Introduction: High reliability and bundling initiatives focus on reducing unnecessary practice variation to improve the value of care. It is uncertain whether models that address provider variability for elective procedures can be translated to analyze team-based care of patients with acute stroke.
Methods: All stroke discharges from 2015 at University Hospitals- Case Medical Center were analyzed for clinical and quality data from the GWTG PMT, including admission stroke severity scores, and reconciled with EPSi™ financial data. Tableau was used for statistical analysis.
Results: Variation by provider for the 6 Stroke faculty for DRGs 61-69 ranged from average LOS 2.3-5.6 days and total margin $257,301 to ($51,846). However, the provider-defined as Attending at Discharge- represented the key decision-maker in < 50% of cases (mean 103, range 16-176) due to service rotations of 2-18 wks/year. Variation in total cost/case was driven by Room & Board and LOS- especially ICU LOS- more than pharmacy, radiology or lab costs. Variation by admission stroke severity score tracked with patient outcome at discharge. The lowest variation in LOS and total cost was observed for patient groups: NIHSS 0-3, 4-6, ICH Score 4, 5, and Hunt & Hess Score 5 and was significantly related to either rapid recovery or early mortality. The greatest variation in direct cost per case, LOS and ICU LOS was seen for NIHSS 21+, 16-20, ICH Score 2, 3, and Hunt & Hess Score 1, 2. Patients with severe ischemic stroke NIHSS 21+ had the highest utilization of pharmacy and radiology resources.
Conclusions: Admission stroke severity is a major driver of clinical variation in the cost of care, resource utilization and length of stay for patients with acute stroke. Using stroke severity scores to guide data analysis showcases opportunities for new clinical practice guidelines and care paths. Provider variability data is only reliable when is the attributed provider was the key decision maker in the patient’s care.