004-Q4 Length of stay has not changed (27.2 days)

1.2 Change in FIM efficiency 1.0 FIM efficiency 0.8 0.6 0.4 0.2 0.0 2000-Q1 2000-Q2 2000-Q3 2000-Q4 2001-Q1 2001-Q2 2001-Q3 2001-Q4 2002-Q1 2002-Q2 2002-Q3 Quarter 2002-Q4 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 2004-Q4 FIM efficiency has increased 0.19 points/day

100% Discharge destination (private residence) 90% 80% 70% Percentage 60% 50% 40% 30% 20% 10% 0% 2000-Q2 2000-Q3 2000-Q4 2001-Q1 2001-Q2 2001-Q3 2001-Q4 2002-Q1 2002-Q2 2002-Q3 2002-Q4 Quarter Proportion discharged to a private residence remained unchanged at 83.5% 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 2004-Q4

40 Change in FIM score by AN-SNAP class (episode begin to end) 35 30 FIM change 25 20 15 10 5 0 2000-Q1 2000-Q2 2000-Q3 2000-Q4 2001-Q1 2001-Q2 2001-Q3 2001-Q4 2002-Q1 204 205 206 207 208 2002-Q2 2002-Q3 Quarter 2002-Q4 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 2004-Q4

Summary of FIM change - by class The severest strokes (lowest admission FIM), had the greatest functional gain as expected ceiling effect of the FIM score (maximum is 126) Over the five years the greatest increase in FIM change was 2.8 points in class 207, followed by 1.6 points in class 206

60 Change in Length of Stay by AN-SNAP class 50 40 LOS 30 20 10 0 2000-Q1 2000-Q2 2000-Q3 2000-Q4 2001-Q1 2001-Q2 2001-Q3 2001-Q4 2002-Q1 204 205 206 207 208 2002-Q2 2002-Q3 Quarter 2002-Q4 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 2004-Q4

Summary of LOS - by class Length of stay increased with severity of stroke as expected. The greatest change in LOS was an increase of 3.3 days in class 207 and a decrease of 1.9 days in class 206 There was no change in the other classes.

2.5 Change in FIM efficiency by AN-SNAP class 2.0 FIM efficiency 1.5 1.0 0.5 0.0 2000-Q1 2000-Q2 2000-Q3 2000-Q4 2001-Q1 2001-Q2 2001-Q3 2001-Q4 2002-Q1 204 205 206 207 208 2002-Q2 2002-Q3 Quarter 2002-Q4 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 2004-Q4

Summary of FIM efficiency - by class Overall, class 206 had the highest FIM efficiency. Between 2000 and 2004 classes 206 and 207 had the greatest change in FIM efficiency (0.20 and 0.14 points per day, respectively)

35 Change in FIM score by sector (episode begin to end) 30 25 FIM change 20 15 10 5 0 2000-Q1 2000-Q2 2000-Q3 Public 2000-Q4 2001-Q1 Private 2001-Q2 2001-Q3 2001-Q4 2002-Q1 2002-Q2 2002-Q3 2002-Q4 Quarter 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 2004-Q4

40 Change in Length of Stay by sector 35 30 25 LOS 20 15 10 5 0 2000-Q1 2000-Q2 2000-Q3 Public 2000-Q4 2001-Q1 Private 2001-Q2 2001-Q3 2001-Q4 2002-Q1 2002-Q2 2002-Q3 Quarter 2002-Q4 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 2004-Q4

1.8 1.6 Change in FIM efficency by sector 1.4 1.2 FIM efficiency 1.0 0.8 0.6 0.4 0.2 0.0 2000-Q1 2000-Q2 2000-Q3 Public 2000-Q4 2001-Q1 Private 2001-Q2 2001-Q3 2001-Q4 2002-Q1 2002-Q2 2002-Q3 Quarter 2002-Q4 2003-Q1 2003-Q2 2003-Q3 2003-Q4 2004-Q1 2004-Q2 2004-Q3 2004-Q4

Summary of outcomes - by sector No difference in FIM change was found between the sectors, however the public sector had a significantly higher length of stay, resulting in a lower FIM efficiency

Summary of outcomes - by sector LOS initially increased in the public sector, the last 18 months saw LOS declined to 27.7 days. LOS in the private sector varied by a day or two either side of 27 days. FIM efficiency between 2000 and 2004 has increased slightly in the public sector, however it appears to be declining in the private sector.

In summary...

Stroke outcomes - key findings FIM change has increased 2 points driven by AN-SNAP class 207 (2.8 points) LOS has not changed AN-SNAP class 206 declined 2 days AN-SNAP class 207 increased 3 days FIM efficiency has improved 0.19 points / day AN-SNAP class 206 improved at a greater rate improvement is driven by the public sector

Strengths of AROC data Volume of data available Consistency of data collected AROC version 2 data set Training in the use of the FIM

Weaknesses of AROC data Not all facilities collect every data item in the version 2 data set - leading to missing data For stroke research need better reporting of time to onset first admission discharge destination

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