Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention A clinical and resource impact assessment May 2009 © NHS Quality Improvement Scotland 2009 NHS Quality Improvement Scotland (NHS QIS) consents to the photocopying, electronic reproduction by ‘uploading’ or ‘downloading’ from the website, retransmission, or other copying of this report for the purpose of implementation in NHSScotland and educational and ‘not-for-profit’ purposes. No reproduction by or for commercial organisations is permitted without the express written permission of NHS QIS. CONTENTS 1 EXECUTIVE SUMMARY ......................................................................................... 1 2 INTRODUCTION...................................................................................................... 8 2.1 Objective ........................................................................................................... 8 2.2 Key recommendations ...................................................................................... 8 2.3 Document overview ........................................................................................ 10 3 BACKGROUND AND METHODOLOGY............................................................... 12 3.1 Introduction ..................................................................................................... 12 3.2 Methodology to estimate clinical benefit ......................................................... 12 3.3 Methodology to estimate resources required/associated costs and savings... 13 3.4 Methodology to estimate cost of resources and associated savings............... 14 3.5 Limitations....................................................................................................... 18 4 SCOTTISH STROKE EPIDEMIOLOGY ................................................................ 19 4.1 Introduction ..................................................................................................... 19 4.2 Incidence of a first hospital admission as a result of stroke or TIA.................. 19 5 TIMELY THROMBOLYSIS .................................................................................... 25 5.1 Background..................................................................................................... 25 5.2 Patient group................................................................................................... 25 5.3 Clinical benefit and associated resource savings............................................ 25 5.4 Resource requirements................................................................................... 26 5.5 Costs............................................................................................................... 28 5.6 Sensitivity analysis.......................................................................................... 28 5.7 Analyses by NHS board .................................................................................. 29 6 TIMELY CAROTID IMAGING AND CAROTID ENDARTERECTOMY.................. 34 Background..................................................................................................... 34 6.1 6.2 Patient group................................................................................................... 34 6.3 Clinical benefit and associated resource savings........................................... 35 6.4 Resource requirements................................................................................... 36 6.5 Costs............................................................................................................... 36 6.6 Sensitivity analysis.......................................................................................... 36 6.7 Analyses by NHS board .................................................................................. 37 7 TIMELY CT DIAGNOSTICS ................................................................................. 41 7.1 Background..................................................................................................... 41 7.2 Patient group................................................................................................... 42 7.3 Clinical benefits............................................................................................... 42 7.4 Resources....................................................................................................... 42 7.5 Costs............................................................................................................... 44 7.6 Sensitivity analysis.......................................................................................... 44 8 9 REFERENCES....................................................................................................... 45 APPENDICES........................................................................................................ 47 Appendix 1 Key recommendations .................................................................. 47 Appendix 2 Acknowledgements ....................................................................... 49 Appendix 3 Resource impact assessment process.......................................... 50 Appendix 4.1 ICD-10 codes for stroke or TIA...................................................... 51 Appendix 4.2 ICD-10 codes for other cerebrovascular diseases ........................ 52 Appendix 5.1 Incidence of first ever hospital admission for stroke and TIA for year ending 31 March 2007 .......................................................... 53 Appendix 5.2 Survival rates for stroke and TIA after a first ever hospital admission for year ending 31 March 2007 .................................... 54 Appendix 5.3 Re-admission rates for stroke and TIA after a first ever hospital admission for year ending 31 March 2007 .................................... 55 Appendix 5.4 Prior admission of patients who had a first ever admittance for stroke or TIA for year ending 31 March 2007................................ 56 Appendix 5.5 Incidence of stroke and TIA resulting in a first ever hospital admission by NHS board for year ending 31 March 2007............. 57 Appendix 5.6 Predicted mortality for patients with first admission of ischaemic stroke for year ending 31 March 2007........................................... 58 Appendix 5.7 Predicted mortality and disability for patients with first admission of ischaemic stroke for year ending 31 March 2007.......................... 59 Appendix 6.1 Estimated first hospital admissions for stroke or TIA..................... 60 Appendix 6.2 Estimated survival rates for patients following a first admission to hospital for stroke or TIA ............................................................... 61 Appendix 6.3 Estimated re-admission rates for patients following a first admission to hospital for stroke or TIA .......................................... 62 Appendix 6.4 Estimated prior admission rates for patients later admitted for stroke or TIA for the first time ........................................................ 63 Appendix 6.5 Estimated admission rates for patients who have attended a neurovascular outpatient clinic ...................................................... 64 Appendix 7.1 Costs for the Scottish Ambulance Service .................................... 65 Appendix 7.2 Costs for attendance at an A&E department................................. 66 Appendix 7.3 Costs per event for CT, MRI and ultrasound diagnostics .............. 67 Appendix 7.4 Costs for a stroke consultant outpatient attendance ..................... 68 Appendix 7.5 Costs for a consultant vascular surgeon outpatient attendance.... 69 Appendix 7.6 Mean variable cost per day (excluding overheads and theatre costs) in a surgical ward................................................................ 70 Appendix 7.7 Mean variable cost per day (excluding overheads and theatre costs) in a general medical ward................................................... 71 Appendix 7.8 Costs per hour for theatre time inclusive of overheads, staff costs and consumables .......................................................................... 72 Appendix 7.9 Costs by function in NHS Greater Glasgow and Clyde ................. 73 LIST OF TABLES Table 1-1 Clinical benefits measured as the number of bed days saved ................... 4 Table 1-2 Additional costs required to implement key recommendations ................. 6 Table 1-3 Total budgetary impact for Scotland and NHS board ................................ 7 Table 3-1 Table 3-2 Table 3-3 Gross salary costs for non-consulting staff ............................................. 15 Gross salary costs for consulting staff .................................................... 15 Consolidated surgical costs for carotid endarterectomy .......................... 17 Table 4-1 Table 4-2 Table 4-3 Table 4-4 Re-admission rates .................................................................................. 21 Annual re-admission rates estimated from first ever hospital admissions 21 Classification of the subtypes of cerebral infarcts .................................... 22 Extending OCSP model of infarction subtypes to population age groups 23 Table 5-1 Table 5-2 Table 5-3 Table 5-4 Table 5-5 Table 5-6 Table 5-7 Table 5-8 Clinical benefits of additional thrombolytic therapy .................................. 26 Additional costs to deliver thrombolytic therapy ....................................... 28 Additional costs if patients not directed to hospitals with CT scanners .... 29 Additional costs to deliver thrombolytic therapy ....................................... 29 Anticipated patients by NHS board .......................................................... 30 Additional benefit from timely thrombolysis by NHS board ...................... 31 Additional costs from timely thrombolysis by NHS board......................... 32 Sensitivity analysis: SAS unable to deliver patients to specified.............. 33 Table 6-1 Table 6-2 Table 6-3 Table 6-4 Table 6-5 Calculation to estimate number of patients eligible for surgery................ 35 Patients who are potential candidates for carotid endarterectomy........... 38 Estimated clinical benefit from timely carotid endarterectomy ................. 39 Estimated additional cost to achieve timely carotid endarterectomy........ 39 Sensitivity analyses of higher costs incurred if carotid Doppler required . 40 Table 7-1 Table 7-2 Table 7-3 Patient groups requiring CT scanning facilities ........................................ 42 Operational CT scanning hours per week in Scottish hospitals ............... 43 Costs to provide capacity to scan 24,300 people with stroke symptoms . 44 1 EXECUTIVE SUMMARY In their recent report, Reducing Brain Damage: Faster access to better stroke care1, the National Audit Office stated that in England and Wales, stroke costs the NHS and the economy approximately £7 billion a year. Of this sum, £2.8 billion is estimated to be in direct costs to the NHS, £2.4 billion of informal care costs borne by the patients’ family and other carers, with a further £1.8 billion being lost productivity and disability income for those under the age of 65 who are unable to work as a result of their condition. Translating these numbers to Scotland suggests that the cost to the Scottish economy as a result of stroke is in the region of some £700 million. Whilst stroke is primarily associated with age and ageing, it is important to note that the number of patients under the age of 65 who are being admitted to Scottish hospitals due to stroke is increasing. This group now represents 26.5% of all stroke admissions; up 32.5% from the 20.0% of admissions reported in 2000 as part of the Scottish Borders Stroke Study2. Moreover, while the reported incidence of stroke has decreased marginally over the last 10 years, this trend may not continue because of the population demographics. In the next 10 years, one of the largest population deciles, the 55–65 age group, or the ‘baby boomers’, will progressively move into the next of the higher risk stroke age groups. The objective of this clinical and resource impact assessment is to facilitate more rapid implementation of the key recommendations in SIGN Guideline 108 Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention3. The report provides each NHS board with an estimate of the resources and costs required to implement the key recommendations, together with the associated clinical benefits, including potential cost savings. The guideline development group judged 15 recommendations to be clinically very important and should be prioritised for implementation. Following discussion with members of the group it was agreed that eight recommendations would not change current practice and therefore would not have a material impact on current resource use. These have been excluded from further analysis. A short explanation of each recommendation including commentary for those that have been excluded is provided in Appendix 1. Seven recommendations were judged to be clinically important and to require significant resources on implementation. The associated clinical benefits, resources and costs to implement these key recommendations are estimated in this report. These have been grouped into two headings; timely thrombolysis and timely carotid imaging and carotid endarterectomy. Implementing these two interventions are the key challenges for NHS boards. The individual recommendations for each intervention are: 1 Recommendations for timely thrombolysis • Emergency medical services should be redesigned to facilitate rapid access to specialist stroke services. • Stroke patients requiring admission to hospital should be admitted to a stroke unit staffed by a co-ordinated multidisciplinary team with a special interest in stroke care. • All patients with suspected stroke should have brain imaging immediately on presentation. • Patients admitted with stroke within 