Needs Assessment of Stroke Services in Ontario, Canada

Abstract

A needs assessment of stroke patients in Ontario, Canada, by the Queen’s Health Policy Research Unit requires an analysis of risk factors related to stroke, treatments and interventions appropriate for those risk factors, availability and provision of relevant interventions, and estimated need for relevant interventions. This paper highlights appropriate resources, including the Center for Disease Control’s International Classification of Diseases, Ninth Edition (ICD-9), which details risk factors related to specific diseases. Additionally, resources on relevant Ontario statistics necessary to carry out the analysis are detailed, which include: the Canadian Community Health Survey 2011/2012, published by the Canadian government’s Statistics Canada (2013); the Institute for Clinical Evaluative Sciences’ Ontario Stroke Evaluation Report 2013; Statistics Canada’s Vital Statistics Death Database (2013); and a Health Analyst’s Toolkit (2012) published by the Ontario Ministry of Health and Long-Term Care. When analyzing available data for hypercholesterolemia patients, 50.4% of patients requiring dietary treatment have unmet needs and 65% of patients requiring pharmacological treatment are left untreated. There are likewise very high instances of interventions needed, but not available, for acute stroke survivors and chronic stroke patients with disabilities. Patient unmet intervention needs include: 82% of thrombolytics, 70.0% of CT scans, 22.2% of MRIs, 87.2% of necessary non-invasive vessel imaging, 28.3% of similar invasive vessel imaging, 17.6% of rehabilitation needs for acute stroke victims, and 48.3% of home care service chronic stroke victims with disabilities was needed and not provided.

Needs Assessment for Stroke Services in Ontario, Canada

An assessment of stroke services in Ontario, Canada, by the Queen’s Health Policy Research Unit (QHPRU) compares health care services needed by stroke patients with those services that are currently available. This determination exposes any disparities in service availability for stroke patients in Ontario. To establish reasonable figures related to stroke patient needs, QHPRU analyzed estimates of patients in the region for stroke risk factors, acute stroke cases, and complications caused by stroke. They then compared these numbers with treatment services available to evaluate whether patient needs can be met with the services currently available.

Risk Factor Resources

In order to assess patient needs in Ontario, an accurate risk assessment must take place. This involves using measurements of risk factors from reliable and accurate sources. Choosing an appropriate source material determines whether or not the case study is reliable and meaningful. In assessing sources, a determination of those that will provide complete and reliable numbers must be effectuated. An analysis of what resources have the ability and the incentive to perform thorough and unbiased assessments should take place. Government agencies and well-respected non-profit organizations are often good resources for health statistics, so long as they follow generally accepted methods for surveying and measuring data.

Risk factors measured need to include: heavy alcohol consumption, atrial fibrillation, diabetes, hypercholesterolemia, hypertension, obesity, low physical activity, smoking, ischemic heart disease, and transient ischemic attack. The International Classification of Diseases, Ninth Edition (ICD-9), which can be found on the Center for Disease Control’s website, is the gold standard for classifying diseases and related risk factors. The Canadian government performs an annual survey titled The Canadian Community Health Survey that provides health-related information by geographical region. The survey includes information by province and territory for heavy drinking, diabetes, high blood pressure, physical activity during leisure time, smoking population, and chronic obstructive pulmonary disease. Additionally, the Canadian government puts out several other health-related reports, such as the Canadian Health Measures Survey. The Ontario Stroke Evaluation Report 2013: Spotlight on Stroke Prevention and Care, published by The Institute for Clinical Evaluative Sciences, fills in gaps in administrative information available on stroke risk factors, including atrial fibrillation and transient ischemic attack as well as discusses methods for stroke prevention. Additional resources include: the Public Health Agency of Canada’s database called the Chronic Disease Infobase, allowing researchers to sort health information by region, gender, age group, and disease. This resource is user-friendly and provides reliable information that can be easily accessed. The Health Analyst’s Toolkit—put out by the Ontario Ministry of Health and Long-Term Care—can help a consultant or analyst understand the resources available and how to utilize them effectively and accurately.

Effective Intervention Availability for Hypercholesterolemia Patients

For hypercholesterolemia patients, Table 4.3 (Fleming, 2008), Interventions for Hypercholesterolemia, recommends three separate interventions appropriate for specific proportions of high-risk individuals. A Nonpharmacologic Fasting Lipoprotein analysis is indicated for everyone with the risk factor or 95% of at-risk individuals with indications. The Nonpharmacologic Dietary Intervention is appropriate for those with a high LDL cholesterol level and the presence of one cardiovascular risk factor, which is equivalent to about 75% of at-risk patients. And, finally, all of those with high LDL cholesterol levels require the pharmacological treatment in addition to the diet and those with only moderate improvement after 6 months or more on the diet are indicated for pharmacologic intervention. Both together total about 25% of at-risk individuals.

