Prospective Interventions to Reduce Stroke Care Variation in a Hub-and-Spokes System.

Background: Care variation reduction (CVR) is a central objective of quality management to decrease wasted spending.

Objective: To analyze stroke care variation at a hub-and-spokes system and determine interventions to prospectively reduce unwarranted variation.

Methods: In this prospective cohort single arm intervention study providers were blinded to pre-specified endpoints. Care variation was measured for DRGs 61-66 and 69 in USD, and severity level by Case Mix Index (CMI) by provider. A multi-disciplinary task force chaired by Vascular Neurologist analyzed data extracted from Crimson, a patient centric data analysis tool, and determined interventions. The primary measure outcome was change in CMI post intervention.

Results: Annualized baseline care variation was $ 0.7-1.2M (2017) in a drip-and-ship thrombolytic treatment model within the hub-and-spokes system. Pharmacy expenses contributed to 42% of variation followed by laboratory 12%, physical therapy 11%, supplies 11% and imaging 9%. Interventions to achieve CVR were prospectively implemented in 2018 and CVR was measured in January 2019. Based on 2017 CMI of 1.28, the goal of intervention was set to achieve 7% increase to 1.37 with projected increased revenue of $774,144. After implementation of interventions the actual achieved average CMI in 2018 was 1.40 paralleled by improvement in secondary outcomes of length of stay, observed over expected mortality and re-admission.

Conclusions: A drip-and-ship stroke model within a single hub-and-spokes healthcare system can achieve substantial reduction in care variation and associated cost along with improvement in patient care indicators.