4.5 hours of definite onset of symptoms, who are considered suitable, should be treated with 0.9 mg/kg (up to maximum 90 mg) intravenous recombinant tissue plasminogen activator (rt-PA). Recommendations for timely carotid imaging and carotid endarterectomy • All patients with non-disabling acute stroke syndrome/transient ischaemic attack (TIA) in the carotid territory who are potential candidates for carotid surgery should have carotid imaging. • All patients with carotid artery territory stroke (without severe disability, modified Rankin Scale [mRS] ≤2) or TIA should be considered for carotid endarterectomy as soon as possible after the index event. • Carotid endarterectomy (on the internal carotid artery ipsilateral to the cerebrovascular event) should be considered in all: - male patients with a carotid artery stenosis of 50–99% (by NASCET method) - female patients with a carotid artery stenosis of 70–99%. • For all patients, carotid endarterectomy should be performed as soon as the patient is stable and fit for surgery, ideally within 2 weeks of the initial event. Implementing both interventions requires the use of radiological diagnostics to assist in the primary determination of specific stroke type. The analysis contained in Section 7 on timely computed tomography (CT) diagnostics suggests approximately 24,300 CT scans will be required annually for all patients with potential strokes, to include those scanned immediately after thrombolysis. The resources and costs to manage a service to deliver these are also discussed. The methodology used to develop this report adopts proven processes and principles4-7. Members of the guideline development group and other experts have provided advice and participated in peer review. The draft findings were presented to representatives from NHS Dumfries & Galloway, NHS Ayrshire & Arran, NHS Lanarkshire and NHS Greater Glasgow and Clyde. Due to time constraints, it was not possible to visit all NHS boards in Scotland. However, the remaining boards were provided with drafts of all the underlying analyses for comment and feedback. The boards visited represent the 2 varying spatial diversity of all boards, namely those that have one major hospital, two major hospitals, three major hospitals and multiple sites. The feedback from the visits has been adapted for the remaining boards. The information contained within this report at a national level represents the clinical, resource and budget impact consolidation of each of the individual mainland NHS boards, with the boards of NHS Orkney, NHS Shetland and NHS Western Isles combined into a single entity, the NHS island boards. The epidemiological variations that exist between the boards in Scotland have been taken into account in the preparation of this work through extensive epidemiological modelling covering the last 3 years. Estimated clinical benefits of implementing the key recommendations Implementing SIGN 108 is forecast to require: • 810 more patients receiving thrombolysis, compared to the current number of 205, and • 608 more patients receiving a carotid endarterectomy, and improving the timeliness of the current 552 procedures such that these are delivered within 14 days from event. Diagnosing and managing these patients will require radiology departments to provide CT scanning and other imaging services for approximately 24,300 patients per year. The clinical benefits forecast following these interventions are estimated to be: • 82 patients making a full recovery and 364 having an improved outcome following thrombolysis, and • 217 recurrent strokes avoided from timely carotid endarterectomy. The associated bed days saved are estimated at 10,611, of which 4,752 are achieved by timely thrombolysis and 5,859 from timely carotid endarterectomy. The financial benefits are estimated at £2.94 million. This is calculated by applying a weighted average variable cost for Scotland (excluding overheads) of £277 per bed day. Table 1–1 gives the benefits by NHS board for each intervention. No account has been taken of the savings that successful implementation will have in the longer term, particularly from lower rehabilitation costs. Further analysis is provided in Sections 5 and 6 of this report. 3 Table 1-1 Clinical benefits measured as the number of bed days saved Timely Timely NHS board thrombolysis carotid NHS Ayrshire & Arran 621 405 NHS Borders 153 135 NHS Dumfries & Galloway 234 189 NHS Fife 423 351 NHS Forth Valley 243 243 NHS Grampian 414 405 NHS Greater Glasgow and Clyde 801 1,809 NHS Highland 180 270 NHS Island Boards 36 54 NHS Lanarkshire 657 945 NHS Lothian 585 702 NHS Tayside 405 351 NHSScotland 4,752 5,859 Total bed Average days weighted Total saved cost savings 1,026 £193 £198,018 288 £204 £58,752 423 £323 £136,629 774 £439 £339,786 486 £176 £85,536 819 £223 £182,637 2,610 £233 £608,130 450 £410 £184,500 90 £295 £26,550 1,602 £210 £336,420 1,287 £368 £473,616 756 £415 £313,740 10,611 £277 £2,944,314 Additional staff required to implement the key recommendations Timely thrombolysis Additional staff will be required to assess, deliver and immediately manage patients receiving thrombolytic therapy. Each NHS board is assumed to require: • a band 7 specialist nurse who spends 1 hour assessing each of the 1,900 patients who may be eligible for the therapy. If the responses indicate that the patient may be eligible for the therapy then the nurse is assumed to call for a consultant. Thereafter the nurse will attend patients receiving the therapy for a further 6 hours as the drug is administered and to oversee the initial management. • consultant stroke physicians. Each NHS board is assumed to manage with no additional consultant resource during the core weekday hours. The additional workload associated with thrombolysing patients who present during core hours is assumed to displace the existing workload. However, this should reduce as the upfront investment in delivering the therapy is rewarded by having more patients with improved outcomes and consequently discharged earlier. This assumption will be particularly challenging for smaller boards where the consultant may have duties to conduct outwith the main hospital. Seven NHS boards, being those forecast to have more than 30 patients a year presenting for this therapy in the early evening, are forecast to recruit an extra 0.5 whole time equivalent (WTE) consultant each to 4 cover five planned activities per week, providing cover until 8pm. All other out of hours work is assumed to be undertaken by on-call arrangements. The total staff required is estimated to be 4.2 WTE nurses, 35 additional planned activities per week to provide consultant resource in the early evening and 760 out of hours call-outs. An analysis of the staffing required by NHS board is provided in Section 5.7. Carotid endarterectomy Delivery of a timely carotid endarterectomy service will require staff to perform an additional 608 carotid endarterectomy procedures. The additional staff required are 1.1 WTE vascular surgeons, 0.65 WTE band 5 and 0.65 WTE band 6 theatre nurses and 0.65 WTE anaesthetist. Most inpatients should be able to receive the procedure during their initial inpatient stay, whilst outpatients are assumed to be admitted for 2 nights, one before and one after the procedure. The benefits from fewer recurrent strokes will reduce the demand for bed days over time. For example, undertaking five carotid endarterectomy procedures within 14 days of the original events, will require a total of 10 bed days (2 night stay in a surgical ward as a maximum) initially but may be rewarded by preventing one recurrent stroke, saving some 27 bed days. However, there may be a timing issue for hospitals since the extra beds and associated services are needed immediately but the overall long term benefit could potentially be over 5 years8. Timely CT diagnostics The total number of staff required to provide a timely CT scanning service for patients suspected of a stroke or TIA, and their subsequent management, is estimated to be almost 740 planned activity sessions for stroke consultants to read the images and approximately six band 7 radiographers, six band 6 radiographers, six band 3 helpers and six band 2 clerical officers. Many of these staff will be in place. However, it has not been possible to identify whether any additional staff could be required. Rather, an analysis of the current service provision suggests there is sufficient capacity in the system. An estimated 3.8 WTE additional band 6 business administration managers are forecast to be required across Scotland, in the first year, to support implementation. Estimated costs required to implement the key recommendations The estimated costs of implementing the key recommendations are £3.5 million in the first year. Thereafter the £0.13 million for business support should fall, leaving additional costs to the service of around £3.4 million. 5 Table 1–2 analyses the cost by NHS board for each of the three interventions. These costs exclude any costs for additional diagnostics. Provision of an efficient CT scanning service could cost approximately £0.95 million a year. It is not possible to estimate the current costs and thus whether additional costs are required. Table 1-2 Additional costs required to implement key recommendations in SIGN 108 Timely Business Timely carotid admin Total NHS board thrombolysis endarterectomy support costs NHS Ayrshire & Arran £210,140 £33,439 £10,300 £253,879 NHS Borders £34,314 £32,707 £5,150 £72,171 NHS Dumfries & Galloway £52,696 £10,469 £5,150 £68,315 NHS Fife £179,205 £69,429 £10,300 £258,934 NHS Forth Valley £64,006 £17,460 £5,150 £86,616 NHS Grampian £297,275 £29,960 £10,300 £336,534 NHS Greater Glasgow and Clyde £294,679 £591,189 £36,049 £921,917 NHS Highland £259,096 £22,427 £5,150 £286,673 NHS Island Boards £5,133 £7,502 0 £12,635 NHS Lanarkshire £229,262 £285,210 £15,449 £529,921 NHS Lothian £217,764 £210,573 £15,449 £443,786 NHS Tayside £178,759 £67,819 £10,300 £256,878 NHSScotland £2,022,329 £1,377,185 £128,747 £3,528,260 Estimated net costs required to implement the key recommendations Comparing the total cost of implementing the guideline with a valuation based on the bed days saved is difficult to interpret. This is because reducing bed days seldom releases additional funding or staff resources; rather the beds are used to manage additional patients or non-stroke patients and staff are re-deployed elsewhere in the board. Despite that caveat, the estimated net cost (before any enhancements are made to the provision of diagnostic services) from implementing SIGN 108 is estimated at approximately £0.6 million in year one, as detailed in Table 1–3. 6 Table 1-3 Total budgetary impact for Scotland and NHS boards of SIGN 108 NHS board NHS Ayrshire & Arran NHS Borders NHS Dumfries & Galloway NHS Fife NHS Forth Valley NHS Grampian NHS Greater Glasgow and Clyde NHS Highland NHS Island Boards NHS Lanarkshire NHS Lothian NHS Tayside NHSScotland Estimated savings £198,018 £58,752 £136,629 £339,786 £85,536 £182,637 £608,130 £184,500 £26,550 £336,420 £473,616 £313,740 £2,944,314 Total costs £253,879 £72,171 £68,315 £258,934 £86,616 £337,535 £921,917 £286,673 £12,635 £529,921 £443,786 £256,878 £3,528,261 Net cost impact £55,861 £13,419 (£68,314) (£80,852) £1,080 £153,898 £313,787 £102,173 (£13,915) £193,501 (£29,830) (£56,862) £583,946 NHS board reports In support of this national report, each NHS board (with the islands combined) has received spreadsheets covering: • data from ISD on the incidence and outcome of stroke that has resulted in a hospital admission over the last 3 years, and • the assumptions, values for each key parameter and analysis used to estimate their individual cost and savings. It is hoped that these spreadsheets will provide a framework for boards to enable them to model potential solutions to the challenges presented in implementing the key recommendations in SIGN 108. 7 2 INTRODUCTION 2.1 Objective The objective of this clinical and resource impact assessment is to facilitate more rapid implementation of the key recommendations in SIGN Guideline 108 Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention3. The report provides each NHS board with an estimate of the resources and costs required to implement the recommendations, together with the associated clinical benefits. This report does not reproduce the SIGN guideline and should be read in conjunction with it. A recent Audit Commission report concluded that the lack of robust information on the resources required and associated costs including any potential savings was one of the biggest difficulties in developing plans to implement clinical guidelines9. This report aims to provide such information to support implementation of the recommendations in NHS boards. It does not attempt to cost all aspects of the current diagnosis and management of patients with stroke or transient ischaemic attack (TIA). No cost effectiveness analyses are presented within this report. 