Appropriate Patients for Acute Stroke Interventions

Experts recommend specific acute stroke services for proportions of the population of acute stroke patients (not including those who die en route to the hospital): hospitalization for 85%)—leaving 15% nonhospitalized. Of the same population, 10% of those hospitalized needed thrombolytic therapy. Physicians ordered imaging of the brain in the form of CT scans for 98% of the population measured (including the non-hospitalized) and MRIs for 9% of that wider population. 98% of patients—including both the hospitalized and nonhospitalized populations—required imaging of the vessels in a noninvasive manner, while 7% required invasive imaging. Only 5% of the applicable patient population required carotid endarterectomy and 50% of the surviving acute stroke cases needed rehabilitation. This list includes only those acute stroke patients who survived post-stroke. (Fleming, 2008)

Fasting Lipoprotein Analysis and Dietary and Pharmacologic Interventions for Percent of Population Likely to Have Hypercholesterolemia

According to the relevant estimates, 177,500 people in Eastern Ontario have hypercholesterolemia (including 42,000 in the 25-44-year-old range, 75,500 in the 45-64-year-old range, and 59,000 in the 65+ range). Using that figure, 168,625 need fasting lipoprotein analysis; 133, 125 require non-pharmacologic dietary intervention; and 44,375 should receive a pharmacologic intervention. (Fleming, 2008 )

Unmet Need for Recommended Hypercholesterolemia Treatments (both Dietary and Pharmacological)

If Eastern Ontario provides only 66,000 patients with hypercholesterolemia with dietary intervention, then 67,125 of patients with hypercholesterolemia require but are not receiving, a dietary intervention for their condition. 50.4% of those who need dietary intervention are not having those needs met. Similarly, if only 15,500 patients with hypercholesterolemia in Eastern Ontario are receiving a pharmacologic intervention, then there are 28,875 patients—equal to 65% of the patients requiring treatment—left untreated (which equals needs not being met). (Fleming, 2008)

Acute and Chronic Stroke Patient Services Need versus Availability

3,500 patients qualify as acute stroke cases, though the number must be adjusted for the 100 patients who were DOA, leaving 3,400 acute stroke cases requiring acute stroke services. Using 3,400 as the total population, 10%—or 340—did not need hospitalization and doctors admitted 85%—or 2890—to the hospital. Physicians determined 10% of acute stroke survivors admitted to the hospital required thrombolytic therapy, or 289 patients requiring thrombolytics. Out of the surviving acute stroke patients, 98% required a CT scan, while only 9% required an MRI. So, patients received 3332 CT scans and 306 MRIs. Imaging of the vessels broke down similarly, with non-invasive imaging of the vessels carried out on 98%, or 3332, of the survivors, and invasive imaging performed on 7%, or 238, of the survivors. Only 5%. or 170, of the 3,400 patients required carotid endarterectomy. Finally, half, or 1700, of the acute stroke survivors required rehabilitation. (Fleming, 2008, p. ). 100% of the 4,300 chronic stroke patients, equaling 4,300 patients in total, require assistance in performing activities of daily living. (Fleming, 2008, p. )

Availability of Specific Acute and Chronic Stroke Patient Treatments versus Need

If Eastern Ontario provides thrombolytics to only 50 acute stroke survivors, then of the estimated 289 necessary interventions, patients needed and did not receive 239 necessary interventions. In contrast, the number of carotid endarterectomies performed outpaced the estimated need by 30, with 200 actually performed versus an estimate of 170. This might indicate an overperformance of the procedure in the relevant region. Of the estimated 3332 CT scans, doctors ordered only 1000, leaving 2332 patients without the necessary treatment; and of the anticipated 306 MRIs, only 238 were performed, so 68 patients went without. With respect to vessel imaging, physicians ordered non-invasive imaging for only 425 patients of the 3332 who needed it, leaving a shortfall of 2907. Of the 237 estimated invasive procedures, 170 were performed, leaving 67 acute stroke survivors without the appropriate treatment. 1700 acute stroke victims required rehabilitation, but only 1400 received it. 300 acute stroke victims needed and did not receive rehabilitation. If 4300 chronic stroke victims with disabilities actually required homecare services and only 1400 received it, then 2900 chronic stroke patients with disabilities were left without at-home assistance.

In terms of percent of need not being met in Eastern Ontario, 82% of the patient thrombolytics need is not being met, while endarterectomies seem to be oversupplied at 117%—suggesting a possible surplus or overmet need. A 70.0% need for CT scans is not being met, along with a 22.2% need for MRIs. 87.2% of patients needed and did not receive non-invasive vessel imaging, while there was a 28.3% shortfall in the provision of invasive vessel imaging to those who needed it. Out of the 1700 survivors projected to require rehabilitation, Eastern Ontario did not meet 17.6% of the need. Finally, 48.3% of home care service needs for chronic stroke victims with disabilities were not met. (Fleming, 2008 )

These figures all presume that the procedures and interventions actually performed were performed on patients who fall within the estimated population of patients who need the procedures or interventions. If they were actually performed on patients falling outside the estimated population, these figures will not accurately reflect expected versus actual results.

References

CDC/National Center for Health Statistics. (1999). International classification of diseases, Ninth Revision (ICD-9). Washington, DC: U.S. Government Printing Office. Retrieved from ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/ICD-9

Fleming, S. (2008). Managerial epidemiology: Concepts and cases. Health Administration Press.

Hall, R., Khan, F., O’Callaghan, C., Capral, M. K., Hodwitz, K., Kapila, S., Li, S., … Bayley, M. (2013). Ontario stroke evaluation report 2013: Spotlight on secondary stroke prevention and care. Toronto: Institute for Clinical Evaluative Sciences. Retrieved from http://www.ices.on.ca/flip-publication/stroke-report-2013/stroke-report-2013.html#/1/

Ontario Ministry of Health and Long-Term Care. (2012). Health analyst’s toolkit. Ottawa, ON, Canada: Health System Information Management and Investment Division, Health Analytics Branch, February 2012. Retrieved from http://www.health.gov.on.ca/english/providers/pub/healthanalytics/health_toolkit/health_toolkit.pdf

Statistics Canada. (2013). Canadian community health survey 2011/2012. Retrieved from http://www.statcan.gc.ca/daily-quotidien/130621/dq130621d-eng.pdf