2.2 Key recommendations Timing is a central theme throughout SIGN 108. The changes in practice that are required to facilitate implementation of the key recommendations are not necessarily a marked departure from current clinical practice or the patient pathway of care within the acute setting. Rather, successful implementation requires doing the same things to a more demanding timescale. Stroke and TIA’s share common morbidity or co-morbidities with primarily, coronary heart disease, peripheral vascular disease and diabetes10, each of which in turn require the same resources, be that the Scottish Ambulance Service (SAS), radiological diagnostics or indeed theatre time. For each of the key recommendations, a synopsis of the relevant considerations that have been taken into account as part of the workflow arrangements which led to the preparation of this report is noted below. Timely thrombolysis Emergency medical services should be redesigned to facilitate rapid access to specialist stroke services (recommendation 2.1) The costings have focussed on the front line diagnostics required to determine the stroke type; a computed tomography (CT) scanner in the first instance. Adopting a protocol for SAS that enables the paramedics to recognise a potential stroke patient and to deliver the person to a hospital with a CT scanner rather than the nearest ‘place of safety’ should reduce the number of secondary transfers from non-CT scanning Accident & Emergency (A&E) departments. However, this may result in potentially 8 longer journeys in both distance and time. Under these circumstances, the use of the air ambulance service may be required as the only method of transport suitable to move patients to an appropriate place for thrombolytic therapy within the period of 4.5 hours of symptom onset. Stroke patients requiring admission to hospital should be admitted to a stroke unit staffed by a co-ordinated multidisciplinary team with a special interest in stroke care (recommendation 2.2) All of Scotland’s hospitals which have a CT scanner also have a stroke unit associated11; either as an acute receiving unit, a rehabilitation unit or a combination of both. Geographical variations between and within NHS boards means that not all hospitals are in a position to offer thrombolytic therapy or to provide surgical facilities for carotid endarterectomy. Recruiting specialist nurses to deliver timely thrombolysis is judged to be sufficient to ensure all hospitals admitting stroke patients are staffed by a co-ordinated multidisciplinary team with a special interest in stroke care. All patients with suspected stroke should have brain imaging immediately on presentation (recommendation 2.3.1) The imaging may take place following assessment at A&E or by elective attendance at a neurovascular clinic. The report has quantified the demand for CT scanning services in all settings and assessed the capacity required to meet this demand. Patients requiring assessment for timely thrombolysis would still require to be seen on an urgent basis. Patients admitted with stroke within 4.5 hours of definite onset of symptoms, who are considered suitable, should be treated with 0.9 mg/kg (up to maximum 90 mg) intravenous rt-PA (recommendation 2.4) The process of delivery of the thrombolytic agent can, depending on the weight of the particular patient, take up to 1.5 hours to be delivered. Thereafter a period of 6 hours must be allowed for patient recovery in an environment akin to either a high dependency unit or an intensive care unit and thus require dedicated specialist care. Timely carotid endarterectomy All patients with non-disabling acute stroke syndrome/TIA in the carotid territory who are potential candidates for carotid surgery should have carotid imaging (recommendation 2.3.2) All patients with carotid artery territory stroke or TIA should be considered for carotid endarterectomy as soon as possible after the index event (recommendation 2.6.1) Carotid endarterectomy (on the internal carotid artery ipsilateral to the cerebrovascular event) should be considered in all: - male patients with a carotid artery stenosis of 50–99% (by NASCET method) - female patients with a carotid artery stenosis of 70–99% 9 For all patients, carotid endarterectomy should be performed as soon as the patient is stable and fit for surgery, ideally within 2 weeks of the initial event (recommendation 2.6) Implementing these recommendations will require arrangements to be made for possible surgical intervention as soon as possible after initial symptom onset; ideally within less than 14 days for maximum potential benefit based on the number needed to treat (NNT) to avoid a single recurring stroke event. Given the tendency for this procedure to be geared towards those with mild strokes (modified Rankin Scale [mRS] ≤2) and TIA’s the provision of this service must encompass not only those who have been admitted, but also those who have had an initial referral to a neurovascular outpatient clinic. 2.3 Document overview Section 3 describes the methodology used to estimate the clinical benefit (which is expressed as a number of bed days saved with the associated weighted average variable costs [excluding overheads]), the estimate of resources required (including cost calculations for consulting and non-consulting staff) and the provisions for consumable costs, theatre operating rates per hour and the weighted average cost of the essential radiological scans. Section 4 describes the methodology adopted together with the background with regards to stroke. This involved the development of a model to predict mortality at 1 month following a first hospital admission, and the predictability of recurrent events that result in a re-admission at 3 months following an initial discharge for those who have survived. Sections 5, 6 and 7 report the estimates for each of the key recommendation groupings; timely thrombolysis, timely carotid endarterectomy and timely CT diagnostics in more detail. Sensitivity analyses are provided within each section. The detailed appendices contain the following information: Appendix 1 lists the 15 clinically important recommendations and explains why some were excluded from further study. Appendix 2 acknowledges those who have contributed to the development of this report. Appendix 3 provides a flowchart on the resource impact assessment process and implementing guidelines. Appendix 4 details the International Classification of Disease (ICD 10) codes as they relate to cerebrovascular disease. Appendix 5 details the epidemiological model for Scotland that has been derived from the analysis of mortality records from the General Register Office for Scotland (GROS) and Scottish Morbidity Admission Records (SMR01) databases from Information Services Division (ISD). Appendix 6 illustrates how these data has been used to drive the consolidated demand for admissions, re-admissions and survival rates for patients who are both inside and outside the follow up window of one year. 10 Appendix 7 provides an index to the sources of information which are published annually by ISD in relation to costs in NHSScotland. Further information For further information on this report, to obtain a copy, or to provide feedback on its usefulness please contact: Joyce Craig Lead Health Economist NHS Quality Improvement Scotland Delta House 50 West Nile Street GLASGOW G1 2NP 0141 225 6985 [email protected] 11 3 BACKGROUND AND METHODOLOGY 3.1 Introduction Stroke is the third biggest cause of mortality and the primary cause of acquired disability in the adult population1. It is estimated that hospital care for patients with a stroke accounts for 7% of total beds occupied in Scottish hospitals and that the total cost of care represents nearly 5% of the entire NHSScotland budget11. The outcome for patients following stroke is generally referred to in terms of survival, functional status (dependence and disability) and the risk of recurrence12-14. Recurrent stroke carries a higher risk of mortality and can lead to profound long term disability in those who have survived their initial stroke, depending on the base level of impairment from that event. Implementing the key recommendations in SIGN 108 is anticipated to improve patient outcomes by enabling the appropriate therapies to be administered in the optimal time frames. Delivery of timely carotid endarterectomy should reduce the risk of a recurrent cerebrovascular event. Delivery of timely thrombolysis should reduce the level of possible dependency following a stroke and facilitate earlier hospital discharge. 3.2 Methodology to estimate clinical benefit The mean length of stay as a result of stroke in Scottish hospitals is estimated at 27 days per event. This is a weighted average of the mean length of stay of 25.4 days reported by the Scottish Stroke Care Audit (SSCAS)11 and the mean length of stay of 28.9 days for ischaemic stroke and 27.2 days for inconclusive stroke, reported by ISD15. Preventing a stroke event that would otherwise result in either a repeat admission (if the patient had already been admitted previously and then subsequently discharged) or a first ever admission (if the patient had previously been seen at a neurovascular outpatient clinic) is assumed to save 27 bed days. SIGN 108 reports the clinical studies that demonstrate treatment with recombinant tissue plasminogen activator (rt-PA) within 4.5 hours of symptom onset improves the outcome of some but not all patients who are eligible for treatment. It should not be seen as a ‘cure’ for ischaemic stroke, including the possibility of preventing recurrent events; rather for some patients successful therapy can reduce the severity, including the level of disability or impairment, which can accompany the event. In the pathway from admission to final discharge the outcome from thrombolytic therapy has been estimated to enable 10% of patients to make a full recovery and be discharged early (the ‘Lazarus Effect’), whilst 45% of patients will have a significantly improved outcome enabling earlier discharge16. The question of time from symptom onset is fundamental in the delivery of thrombolytic therapy. Patients who arrive at hospital where the time of symptom onset is judged to be greater than 4.5 hours will not be eligible for therapy under the current licence for use. In the preparation of this report, the ICD 10 code for inconclusive stroke (I64) has been taken as an indicator, given the geographical variations within the epidemiology 12 (see Section 4) of the percentage of patients who currently do not arrive within the appropriate time frame for thrombolytic consideration. The time from symptom onset is also relevant for the effective provision of carotid endarterectomy. Section 11.1.1 of SIGN 108 demonstrates that the NNT to prevent one recurrent event rises as the time from symptom onset progresses. To calculate the clinical benefit from carotid endarterectomy, this report assumes NHS boards are able to provide the procedure within 14 days of the event, in line with the SIGN recommendation. This maximises the potential clinical benefit. This section of SIGN 108 also notes that ‘A proportion of patients who are severely disabled immediately following their stroke event can make rapid recovery such that they meet the criteria used in the studies’ for carotid endarterectomy’. This report assumes thrombolysis can improve the outcome of patients sufficiently to enable them to be considered for carotid evaluation and possible surgical intervention prior to discharge. Following administration of thrombolytic therapy, carotid artery occlusion and the anterior circulation infarcts that stem from this type of underlying cause have been reported as a determinant of poor outcome in the 3 months following treatment17, when by inference the risk of a recurrent event is greatest in this particular subtype of ischaemic stroke (see Section 4)12-14. This may be reduced by carotid endarterectomy. Not all patients who arrive within 4.5 hours of symptom onset will be eligible for thrombolytic therapy. The Summary of Product Characteristics (http://emc.medicines.org.uk/medicine/308/SPC/Actilyse/) does not recommend use for patients over the age of 80 years. Other contraindications include patients with severe stroke as assessed clinically and/or by appropriate imaging techniques, patients receiving oral anticoagulants and evidence of any haemorrhage events, including liver disease. These exclusions have been modelled in this report by assuming a specialist nurse trained in thrombolytic therapy undertakes an assessment in an A&E environment. For those patients who are assessed as unsuitable for thrombolysis but candidates for carotid endarterectomy, rapid access to carotid imaging and potential surgical intervention should be facilitated in order to meet the 14 day timeline for maximum clinical benefit. Due to the current low numbers being treated for thrombolysis this element has been difficult to model for this report, however it will be a significant factor to consider as implementation progresses. 3.3 Methodology to estimate resources required and associated costs and savings Appendix 3 outlines the process developed and adopted to produce this report. Once the key themes and associated recommendations had been identified, draft patient pathways showing the changes required to implement each key recommendation were developed. These were informed by the results of a literature search on the epidemiology of stroke. ISD also provided extensive data on Scottish epidemiology and the facilities available at each NHS board. These data were combined with knowledge gained from intensive discussions with a number of the members of the guideline development group, feedback from members of the stroke managed clinical networks 13 and on-site visits. Discussions were also held with representatives from SAS. Planners from SAS modelled the implications of changing the destination for potential stroke patients, depending on the availability of CT scanning facilities. The data from these sources were combined into several models. An independent expert, with extensive knowledge of SSCAS was asked to validate the outcomes of the epidemiological model and other clinical experts were asked to validate the pathways assumed for their NHS board. Where possible published resource and cost data from ISD were used and supplemented by other published data as appropriate. Occasionally, unpublished sources were used and referenced. The models were made available to clinicians in all mainland NHS boards for review, supported, where possible, by meetings to discuss the findings. Data values and associated spreadsheets were quality assured by an independent health economist. An evaluation of the usefulness of this report to NHS boards as they seek to implement the recommendations in SIGN 108 will be commissioned by NHS Quality Improvement Scotland. 3.4 Methodology to estimate cost of resources and associated savings The cost of rt-PA alteplase was taken from BNF 56 (www.bnf.org) being: • 10 mg • 20 mg • 50 mg £135 excluding VAT; £158.63 including VAT at 17.5% £180 excluding VAT; £211.50 including VAT at 17.5% £300 excluding VAT; £352.50 including VAT at 17.5%. For the purpose of this report the cost of alteplase has been taken as an average of 80 mg at a cost of £723 including VAT. Costs for events such as SAS journeys, A&E attendance, radiology attendance, outpatient consultation, inpatient stay and theatre costs per hour are routinely published by ISD (http://www.isdscotland.org/isd/5822.html). The costs adopted in this report are a weighted average taking into consideration the total costs (overheads, staff resources, supplies and consumables) and dividing this by the number of events or patients who have attended. To calculate the value of a ‘bed day saved’ the inpatient rate per day has been adjusted to remove overheads and theatre costs, leaving primarily staff costs plus some consumables that would normally be required during an inpatient stay. This approach, primarily applied to the cost data for the mainland NHS boards, gives a Scottish mean weighted cost for an overnight stay in a general medical ward, where stroke unit costs are recorded, of £277 per day (see Table 1–1). 14 Appendix 7 details all of the costs that have been used in this report. These are available to download from the ISD website at www.isdscotland.org/isd/4434.html. On an individual NHS board level the supporting excel spreadsheets have the facility to change the cost matrix should the need arise. The mean staff costs for the additional staff required as a result of implementing SIGN 108 have been taken as the mid-point within the Agenda for Change pay scales as it affects both consulting and non-consulting staff. This salary mid-point is ‘grossed up’ by 22% to take account of the current rate of national insurance contributions and pension overhead. Translating costs into the relevant WTE for the additional members of staff requires a further adjustment [52/42] to account for abstractions due to holiday entitlement and training. Table 3–1 details the mid-point on the pay scale bands under the current terms of employment in the NHS effective from 1 April 2008 for nonconsulting staff. Table 3–2 details the mid-point on the pay scale bands under the current terms of employment in the NHS effective from 1 April 2008 for consulting staff. Full details of NHS employment contracts for both consulting and non_consulting staff are available from http://www.nhsemployers.org/PayAndContracts/Pages/Pay-andcontracts.aspx. Table 3-1 Band 2 3 4 5 6 7 Table 3-2 Gross salary costs taken as mid-point within each salary band including and adjustment for WTE costs for non-consulting staff (Agenda for Change) Mid-point 6 10 15 21 27 32 Base Overhead @ 22% £14,428 £3,174 £16,307 £3,588 £19,038 £4,188 £22,797 £5,015 £28,141 £6,191 £33,603 £7,393 Gross Gross WTE £17,602 £21,793 £19,895 £24,632 £23,226 £28,756 £27,812 £34,434 £34,332 £42,506 £40,996 £50,757 Gross salary costs taken as the mid-point salary band including and adjustment for WTE costs for consulting staff (pay circular M&D 3/2008) Pay Scale Point Base Overhead @ 22% Gross Gross WTE MC72/LC72 9 £88,049 £19,371 £107,420 £132,996 Clinical Excellence Awards 5 £14,565 £3,204 £17,769 £22,000 Total £102,614 £22,575 £125,189 £154,996 Cost per individual session Annual cost of one session per week 15 £397 £20,666 The cost for carotid endarterectomy as a weighted average for NHSScotland has been derived from the total expected costs of surgery in each of the individual NHS boards to include; a consultant outpatient appointment with a vascular surgeon, a secondary confirmation of carotid disturbance (MRI equivalent) in order to guide the surgical procedure, theatre time at 1.5 hours and a post-surgical carotid Doppler examination. Table 3–3 details the calculation for carotid endarterectomy across the NHS boards in Scotland for those patients who either return to a stroke ward or are cared for in a surgical ward having been previously discharged or attended a neurovascular outpatient clinic. 16 201 £732,696 £1,855 32 Estimated number of cases carried out to 31 March 2008 for analysis of additional cases Total Costs for Outpatient Carotid Surgery Consultant Outpatient - Vascular Surgergy Secondary Confirmation - MRI Equivalent Inpatient Surgery - Cost Per Day's Stay Theatre Costs - 1.5 Hours Secondary Confirmation - Ultrasound Post Surgery Total Unit Costs - Inpatient Carotid Surgery 40 £1,869,010 351 £111,438 £2,443 7 £40,245 £114 £89 £560 £1,563 £42 £2,367 17 50 £102 £163 £636 £1,289 £39 £2,229 NHS Borders 4 £16,266 £114 £89 £1,563 £42 £1,807 9 NHS Borders NHS Ayrshire & Arran 25 £50,968 £102 £163 £1,289 £39 £1,593 395 Costing methodology for procedures carried out on NHS Scotland patients requiring a new admission to a surgical total ward either from outpatient attendance or following population early discharge from a stroke ward Total Number of Cases 765 Estimated number of cases carried out to 31 March 2008 for analysis of additional cases Total Costs for Inpatient Carotid Surgery Consultant Outpatient - Vascular Surgery Secondary Confirmation - MRI Equivalent Theatre Costs - 1.5 Hours Secondary Confirmation - Ultrasound Post Surgery Total Unit Costs - Inpatient Carotid Surgery Total Number of Cases NHS Ayrshire & Arran NHS Scotland total population 17 £45,941 £114 £144 £508 £1,463 £68 £2,297 20 NHS Dumfries & Galloway 11 £23,258 £114 £144 £1,463 £68 £1,789 13 NHS Dumfries & Galloway 17 21 £95,376 £87 £302 £582 £1,317 £38 £2,326 41 NHS Fife 14 £105 £302 £1,317 £38 £1,762 £0 £47,581 27 NHS Fife 26 £67,844 £82 £305 £540 £1,116 £77 £2,120 32 NHS Forth Valley 16 £30,023 £82 £305 £1,116 £77 £1,580 19 NHS Forth Valley 36 £101,228 £108 £153 £548 £1,425 £66 £2,301 44 NHS Grampian 29 £61,552 £114 £153 £1,425 £66 £1,759 35 NHS Grampian 92 £699,501 £120 £240 £562 £1,674 £63 £2,660 NHS Greater Glasgow & Clyde 263 34 £207,640 £120 £240 £1,674 £63 £2,097 NHS Greater Glasgow & Clyde 99 31 £98,706 £168 £604 £528 £1,289 £79 £2,668 37 NHS Highland 19 £47,074 £168 £604 £1,289 £79 £2,140 22 NHS Highland 0 £0 £0 0 NHS Island Boards 3 £12,003 £114 £228 £1,025 £134 £1,500 8 NHS Island Boards 21 £262,801 £114 £161 £422 £1,320 £53 £2,069 127 NHS Lanarkshire 8 £79,075 £114 £161 £1,320 £53 £1,647 48 NHS Lanarkshire 39 £256,175 £134 £119 £704 £1,721 £48 £2,725 94 NHS Lothian 22 £105,210 £136 £119 £1,721 £48 £2,023 52 NHS Lothian 21 £89,755 £105 £236 £574 £1,298 £31 £2,244 40 NHS Tayside 16 £52,045 £114 £236 £1,298 £31 £1,679 31 NHS Tayside Consolidated surgical costs for carotid endarterectomy, based on whether the patient returns to a stroke ward or has a separate admission to a surgical ward Costing methodoly for procedures carried out on existing inpatients where after surgery the patient returns back to the stroke (general medicine) ward Table 3-3 3.5 Limitations The current report has a number of limitations in that it is primarily based on an overall model which encompasses a number of smaller models. The epidemiological model balances across Scotland and is within 10% for individual NHS boards. It has therefore been assumed to be robust and to generalise to events in future. Other important assumptions are set out below. • On full implementation of SIGN 108, NHS boards will not transfer patients across boundaries for thrombolysis or carotid endarterectomy. • An appropriate number of beds are available in the short term to accommodate the anticipated demand for patients receiving timely thrombolysis and carotid endarterectomy. Such interventions will reduce the demand for beds in the longer term but there will be a mismatch between the immediate requirements and realising the longer term benefit. • Each hospital modelled to deliver thrombolysis has sufficient beds in a high dependency or intensive care unit available to accommodate the patients receiving such therapy. These patients should be monitored for adverse events during the immediate few hours after delivery of the drug. • No growth in the number of stroke patients managed beyond the 2007 mid-year population baseline is assumed. • Staff and facilities will be shared efficiently across Scotland. For example, there may be a need for an extra 4 WTE specialist nurses across Scotland to provide timely thrombolysis. This may equate to, say, 0.2 WTE of a nurse in one hospital. Recruiting such small increments of staff may not be possible, in which case the staff numbers required will be a material underestimate. • The terminology refers to bed days ‘saved’, being bed days that will no longer be required because the intervention reduces the risk of future strokes. In reality these beds are likely to be occupied by patients with other conditions and thus the beds will still be used. • The analyses do not aggregate the resources required to implement a revised service with the potential savings from fewer clinical events. This is partly because of timing differences, but also because the two estimates are made using different approaches. However, users may wish to consider a net table. • Some significant cost categories have been excluded, particularly the cost of service redesign and associated training and recruitment costs. • The role of telemedicine has also not been considered. The analysis is not intended to be an absolute definitive solution to the implementation challenges that are faced by NHS boards in Scotland either currently or when implementing SIGN 108. Much of the work which is being presented here will have to be repeated as time progresses, particularly as the true admission pattern for thrombolytic therapy is revealed at individual board level. 18 4 SCOTTISH STROKE EPIDEMIOLOGY 4.1 Introduction In order to better understand how implementing the key recommendations in SIGN 108 can improve patient outcomes it has been necessary to undertake an epidemiological study of stroke as it relates to hospital admissions, rates of survival, the possibility of recurrence and by inference the likelihood of dependency. The principal drivers behind this study have been taken by way of extension from the published work of the Oxfordshire Community Stroke Project 1981-1986 (OCSP)12-14 and the CommunityBased Stroke Incidence in a Scottish Population, the Scottish Borders Stroke Study 1998-2000 (SBSS)2. This section details the work that has been undertaken at both a national and local level in relation to stroke for the years ended 31 March 2006, 2007 and 200818. From the information gathered, a model has been developed at a national level which predicts the mortality of patients who have been admitted to hospital for the first time as a result of their stroke to within 99% accuracy. At NHS board level the same model can predict mortality, to within 90% or greater accuracy, in each of the 3 years. 4.2 Incidence of a first hospital admission as a result of stroke or TIA Scotland has some of the best health service data in the world, in particular the SMR01 database of hospital admission records and the GROMR database of mortality records, which are held by ISD and GROS respectively. The high quality data, consistency, national coverage and the specific ability to link data between the two databases in order to allow patient based analysis and follow up has been fundamental in the analysis of patients who have been admitted to hospital for stroke or TIA. Following the protocols defined in both the SBSS and OCSP in relation to first ever stroke both ISD and GROS were asked to deliver data based on the following selection criteria from the ICD 10 codes for cerebrovascular disease. Full details of the codes are provided in Appendix 4: • For hospital admissions: Include all patients who had a unique admission record (with subsequent discharge) in the range of ICD 10 codes specified for cerebrovascular disease including TIA’s for each of the years ended 31 March 2006–31 March 2008 inclusive. • For mortality records: Include all deaths recorded (including autopsy) in the range of ICD 10 codes specified for cerebrovascular disease including TIA’s for each of the years ended 31 March 2006–31 March 2008 inclusive. 19 • Linked data: For hospital admissions, link the patient identification number and scan through the historical database records for a period of up to 10 years and eliminate any corresponding record that has had a previous entry in any of the ICD 10 codes specified. For mortality records, link the patient identification number and scan through the SMR01 database records and eliminate any corresponding admission record found that had an entry in any of the ICD 10 codes specified. The resultant output combines unique records for patients who have either been admitted on the first occasion with a diagnosis of stroke or TIA (discharge code) or have died in the community as a result of their stroke, having never been admitted to hospital historically for the condition. The unique records of hospital admissions can be indexed within each of the individual years and linked back into the SMR01 database to search for further information based on the patients’ identification number. Historical information such as the last known hospital admission prior to the current event has revealed the growing problem of liver toxicity, brought about through drug and alcohol abuse, particularly in the younger cohort of patients being admitted for stroke in Scotland. Whilst for older patients, the increasing significance of diabetes type 2 and clinical obesity in relation to stroke is becoming more evident. Likewise, cross referencing the linked patient identification numbers for each of the years in question to the GROMR database has provided detailed information on the survival rates following stroke at 1, 3, 6 and 12 months, regardless of whether the patient died in hospital or in the community after having been discharged19. Appendices 5–1 to 5–5 provide details of the consolidated results for Scotland for the year ending 31 March 2007, which is the most recent year where all data collected through the SMR01 database is most complete. As a result of the extensive epidemiological studies carried out in the preparation of this report, there is some evidence to suggest that the rate of recurrence of stroke, but not TIA, in patients who have originally presented for a hospital admission in an historical period in excess of 1 year is increasing. Table 4–1 analyses hospital admissions in the years ending 31 March 2005, 2006 and 2007, being the last three years in which the ISD SMR01 database has complete hospital submission records for patient admittance and subsequent re-admittance following discharge. Recurrent events are linked to a first ever admission in each of the years in question. The difference between total first ever events and actual admissions indicates that a patient cohort has been admitted from a prior period and that the percentage of patients this number represents is increasing. 20 Table 4-1 Re-admission rates estimated from data collected from the ISD SMR01 database Annual readmission rates calculated from Stroke total admissions & first ever stroke Classifications presentations Recurrent % Total actual event from Additional admissions a prior recurrence year First ever event Recurrent events Total events Readmission rate for 2005 Transient Readmission rate for 2006 Ischaemic Attack Readmission rate for 2007 Average readmission from prior years 1,557 1,545 1,625 1,576 247 252 240 246 1,804 1,797 1,865 1,822 2,040 2,011 2,061 2,037 236 214 196 215 15.2% 13.9% 12.1% 13.7% Readmission rate for 2005 Haemorrhagic Readmission rate for 2006 Stroke Readmission rate for 2007 Average readmission from prior years 1,185 1,165 1,198 1,183 126 137 131 131 1,311 1,302 1,329 1,314 1,544 1,498 1,561 1,534 233 196 232 220 19.7% 16.8% 19.4% 18.6% Readmission rate for 2005 Ischaemic Stroke Readmission rate for 2006 Readmission rate for 2007 Average readmission from prior years 6,334 6,112 5,879 6,108 1,033 965 881 960 7,367 7,077 6,760 7,068 8,706 8,339 8,198 8,414 1,339 1,262 1,438 1,346 21.1% 20.6% 24.5% 22.1% While there is evidence that a simple score (ABCD or ABCD2) can be used to identify patients who, following an initial TIA, are likely to be at risk of developing an ischaemic stroke event, the admissions history from the SMR01 database will not record all of these, unless the stroke results in a hospital admission. What can be established is that the relationship between age and the percentage of multiple hospital re-admissions differs between TIA and both haemorrhagic and ischaemic stroke. For those suffering a TIA, multiple re-admissions are more prevalent in the over 65 age groups, whilst in either haemorrhagic or ischaemic stroke a greater percentage of stroke patients under the age of 65 are presenting for repeat admissions, as detailed in Table 4–2. Table 4-2 Annual re-admission rates estimated from first ever hospital admissions Stroke Annual readmission rates calculated from Total Classifications first ever stroke presentations population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years Readmission rate for 2005 Transient Readmission rate for 2006 Ischaemic Attack Readmission rate for 2007 Average readmission rate - current year 15.9% 16.3% 14.8% 15.6% 15.4% 3.6% 10.8% 9.9% 15.2% 15.2% 7.0% 12.5% 17.8% 15.3% 8.1% 13.7% 13.8% 16.1% 14.4% 14.8% 16.5% 18.3% 20.2% 18.4% 16.7% 19.4% 18.5% 18.2% Readmission rate for 2005 Haemorrhagic Readmission rate for 2006 Stroke Readmission rate for 2007 Average readmission rate - current year 10.6% 11.8% 10.9% 11.1% 19.0% 15.9% 11.0% 15.3% 13.6% 14.9% 9.1% 12.5% 13.2% 15.3% 12.4% 13.7% 11.4% 8.9% 13.7% 11.4% 8.9% 10.3% 9.5% 9.6% 4.2% 11.2% 9.3% 8.2% Readmission rate for 2005 Ischaemic Stroke Readmission rate for 2006 Readmission rate for 2007 Average readmission rate - current year 16.3% 15.8% 15.0% 15.7% 19.1% 19.3% 14.9% 17.8% 20.6% 17.2% 15.7% 17.8% 18.0% 15.9% 15.5% 16.5% 17.4% 18.1% 16.5% 17.3% 16.5% 15.3% 15.3% 15.7% 11.8% 12.7% 12.3% 12.3% 21 The relationship between mortality and recurrent events which are likely to result in a hospital re-admission can be explained by way of a clinical model. Clinical model The classification and natural history of clinically identifiable subtypes of cerebral infarction has been described in detail as part of the OCSP12-14. In summary the four different subtypes of infarct describe the estimated size of the lesion involved, the likelihood of the cause and, where practicable, the level of recurrence that might be expected for each of the groups on an annual basis. Table 4–3 details the four clinically identifiable subtypes of cerebral infarction; Lacunar Infarcts (LACI or Lacunar Syndrome LACS), Total Anterior Circulation Infarcts (TACI or Total Anterior Circulation Syndrome TACS), Partial Anterior Circulation Infarcts (PACI or Partial Anterior Circulation Syndrome PACS) and Posterior Circulation Infarcts (POCI or Posterior Circulation Syndrome POCS). Rates of recurrence, population split, mortality and functional outcome are from the original OCSP model. Information in relation to the likelihood of carotid distortion and cardio-embolic origins, together with the estimated size of the lesion, have also been included in Table 4–3 to illustrate the relationship between anterior circulation infarcts and the disturbances in the carotid territory that are associated with them. Table 4-3 Classification of the subtypes of cerebral infarcts OCSP classification of cerebral infarcts Clinical features: Size of lesion LACI TACI PACI POCI small large medium Likelihood of carotid disturbance low high high Likelihood of cardio-embolic source Likelihood of recurrent event Average population split Outcome at one year: Mortality Functional dependence Functional independence Total low 9% 25% high 6% 17% high 17% 34% small to medium not applicable medium 20% 24% 11% 28% 61% 100% 60% 36% 4% 100% 16% 29% 55% 100% 19% 19% 62% 100% The population split between the four subtypes is an average of the population taken over the 5 years of this particular study between 1981–1986, where the average age range was more heavily concentrated in the region of 60–85 years (72.5 ± 12.6 standard deviation). While the general stroke population of those who have been admitted to hospital in Scotland is also predominantly concentrated within this group, this should not detract from the fact that there are patients outside of this age range who 22 are also being admitted. Closer inspection of the age specific incidence rates published in the OCSP illustrates that, although a very rare occurrence at that time, Partial Anterior Infarcts were predominantly evident in the under 45 age group and thereafter diminishing across the age groups as the other types of infarcts took prominence. The current adaptation of the four subtypes of infarction is shown in Table 4–4 where the number of potential infarcts is exclusive of the estimates for cryptogenic stroke. The allocation between the four subtypes is based on a ‘best fit’ to reach the population average reported in the original study. Table 4-4 Extending the OCSP model of infarction subtypes to population age groups Original known admissions reported by ISD as Total at 31 March 2008 population Number of FES - TIA's Admitted 1,607 Number of FES - Haemorrhagic Admitted 1,193 Number of FES - Infarcts Admitted 5,743 Total Admissions 8,543 0 - 44 years 70 95 204 369 45 - 54 years 168 102 380 650 55 - 64 years 301 173 774 1,248 65 - 74 years 400 288 1,298 1,986 75 - 84 years 442 343 1,871 2,656 85+ years 226 192 1,216 1,634 Predictive Outcome Model (Adapted from OCSP 1986) - Identifying the Four Subtypes of Infarction Cryptogenic Stroke - Not Included Cryptogenic Stroke - Patients Excluded Clinically identifiable subtypes of cerebral infarction LACI - Lacunar Infarcts TACI - Total Anterior Circulation Infarcts PACI - Partial Anterior Circulation Infarcts POCI - Posterior Circulation Infracts 5% 300 40% 82 20% 76 10% 77 5% 65 0% 0 0% 0 Total population 25% 17% 34% 24% Subtotal 0 - 44 years 5% 5% 85% 5% 100% 45 - 54 years 35% 10% 40% 15% 100% 55 - 64 years 25% 15% 35% 25% 100% 65 - 74 years 25% 15% 35% 25% 100% 75 - 84 years 24% 17% 34% 25% 100% 85+ years 25% 25% 25% 25% 100% LACI - Lacunar Infarcts TACI - Total Anterior Circulation Infarcts PACI - Partial Anterior Circulation Infarcts POCI - Posterior Circulation Infracts 1,347 948 1,842 1,306 6 6 104 6 106 30 122 46 174 105 244 173 308 185 432 308 449 318 636 469 304 304 304 304 Total Infarcts excluding Cryptogenic Stroke 5,443 122 304 696 1,233 1,872 1,216 Outcome of Infarct Analysis Having established the prominence of the four subtypes of infarct the model has been extended to look at the relationship between mortality in the first month and the possibility of re-admission for those who have survived in the first 3 months following discharge, as these are the only events which can be counted in the SMR01 database. Appendices 5.6 and 5.7 detail the full extension of the OCSP model as a best fit within the population groups for the total population of Scotland for the year ending 31 March 2007. These show the relationship between admission, survival and re-admittance. It is not possible to state that all patients who are being re-admitted to Scottish hospitals are as a result of a recurrent cerebrovascular event as this would require access to individual clinical patient information. Nonetheless, this model provides a best fit explanation to help predict the number of surviving patients who are likely to be re- 23 admitted following discharge, together with an estimate of the level of dependency. Its outputs are consistent with the observed data for Scotland and for each NHS board over the last 3 years. Hence it is considered to be robust and to generalise to the future. Given the robustness of the model, which has predicted mortality at 1 month and readmission at 3 months to within 98.9% and 97.2% respectively over the same period, these data have been applied to underpin a principle assumption in this report. In order to ‘save beds’ through effective implementation of the recommendation in SIGN 108, there has to be the correct number of beds available (or allocated) in the first instance so that they can be ‘saved’ or reallocated within the general medical ward, where most stroke units are contained. Appendix 6 details the expected number of patients who are due for admittance in Scottish hospitals for the year ending 31 March 2009 based on the mid-year population estimate provided by the GROS as at 30 June 2007. 24 5 TIMELY THROMBOLYSIS 5.1 Background SIGN 108 recommended administration of thrombolytic therapy with alteplase, within 4.5 hours from stroke onset. The guideline noted this significantly reduces death and disability at 90 days. The recommendations analysed within this report as required to deliver such a service include: • Emergency medical services should be redesigned to facilitate rapid access to specialist stroke services. • Stroke patients requiring admission to hospital should be admitted to a stroke unit staffed by a co-ordinated multidisciplinary team with a special interest in stroke care. • All patients with suspected stroke should have brain imaging immediately on presentation. • Patients admitted with stroke within 4.5 hours of definite onset of symptoms, who are considered suitable, should be treated with 0.9 mg/kg (up to maximum 90 mg) intravenous rt-PA. 5.2 Patient group The patient subgroup assumed to receive thrombolytic therapy are those with a NIH Stroke Scale (NIHSS) score between 5–22, be under 80 years old (in accordance with the recommendation in its licence) and not experiencing a recurrent stroke within 3 months of the previous stroke. This group is forecast to be approximately 1,900 patients annually. Of these almost 50% will not be able to be treated within the 4.5 hour window or will be contraindicated. The anticipated numbers receiving the therapy is 1,015. This compares to an estimated 205 patients who are currently receiving the therapy, an increase of 810 patients. Approximately 48% of these patients are assumed to present at hospital between the hours of 8am–6pm, Monday to Friday, 27% outside these hours on a weekday and the remainder at a weekend. No-one is presumed to present after 11pm. This arrival pattern is based on that known for myocardial infarction, revised to assume a cut-off at 11pm, following discussion with the clinical experts in NHS boards currently administering the therapy. 5.3 Clinical benefit and associated resource savings SIGN 108 notes the main clinical benefit from delivery of effective thrombolytic therapy is that some patients are able to make a full or near-full recovery. A pooled analysis suggests that approximately 10% of patients may make a full recovery, 45% will have a significantly improved outcome and 45% will have no change in outcome or an adverse outcome21. 25 The mean length of continuous inpatient stay for patients with a cerebrovascular disease diagnosis (excluding transient attacks) is 27 days (see Section 3.2). A full recovery is forecast to save 18 days, an improved recovery 9 days and no clinical change or an adverse outcome is assumed to save zero days. The mean cost for an inpatient bed in a medical ward has been estimated to be £277. This cost is a direct cost primarily comprising staff and consumables. It excludes all overheads. Table 5–1 provides an estimate of bed days saved and related costs. Table 5-1 Clinical benefits of additional thrombolytic therapy Patients Estimated number of patients receiving thrombolytic therapy Forecast number of patients receiving thrombolytic therapy on implementation Additional number of patients likely to benefit Forecast outcome for these additional cases: 10% full recovery 45% improved outcome 45% no change in outcome or adverse outcome Number of bed days saved based on mean of 27 days: 10% full recovery saving 18 days 45% improved outcome - saving 9 days Total number of additional bed days saved Total bed days financial savings 5.4 NHSScotland 205 1,015 810 82 364 323 1,476 3,276 4,752 £1,316,304 Resource requirements A key requirement to enable rapid access to specialist stroke services is that all patients with suspected stroke are identified early by paramedics and admitted to a hospital with a CT scanner as a minimum. Currently approximately 9% of stroke patients are estimated to be admitted to hospitals without such a scanner. Discussions with SAS have identified that: • ambulance paramedics and technicians who have undergone training on stroke recognition are accurate in their assessment of potential stroke patients, and • virtually all such patients could be taken to an alternative hospital with a scanner at no extra cost to the service and within SAS response time targets. The analysis assumes NHS boards and SAS agree revised protocols such that all potential stroke patients are delivered to hospitals with a CT scanner. Adopting such protocols would be resource saving for both SAS and the NHS board, onward journeys to hospitals with scanners would be avoided, together with the requirement for two 26 clinical assessments, one at each hospital. The sensitivity analysis explores the costs of not adopting this approach. However, SAS estimates that approximately 100 additional patients will require air transport to enable them to reach hospital in sufficient time to be assessed for thrombolytic therapy. These patients are forecast to be in the Highlands and Grampian. Other key assumptions include that: • the protocol with SAS nominates a lead hospital (or hospitals) for stroke within the NHS board area. Thus, no cross boundary services are assumed. This is different from the current position where NHS Greater Glasgow and Clyde provide services for other boards • each board has sufficient high dependency beds to manage the additional 810 patients to receive thrombolysis, and • staff can be trained to deliver the therapy at minimal cost. The staff resources required to deliver the drug are assumed to be: • band 7 specialist nurse who is assumed to require 1 hour to establish time of onset of stroke and prior history for each of the 1,900 patients who may be eligible for the therapy. If the responses indicate that the patient may be eligible for the therapy then the nurse is assumed to call for a consultant. Thereafter the nurse will attend the patient receiving the therapy for a further 6 hours as the drug is administered and to oversee the initial management. • consultant stroke physicians. Each NHS board is assumed to manage with no additional consultant resource during the core weekday hours. The additional workload from thrombolysing patients who present during weekday core hours is assumed to displace existing workload. However, this should reduce as the upfront investment in delivering the therapy is rewarded by having more patients with improved outcomes and consequently discharged earlier. This assumption will be particularly challenging for smaller boards where the consultant may have duties to conduct outwith the main hospital. Seven NHS boards, being those forecast to have more than 30 patients per year presenting for this therapy in the early evening, are forecast to recruit an extra 0.5 WTE consultant each to cover five planned activities a week, providing cover until 8pm. All other out of hours work is assumed to be undertaken by on-call arrangements. The total staff required is estimated at 4.2 WTE nurses, 35 additional planned activities per week to provide consultant resources in the early evening and 760 out of hours callouts. 27 The other resources required are the alteplase itself and an additional CT scan after administration of the drug. The recruitment of these specialist nurses is judged to be sufficient to ensure all hospitals admitting stroke patients are staffed by a co-ordinated multidisciplinary team with a special interest in stroke care. 5.5 Costs The unit costs for the resources required are: • • • • • • air ambulance: £3,140 (Appendix 7.1) band 7 specialist nurse: £40,996 (Section 3.4) consultant stroke physician: £125,197 including overheads at 22% (Section 3.4) out of hours call-out: £397 (Section 3.4) alteplase: £723 including VAT (source www.bnf.org) CT scan: £127 (Appendix 7.3). Table 5-2 provides the estimated cost of delivering thrombolytic therapy to an additional 810 patients in Scotland. Table 5-2 Additional costs to deliver thrombolytic therapy to an additional 810 patients Event SAS for air ambulance Alteplase CT scan Specialist nurse Additional consultant sessions Additional call-out sessions Total costs 5.6 Total costs £317,415 £585,630 £102,682 £172,183 £542,360 £302,059 £2,022,329 Sensitivity analysis Two sensitivity analyses have been performed on the delivery of thrombolytic therapy. The first models the cost of failure to put in place robust protocols between SAS and the NHS boards for the delivery of possible stroke patients to hospitals equipped with a CT scanner. The analysis by NHS board identifies that almost 1,100 additional journeys would be incurred, of which over 800 are out of hours. Each journey is associated with two A&E admissions, one of which could be saved by adopting the appropriate protocol. The unit costs and total costs of these events are set out in Table 5–3. This optimisation of delivery of patients could save almost £350,000 per annum. 28 Table 5-3 Additional costs if patients are not directed to hospitals with CT scanners Event Unit costs Unnecessary SAS journeys Unnecessary A&E assessments Total costs £213 £101 Total costs £235,873 £111,483 £347,356 The second sensitivity analysis assumes that NHS boards prioritise commissioning services Monday to Friday during core hours only. The additional number of patients to be treated falls to around 390, or by just over 50%. All costs, other than for consultants, fall in line with the patient numbers. Under the assumptions, no additional consultant costs would be required, with thrombolysis displacing other activities. The total cost falls to around £567,149, equivalent to £1,455 per patient. This compares to a cost per patient of almost £2,500 for the 7 days a week, 24 hours a day service (see Table 5–4). Table 5-4 Additional costs to deliver thrombolytic therapy to an additional 390 patients Event SAS for air ambulance Alteplase CT scan Specialist nurse Additional consultant sessions Additional call-out sessions Total costs 5.7 Total costs £152,829 £281,970 £49,530 £82,820 0 0 £567,149 Analyses by NHS board Tables 5–5 to 5–8 provide further information on the epidemiology, costs and benefits from timely thrombolysis by NHS board. Table 5–5 presents the anticipated patients, Table 5–6 the additional clinical benefit, Table 5–7 the additional costs and Table 5–8 the sensitivity analysis assuming SAS are not able to deliver patients to the specified hospital for timely thrombolysis. 29 10% 45% 45% 48% 27% 25% Lazarus Effect - mRS < = 1 Improved Outcome - mRS < = 2 No Change in Dependency Total Outcome Predicted Outcome as a result of Thrombolysis 102 457 457 1,015 11 47 47 105 NHS Ayrshire & Arran NHS Scotland total population NHS Ayrshire & Arran NHS Scotland total population 76 43 40 158 105 1,015 Total Anticipated Candidates 909 511 473 1,894 32.6% 3.4% 47.4% 3.4% Admittance Pattern using Model for Optimal Reperfusion in ST Elevation MI on an Annual Basis Patients Arriving 8am to 6pm Mon - Fri Patients Arriving 6pm to 11pm Mon - Fri Patients Arriving 8am to 11pm Sat / Sun Total Allocation 158 59.7% 57.8% 1,894 194 103 33 265 2,427 1,248 400 3,276 NHS Ayrshire & Arran Subtotal Less: Hospital Admission > 4.5 Hours Contraindications for Diabetes & Liver No FES Infarcts Admitted No of Recurrent Strokes Admitted Less Predicted Recurrence at 3 months Total number of Dependent Infarcts Less: Age Restriction for rt-PA License NHS Scotland total population Anticipated patients by NHS board Dependency Analysis of Ischaemic Strokes mRS > 2 Table 5-5 3 11 11 25 NHS Borders 20 11 10 41 NHS Borders 25 41.9% 2.9% 41 55.9% 56 25 8 73 NHS Borders 30 4 18 18 40 NHS Dumfries & Galloway 30 17 15 61 NHS Dumfries & Galloway 40 34.8% 4.0% 61 52.8% 88 45 16 117 NHS Dumfries & Galloway 7 33 33 74 NHS Fife 65 37 34 136 NHS Fife 74 44.2% 4.2% 136 57.2% 175 94 31 238 NHS Fife 4 19 19 42 NHS Forth Valley 43 24 22 89 NHS Forth Valley 42 51.6% 4.1% 89 60.7% 115 51 20 146 NHS Forth Valley 9 41 41 91 NHS Grampian 83 47 43 172 NHS Grampian 91 46.5% 4.3% 172 59.4% 222 105 37 290 NHS Grampian 26 117 117 261 NHS Greater Glasgow & Clyde NHS Greater Glasgow & Clyde 223 126 116 465 261 41.8% 3.7% 465 60.1% NHS Greater Glasgow & Clyde 561 303 90 775 5 23 23 51 NHS Highland 55 31 29 114 NHS Highland 51 55.1% 4.0% 114 54.0% 155 83 26 212 NHS Highland 1 2 2 5 NHS Island Boards 11 6 6 23 NHS Island Boards 5 73.3% 3.7% 23 53.3% 29 18 5 42 NHS Island Boards 12 55 55 123 NHS Lanarkshire 107 60 56 222 NHS Lanarkshire 123 43.0% 3.6% 222 61.1% 271 137 44 363 NHS Lanarkshire 13 59 59 130 NHS Lothian 119 67 62 247 NHS Lothian 130 47.8% 2.9% 247 52.8% 348 175 55 468 NHS Lothian 7 31 31 68 NHS Tayside 79 45 41 165 NHS Tayside 68 56.4% 3.3% 165 57.4% 213 110 35 288 NHS Tayside 18 9 10% 45% 45% 1,476 3,276 4,752 Total number of additional bed days saved 105 810 54 99 3 11 11 25 25 0 72 162 4 18 18 40 40 0 NHS NHS Dumfries & Borders Galloway 126 297 7 33 33 74 74 0 31 243 72 171 4 19 19 42 42 0 NHS NHS Fife Forth Valley 621 153 234 423 * 25 patients from Ayrshire & Arran trf to Glasgow 198 423 11 47 47 105 1,015 82 364 364 0 NHS Ayrshire & Arran 205 Current estimate of the number of cases of patients receiving thrombolytic therapy in Scotland Forecast number of cases of patients who could receive thrombolytic therapy in the future Additional number of patients likely to benefit Likely outcome for these additional cases: 10% Lazarus Effect - mRS < = 1 45% Improved Outcome - mRS < = 2 40% No Change in Dependency Number of bed days saved based on average of 27 days 10% Lazarus Effect - Saving 18 Days 45% Improved Outcome - Saving 9 Days NHS Scotland total population Additional benefit from timely thrombolysis by NHS board Additional benefits as a result of improved access to Thrombolytic Therapy Table 5-6 414 126 288 7 32 32 71 91 20 801 252 549 14 61 61 136 261 125 NHS NHS Greater Grampian Glasgow & Clyde 180 54 126 3 14 14 31 51 20 NHS Highland 36 18 18 1 2 2 5 5 0 657 198 459 11 51 51 113 123 10 NHS NHS Island Lanarkshire Boards 585 180 405 10 45 45 100 130 30 NHS Lothian 405 126 279 7 31 31 68 68 0 NHS Tayside Total additional costs likely to be incurred in the implementation of thrombolytic therapy throughout Scotland Scottish Ambulance Service - additional air transport services required to deliver patients for thromolysis Air ambulance costs per journey Total additional costs for the Ambulance Service Estimated number of patients likely to receive thrombolytic therapy within the 4.5 hour window and without complications: Estimated number of patients likely to have received thrombolysis to date Additional number of patients following successful implementation who could receive thrombolytic therapy on a timely basis: Cost of Alteplase rt-PA including VAT as per BNF Cost of CT scan event in target hospital for thrombolysis Total additional costs for drugs and diagnostics Additional specialist nursing hours Band 7 WTE Specialist Nurse Total additional costs for specialist nursing Additional consultant planned activities covering Monday to Friday OOH from 5.30 pm to 9.00 pm Additional consultant planned sessions cancelled as a result of an OOH call out Monday to Friday Additional consultant planned sessions cancelled as a result of an OOH call out at the weekend Additional costs for WTE consultant sessions Additional costs for cancelled sessions following call out Total additional costs for Consultants 74 42 NHS Grampian 21 40 £77,480 £24,047 £101,527 292 468 £542,360 £302,059 £844,419 £210,140 5 35 £2,022,329 £723 £117 £88,115 788 0.5 £20,498 £723 £127 £688,311 6,373 4.2 £172,183 0 105 810 205 32 £34,314 £0 £8,395 £8,395 10 11 0 £723 £150 £21,820 191 0.1 £4,100 25 0 £52,696 £0 £12,707 £12,707 15 17 0 £723 £72 £31,790 301 0.2 £8,199 40 0 £179,205 £77,480 £20,662 £98,142 34 18 5 £723 £151 £64,665 580 0.4 £16,398 74 0 £64,006 £0 £18,354 £18,354 22 24 0 £723 £169 £37,452 341 0.2 £8,199 42 0 £297,275 £77,480 £26,256 £103,736 43 23 5 £723 £98 £58,238 560 0.4 £16,398 71 20 91 40 NHS NHS Fife Forth Valley 1,015 25 NHS NHS Dumfries & Borders Galloway 38 £3,129 £118,902 105 NHS Ayrshire & Arran 101 £3,143 £317,415 NHS Scotland total population Additional costs from timely thrombolysis by NHS board Additional costs as a result of improved access to thrombolytic therapy Table 5-7 £294,679 £77,480 £71,252 £148,732 116 63 5 £723 £140 £117,250 1,058 0.7 £28,697 136 125 261 NHS Greater Glasgow & Clyde £259,096 £0 £23,596 £23,596 29 31 0 £723 £206 £28,788 255 0.2 £8,199 31 20 51 63 £3,151 £198,513 NHS Highland £5,133 £0 £0 £0 0 0 0 £723 £304 £5,133 53 0.0 £0 5 0 5 £229,262 £77,480 £33,972 £111,452 56 30 5 £723 £102 £93,213 882 0.6 £24,598 113 10 123 NHS NHS Island Lanarkshire Boards £217,764 £77,480 £37,645 £115,125 62 33 5 £723 £99 £82,141 790 0.5 £20,498 100 30 130 NHS Lothian £178,759 £77,480 £25,173 £102,653 41 22 5 £723 £155 £59,707 573 0.4 £16,398 68 0 68 NHS Tayside Number of In Hours Transfers for Thrombolysis Number of Out of Hours Transfers for Thrombolysis Unit Cost of Ambulance Transfer Potential additional costs to the Ambulance Service Unit Cost of A&E Attendance Potential additional costs through duplicate attendance in A&E 40 79 £242 £28,904 £99 £11,824 297 811 £213 £235,873 £101 £111,483 NHS Ayrshire & Arran £0 0 0 £495 £0 £123 NHS Borders 33 £2,736 9 19 £460 £12,973 £97 NHS Dumfries & Galloway £4,489 18 35 £192 £10,261 £84 NHS Fife £0 0 0 £176 £0 £97 NHS Forth Valley £3,533 13 25 £264 £10,137 £92 NHS Grampian Sensitivity analysis: SAS unable to deliver patients to specified hospital for timely thrombolysis by NHS board Sensitivity Analysis: The SAS are in the position to make every attempt at establishing the time of symptom onset this information can allow patients to be delivered directly to the NHS Scotland total population target hospital for thrombolysis. If time of onset is established at the closed place of diagnostics, there will be duplicate patient transfers and duplicate A&E admissions: Table 5-8 £40,717 101 341 £163 £72,139 £92 NHS Greater Glasgow & Clyde £9,126 20 43 £489 £30,992 £144 NHS Highland £18,606 73 134 £170 £35,145 £90 NHS Lanarkshire £13,255 0 86 £171 £14,718 £154 NHS Lothian £7,198 22 49 £292 £20,605 £102 NHS Tayside 6 TIMELY CAROTID IMAGING AND CAROTID ENDARTERECTOMY 6.1 Background SIGN 108 refers to the randomised controlled trials and related pooled data that report best medical treatment plus carotid endarterectomy is clinically effective compared to best medical treatment only in preventing recurrent stroke. The greatest benefit was seen in patients with severe stenosis. This evidence base informed the SIGN 108 recommendations on carotid endarterectomy to include that: • all patients with carotid artery stroke without severe disability, (mRS ≤2) or TIA ischaemic attack should be considered for carotid endarterectomy as soon as possible after the index event • carotid endarterectomy should be considered in all: - male patients with a carotid artery stenosis of 50–99% - female patients with a carotid artery stenosis of 70–99% and • carotid endarterectomy should be performed as soon as the patient is stable and fit for surgery, ideally within 2 weeks of event. 6.2 Patient group The relevant patient group for this intervention is those patients with severe stenosis who are fit enough for surgery as measured by the modified Rankin Scale or mRS ≤2. The epidemiological model predicts that the annual incidence could be approximately 11,865 people. Approximately 6,060 of these will be inpatients and the balance will be identified at neurovascular outpatient clinics. The inpatients include some 500 patients who recover sufficiently following thrombolysis to benefit from surgery. It is estimated that around 50% of these patients will not be judged suitable for surgery for various reasons, to include co-morbidities. As noted in the guideline age in itself is not a restriction. Of the remaining 6,010 it is predicted that the carotid Doppler results will show that 80% of the TIA’s and 75% of relevant inpatients have stenosis, with 25% being sufficiently severe to require surgery. Thus approximately 1,160 patients are judged to meet the criteria in SIGN 108 for carotid endarterectomy; of these 395 (35%) will be inpatients and the remaining 765 outpatients. This information is presented in Table 6–1. Currently approximately 552 carotid endarterectomy procedures are performed in Scotland annually; 200 on inpatients and 350 on outpatients. The forecast additional number of procedures is 608, being 194 on inpatients and 414 on outpatients. 34 Table 6-1 Calculation to estimate number of patients eligible for surgery Patient groups TIA's admitted mRS ≤2 TIA's in outpatients mRS ≤2 Infarcts admitted mRS ≤2 Infarcts in outpatients mRS ≤2 Total patients including thrombolysis with mRS ≤2 Of these patients fit for surgery: TIA's admitted TIA's outpatients Infarcts admitted Infarcts outpatients Total patients fit for surgery Of these patients with stenosis: TIA’s with stenosis Infarcts with stenosis Total patients with stenosis Patients with severe stenosis and fit for surgery Of which: inpatients outpatients 6.3 Number of patients in Scotland 2,084 3,187 3,980 2,615 11,866 1,093 1,584 2,037 1,294 6,008 2,141 2,497 4,638 1,160 395 765 Clinical benefit and associated resource savings SIGN 108 notes the main clinical benefit from performing timely carotid endarterectomy is to prevent future strokes. The guideline provides the NNT to prevent one ipsilateral stroke at 5 years in patients with severe stenosis. The NNT rises steeply with the delay between time of surgery and the primary event. Surgery performed within 2 weeks of the event is associated with a NNT of 5 but at longer than 12 weeks the NNT rises to 125. Records from SSCAS show that of the 552 patients currently undergoing this procedure only 150 have it within 30 days of the event. Applying a NNT of 10 to these 150 events suggests the current intervention is preventing approximately 15 strokes at 5 years. Successful implementation of the recommendations in SIGN 108 could result in NHS boards treating 1,160 patients within 14 days, thereby achieving a NNT of 5 and preventing 232 strokes at five years. The additional 217 strokes prevented are equivalent to approximately 5,860 bed days assuming a mean bed day stay of 27 days per stroke patient (source ISD). The financial savings, assuming a mean direct cost for an inpatient bed of £277 (see Section 3.2) is £1.62 million. 35 6.4 Resource requirements The clinical resources required to perform a carotid endarterectomy on a patient who is already in hospital is assumed to be an additional MRI or equivalent scan, 1.5 hours in theatre (to include recovery) and an ultrasound post-surgery to inform the prognosis. It is assumed each outpatient will receive the scan and theatre time and spend 2 nights in hospital immediately prior to and post-surgery. Some surgeons may choose to perform the operation without routinely requiring the patient to be hospitalised for 2 nights once they are familiar with the procedure and associated risks and complications. The additional procedure related staff requirements are assumed to be: • a surgeon who spends 2 hours with each patient, • two theatre nurses (a band 5 and band 6 specialist nurse) who each require 1.5 hours, and • an anaesthetist incurring 1.5 hours. The additional staff required to carry out 608 extra procedures are 1.1 WTE surgeons, 0.65 WTE each of a band 5 and band 6 theatre nurse and 0.65 WTE anaesthetist. The staff required for the additional scans is addressed in Section 7. 6.5 Costs The unit costs associated with performing a carotid endarterectomy during an inpatient stay are estimated at £1,855 (see Section 3.4 and Table 3–3). Conducting the procedure on an outpatient is estimated to incur a cost of £2,443, with the difference being the cost of 2 overnight stays in a surgical ward. Applying these costs to an additional 194 inpatient and 414 outpatient procedures gives a total incremental cost of £1.38 million. This is the central estimate of the additional costs of performing carotid endarterectomy in line with the recommendations in SIGN 108. 6.6 Sensitivity analysis An obvious sensitivity analysis is around patient numbers. For example, if an extra 300 patients are eligible for such a procedure then the costs would increase in proportion. Thus the cost to manage 608 patients is estimated to be £1.38 million, and the costs to manage 908 estimated at £2.06 million [being £1.38*908/608]. The analysis assumes that consultants can identify the 50% who are unlikely to be fit for surgery without undertaking a carotid Doppler examination. If, however, this is not the case then the cost is underestimated by £0.93 million; the cost of 5,570 visits to a general surgery outpatient clinic plus a carotid Doppler examination. The combined mean cost of these is £167 for each NHS board (see Section 3.4 and Table 3–3). 36 6.7 Analyses by NHS board Tables 6–2 to 6–5 provide further information on the epidemiology, costs and benefits from timely carotid endarterectomy by NHS board. Table 6–3 presents the estimated clinical benefit, Table 6–4 the estimated additional costs to achieve timely carotid endarterectomy, and Table 6–5 the sensitivity analysis of the higher costs that would be incurred if a carotid Doppler scan is required to assess patients before surgery. 37 No of TIA's Likely to have Stenosis No of Infarcts Likely to have Stenosis Subtotal Number of Patients with Stenosis severe enough to require surgery Outcome from Carotid Dopplar Examination for Level of Stenosis No of TIA's Admitted No of TIA's in NV Outpatients No of Infarcts - FES Admitted No of Infarcts - NV Outpatients Total Patients Including Thrombolysis 149 179 328 82 1,160 25 49 52 101 NHS Borders NHS Ayrshire & Arran NHS Scotland total population 2,141 2,497 4,638 26 35 45 25 131 86 100 166 73 425 1,093 1,584 2,037 1,294 6,008 NHS Borders NHS Ayrshire & Arran NHS Scotland total population Number of Patients Scheduled for Carotid Dopplar as First Line Investigation for Carotid Stenosis 145 419 5,858 38.1% 14.5% Number of Patients Restricted from Surgery 35.2% 14.4% NHS Borders 37.2% 13.0% NHS Ayrshire & Arran 53 78 91 54 276 2 10 Estimate of patients too infirm to survive surgery Contraindications - T2DM and Clinical Obesity Restrictions on Patients being put forward for Surgery No of TIA's Admitted No of TIA's in NV Outpatients No of Infarcts - FES Admitted No of Infarcts - NV Outpatients Total Patients Including Thrombolysis NHS Scotland total population NHS Ayrshire & Arran NHS Scotland total population Independency Analysis of Ischaemic Strokes & CBV Events mRS < = 2 post thrombolysis 161 206 329 148 844 NHS Borders 53 508 Total Additional Patients 2,084 3,187 3,980 2,615 11,866 12 11 42 102 406 Improvements in mRS < = 1 (Discharged) Improvements in mRS < = 2 (No Discharge) NHS Borders NHS Ayrshire & Arran NHS Scotland total population Additions as a result of Thrombolysis 53 78 81 52 263 NHS Borders 161 206 287 137 791 NHS Ayrshire & Arran 2,084 3,187 3,574 2,513 11,358 No of TIA's Admitted No of TIA's in NV Outpatients No of Infarcts - FES Admitted No of Infarcts - NV Outpatients Total Patients excluding Thrombolysis NHS Scotland total population 33 46 85 131 NHS Dumfries & Galloway 28 30 67 47 172 NHS Dumfries & Galloway 193 40.9% 12.0% NHS Dumfries & Galloway 58 65 139 102 364 NHS Dumfries & Galloway 20 4 16 NHS Dumfries & Galloway 58 65 123 98 344 NHS Dumfries & Galloway 68 123 148 271 NHS Fife 73 81 140 58 352 NHS Fife 381 37.2% 14.8% NHS Fife 147 175 286 124 732 NHS Fife 37 7 30 NHS Fife 147 175 256 117 695 NHS Fife 38 51 91 113 204 NHS Forth Valley 42 72 101 51 265 NHS Forth Valley 244 35.6% 12.3% NHS Forth Valley 79 142 189 99 509 NHS Forth Valley 21 4 17 NHS Forth Valley 79 142 173 94 488 NHS Forth Valley 79 110 207 317 NHS Grampian 81 57 185 91 413 NHS Grampian 430 37.1% 13.8% NHS Grampian 171 119 365 188 843 NHS Grampian 46 9 36 NHS Grampian 171 119 328 179 797 NHS Grampian 362 NHS Greater Glasgow & Clyde 736 712 1,448 NHS Greater Glasgow & Clyde 290 630 514 436 1,870 1,675 35.0% 12.2% NHS Greater Glasgow & Clyde NHS Greater Glasgow & Clyde 524 1,226 951 843 3,544 130 26 104 NHS Greater Glasgow & Clyde NHS Greater Glasgow & Clyde 524 1,226 847 817 3,414 59 104 133 237 NHS Highland 71 59 116 62 308 NHS Highland 349 39.4% 13.7% NHS Highland 149 131 241 136 656 NHS Highland 26 5 21 NHS Highland 149 131 220 131 630 NHS Highland Patients who are potential candidates for carotid endarterectomy Independency Analysis of Ischaemic Strokes & CBV Events mRS < = 2 pre thrombolysis Table 6-2 9 16 18 34 NHS Island Boards 20 0 23 0 44 NHS Island Boards 38 38.2% 8.4% NHS Island Boards 38 0 43 1 82 NHS Island Boards 3 1 2 NHS Island Boards 38 0 41 0 80 NHS Island Boards 175 353 345 698 NHS Lanarkshire 133 309 247 213 901 NHS Lanarkshire 775 34.1% 12.1% NHS Lanarkshire 226 588 457 404 1,676 NHS Lanarkshire 62 12 49 NHS Lanarkshire 226 588 408 392 1,615 NHS Lanarkshire 146 231 354 585 NHS Lothian 130 158 272 201 761 NHS Lothian 829 38.3% 13.9% NHS Lothian 255 345 556 434 1,590 NHS Lothian 65 13 52 NHS Lothian 255 345 504 421 1,525 NHS Lothian 71 133 151 284 NHS Tayside 113 53 162 39 368 NHS Tayside 381 37.1% 13.8% NHS Tayside 221 113 333 82 749 NHS Tayside 34 7 27 NHS Tayside 221 113 306 75 715 NHS Tayside 65 7 10.8% 1 82 16 15 405 552 150 27.2% 15 1,160 232 217 5,859 NHS Ayrshire & Arran 5 135 5 26 36.4% 0 4 11 7 189 7 33 0.0% 0 0 28 NHS NHS Dumfries & Borders Galloway 13 351 14 68 20.0% 1 7 35 9 243 10 51 16.7% 1 7 42 NHS NHS Fife Forth Valley 15 405 16 79 26.2% 1 17 65 Total additional costs likely to be incurred in the implementation of timely carotid endarterectomy throughout Scotland Estimated current number of procedures carried out on patients required to be admitted to a surgical ward having either been previously discharged or having attended an outpatient clinic Additional inpatient procedures for new /re admission Procedure costs by health board Additional costs for inpatient surgery Estimated future number of procedures carried out on patients required to be admitted to a surgical ward having either been previously discharged or having attended an outpatient clinic Estimated future number of procedures carried out on existing inpatients where recovery post surgery is within the existing stroke unit Estimated current number of procedures carried out on existing inpatients where recovery post surgery is within the existing stroke unit Additional inpatient procedures Procedure costs by health board Additional costs for existing inpatient surgery £33,439 £32,707 10 £2,367 £23,670 10 £2,229 £22,290 414 £2,447 £1,013,192 £1,377,185 7 40 17 351 50 5 £1,807 £9,037 7 £1,593 £11,149 194 £1,876 £363,993 765 4 25 201 9 39 £10,469 3 £2,297 £6,891 17 20 2 £1,789 £3,578 11 13 NHS NHS Dumfries & Borders Galloway 32 NHS Ayrshire & Arran 395 NHS Scotland total population £69,429 20 £2,326 £46,520 21 41 13 £1,762 £22,909 14 27 £17,460 6 £2,120 £12,720 26 32 3 £1,580 £4,740 16 19 NHS NHS Fife Forth Valley £28,960 8 £2,301 £18,408 36 44 6 £1,759 £10,552 29 35 £591,189 171 £2,660 £454,860 92 263 65 £2,097 £136,329 34 99 NHS Greater NHS Grampian Glasgow & Clyde 67 1809 72 362 35.7% 5 45 126 NHS NHS Greater Grampian Glasgow & Clyde Estimated additional cost to achieve timely carotid endarterectomy Additional costs as a result of improved timely carotid endarterectomy Table 6-4 Current estimate of the number of cases of patients having Carotid Endarterectomy peformed in Scotland Current estimate of the number of cases of patients having Carotid Endarterectomy performed within 30 days where the NNT = 10 to avoid one recurrent event (from SSCAS as at 31 December 2007) Effectiveness Ratio currently: Current estimate of the number of events avoided: Future estimate of the number of cases of patients having Carotid Endarterectomy peformed in Scotland Assuming 100% effectiveness for all procedures carried out within 14 days where the NNT = 5 to avoid one recurrent event would potentially avoid: Additonal events avoided: Number of bed days saved based on average of 27 days NHS Scotland total population Estimated clinical benefit from timely carotid endarterectomy Additional benefits as a result of improved access to Carotid Endarterectomy Table 6-3 £22,427 6 £2,668 £16,008 31 37 3 £2,140 £6,419 19 22 NHS Highland 10 270 12 59 34.0% 2 17 50 NHS Highland 35 945 35 175 0.0% 0 0 29 £7,502 0 £0 £0 0 0 5 £1,500 £7,502 3 8 £285,210 106 £2,069 £219,314 21 127 40 £1,647 £65,896 8 48 NHS NHS Island Lanarkshire Boards 2 54 2 8 0.0% 0 0 3 NHS NHS Island Lanarkshire Boards £210,573 55 £2,725 £149,875 39 94 30 £2,023 £60,698 22 52 NHS Lothian 26 702 29 146 49.2% 3 30 61 NHS Lothian £67,819 19 £2,244 £42,636 21 40 15 £1,679 £25,183 16 31 NHS Tayside 13 351 14 71 43.2% 1 16 37 NHS Tayside Estimated Attendance for TIA Minor Stroke Clinic Restricted by time - outside of 30 days from onset Restricted by complications and co-morbidity Total % of Attendees unlikely to warrant surgery Number of investigations 'saved' Cost - Consultant Outpatient General Surgery Cost - Carotid Dopplar Examination Total cost saved or incurred by Screening £928,958 49.4% 5,568 11,278 NHS Scotland total population 791 35.2% 14.4% 49.6% 393 £61 £39 £39,300 NHS Ayrshire & Arran 263 38.1% 14.5% 52.6% 139 £115 £42 £21,823 NHS Borders 40 344 40.9% 12.0% 52.9% 182 £30 £68 £17,836 NHS Dumfries & Galloway 695 37.2% 14.8% 52.0% 361 £140 £33 £62,453 NHS Fife 488 35.6% 12.3% 47.9% 234 £119 £77 £45,864 NHS Forth Valley 797 37.1% 13.8% 51.0% 406 £105 £61 £67,396 NHS Grampian 3,414 35.0% 12.2% 47.2% 1,613 £105 £61 £267,758 NHS Greater Glasgow & Clyde 630 39.4% 13.7% 53.1% 335 £121 £110 £77,385 NHS Highland 1,615 34.1% 12.1% 46.2% 746 £89 £49 £102,948 NHS Lanarkshire 1,525 38.3% 13.9% 52.1% 795 £175 £50 £178,875 NHS Lothian 715 37.1% 13.8% 50.9% 364 £95 £35 £47,320 NHS Tayside Sensitivity analyses of higher costs incurred if carotid Doppler required assessing patient before surgery Sensitivity Analysis: Carotid examinations should be carried out with a view to include the most potential candidates for surgery taking into account, time of symptom onset vs delay to initial referral and potential complications and comorbidities. The cost of simply screening is measured as: Table 6-5 7 7.1 TIMELY CT DIAGNOSTICS Background SIGN 108 recommends that ‘All patients with suspected stroke should have brain imaging immediately on presentation’ (recommendation 2.3.1). The use of brain imaging is the first level of diagnostics necessary to distinguish whether a patient is presenting with a haemorrhagic stroke or an ischaemic stroke, including transient ischaemic events. The successful implementation of thrombolytic therapy within 4.5 hours of symptom onset requires the assessment of potential candidates using a CT head scanner immediately on arrival in hospital. This may require the patient to take precedent over others waiting for a scan, thereby interrupting the service for 15 minutes. Other stroke patients requiring scanning are less time critical and thus should be able to be planned within a daily schedule. No definite admission pattern for thrombolytic patients has been established. Feedback from some NHS boards indicates it is likely that a number of potential patients will present mid morning when radiology departments are often at their busiest. Extensive modelling has quantified the potential number of immediate scans required during this peak time to be twice per week in the larger boards and once per fortnight in the smaller boards. This assumes that all patients are delivered by SAS to the nominated target hospital in each NHS board. NHS Quality Improvement Scotland has published clinical standards on Stroke Services: Care of the Patient in the Acute Setting for all patients admitted with a stroke. These require that 80% of patients have CT/MRI imaging within 48 hours of admission. The standards are under review with a proposal to require that 80% of patients have CT/MRI imaging on the day of admission. A model has been developed to measure the demands that CT scanning for stroke places on radiology departments. This encompasses the resources and funding required solely to manage patients with suspected stroke including TIA. This model seeks to address some of the issues raised by members of the stroke managed clinical networks who reported significant delays in the radiological diagnostics service. Such services are tasked with delivering diagnostics to many other medical conditions, which are subject to their own timeframes and waiting time initiatives. The following analysis quantifies the resources required and costs of having a dedicated service for stroke. NHS boards may be able to compare these resources to current service levels to estimate whether additional resources are needed. In addition, in the first year, each NHS board is assumed to require additional support from a business administration manager to undertake the management and reporting of inpatients and outpatients and model patient flows. This activity should assist in optimising the resources required to support diagnostics, thrombolysis and carotid endarterectomy. 41 7.2 Patient group The patient group for timely CT scanning includes all diagnosed stroke inpatients plus those who attend at a neurovascular outpatient clinic. In addition there are a number of known stroke mimics whose symptoms on presentation are sufficiently similar to require CT scanning as a first level diagnostic tool. The scan can eliminate this particular group of patients from the stroke care pathway. The total patient group that gives rise to the demand for CT diagnostics is detailed in Table 7–1. Table 7-1 Patient groups requiring CT scanning facilities Patient groups Inpatient admittance (ISD epidemiology): First ever hospital admission Recurrent stroke event from current year Recurrent stroke event from historical year Uplift by 15% for mimics Subtotal for inpatients Outpatient attendance (SSCAS): Estimated number of TIA patients Estimated number of minor stroke patients 11% of patients with RAO or TMB 29% of patients with non CBV event Subtotal for outpatients NHSScotland total Stroke Mimic Total Attendance 8,814 1,339 1,767 1,759 13,679 3,187 2,513 1,075 2,825 17,620 5,659 9,600 23,279 Key: Retinal Artery Occlusion (RAO); Transient Monocular Blindness (TMB) In addition, the 1,015 patients forecast to benefit from thrombolytic therapy are assumed to receive a scan to assess any potential haemorrhagic activity as a result of the drug administration. Thus, total demand is estimated to be almost 24,300 patients annually. 7.3 Clinical benefits The clinical benefits associated with timely CT scanning are reported in Sections 5.3 and 6.3, being the clinical benefits attributable to timely thrombolysis and carotid endarterectomy. 7.4 Resources The resources required to meet the demand for CT scanning services in Scotland’s hospitals have been calculated assuming 24,300 patients require a CT scan each year. The annual demand is then expressed as a weekly demand assuming 50 operational weeks per annum and no seasonality. Expressing this weekly demand in operational machine hours, with each scan event taking 15 minutes, suggests that for Scotland a 42 total of 122 hours are required (see Table 7–2). This is equivalent to operating 25 scanners for 1 hour per day Monday to Friday. For the majority of NHS boards this will be one scanner per hospital site providing acute stroke services, with the exception of NHS Grampian and NHS Greater Glasgow and Clyde where it is equivalent to 1 hour per weekday on two scanners per tertiary site. Table 7-2 Calculation of operational CT scanning hours per week in Scottish hospitals Resources required for timely CT scanning NHS Ayrshire & Arran NHS Borders NHS Dumfries & Galloway NHS Fife NHS Forth Valley NHS Grampian NHS Greater Glasgow and Clyde NHS Highland NHS Island Boards NHS Lanarkshire NHS Lothian NHS Tayside NHSScotland First diagnostic event 1,728 555 748 1,475 993 1,864 6,561 1,369 179 2,979 3,103 1,723 23,277 Additional scan post thrombolysis 105 25 40 74 42 91 261 51 5 123 130 68 1,015 Total demand 1,833 580 788 1,549 1,035 1,955 6,822 1,420 184 3,102 3,233 1,791 24,292 Number per week (50) 37 12 16 31 21 39 136 28 4 62 65 36 486 Operational hours (15 min per scan) 9.2 2.9 3.9 7.7 5.2 9.8 34.1 7.1 0.9 15.5 16.2 9.0 121.5 No of scanners extended time 2 1 1 2 1 2 7 1 0 3 3 2 25 The staff resources required to provide a weekday service for each scanner are assumed to be: • one 0.5 planned activity session for a stroke consultant to read the scans • 0.2 WTE band 7 radiographer specialising in CT head scanning • 0.2 WTE band 6 radiographer with an interest in CT head scanning • 0.2 WTE band 3 helper, and • 0.2 WTE band 2 clerical officer. The annual resources required to provide a weekday service across Scotland are 625 planned activity sessions for consultants, 5 WTE band 7 radiographers, 5 WTE band 6 radiographers, 5 WTE band 3 helpers and 5 WTE band 2 clerical officers. This simplistic approach provides sufficient capacity to scan all patients on a weekday but not the two sevenths of inpatients; equivalent to approximately 4,340 inpatients who will require a service at weekends. Increasing the resources to provide scanning capability for those inpatients suggests the additional resources required are 737 43 planned activity sessions for consultants, 5.9 WTE band 7 radiographers, 5.9 WTE band 6 radiographers, 5.9 WTE band 3 helpers and 5.9 WTE band 2 clerical officers. Using this approach is consistent with assuming the number of appointments needed to manage 24,300 scans is 28,640. The additional 18% capacity recognises some outpatients will not attend the initial appointment and require a second appointment, the need for repeat scans and cases where the scan takes more than 15 minutes. An estimate of 3.8 WTE support from additional band 6 business administration managers is forecast to be required across Scotland, in the first year, to support implementation. 7.5 Costs The unit costs and total costs for each resource are shown in Table 7–3. Table 7-3 Unit cost and total cost to provide capacity to scan 24,300 people with stroke symptoms per year Resource Stroke consultant Band 7 radiographer Band 6 radiographer Band 3 helper Band 2 clerical officer Total for Scotland Resources required 15 planned activities per week 5.9 WTE 5.9 WTE 5.9 WTE 5.9 WTE Unit costs £20,660 per planned activity £40,996 £34,332 £19,895 £17,602 Total costs £309,900 £241,590 £202,319 £117,241 £103,729 £974,779 The additional cost of the 3.8 WTE band 6 business administration managers is estimated at £128,745. 7.6 Sensitivity analysis Information from SSCAS indicates that some NHS boards provide significantly more outpatient clinics than are indicated to be required to manage this patient group. 44 8 REFERENCES 1. National Audit Office. Report by the Comptroller and Auditor General. Department of Health. Reducing Brain Damage: Faster access to better stroke care. HC 452 Session 2005-2006. 16 November 2005. 2. Syme P., Byrne A., Chen R., Devenny R., Forbes J. Community-based stroke incidence in a Scottish population: the Scottish Borders Stroke Study. Stroke 2005; 36(9): 1837-43. (SBSS) 3. Scottish Intercollegiate Guidelines Network. Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention. A national clinical guideline. SIGN 108. 2008. Available from www.sign.ac.uk 4. Mauskopf J. et al. Principles of Good Practice for Budget Impact Analysis: Report of the ISPOR Task Force on Good Research Practice: Budget Impact Analysis. Value in Health 2007; 10(5): 336-347. 5. Trueman P., Hutton J., Drummond M. Developing Guidance for Budget Impact Analysis. Pharmacoeconomics 2001; 19(6): 609-621. 6. Trueman P., Cardow T. Independent Evaluation of the Resource Impact Tools Developed Alongside the SIGN CHD Guidelines. York Health Economics Consortium March 2008. 7. National Institute for Health and Clinical Excellence. Developing costing tools; Methods guide. January 2008. Available from: www.nice.org.uk 8. Rothwell P., Gutnikov S., Warlow C. European Carotid Surgery Trialist’s C. Reanalysis of the final results of the European Carotid Surgery Trial. Stroke 2003; 34(2): 514-23. 9. Audit Commission. National Report 2005. Managing the financial implications of NICE guidance. Available from www.audit-commission.gov.uk 10. Scottish Goverment. Coronary Heart Disease and Stroke: Strategy for Scotland. 3 October 2002. available from www.scotland.gov.uk 11. NHS National Services Scotland. Scottish Stroke Care Audit. Stroke Services in Scottish Hospitals; Data relating to 2005-2007. 2008 National Report. Available from www.isdscotland.org 12. Bamford J., Sandercock P., Dennis M. et al. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86. 1. Methodology, demography and incident cases of first-ever stroke. J Neurol Neurosurg Psychiatry 1988; 51: 1373-80 45 13. Bamford J., Sandercock P., Dennis M., Burn J., Warlow C. A prospective study of acute cerebrovascular disease in the community: the Oxfordshire Community Stroke Project 1981-86. 2. Incidence, case fatality rates and overall outcome at one year of cerebral infarction, primary Intracerebral haemorrhage and subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 1990; 53: 16-22 14. Bamford J., Sandercock P., Dennis M., Burn J., Warlow C. Classification and natural history of clinically identifiable subtypes of cerebral infarction. Lancet 1991; 337: 1521-26 15. Murphy D. Information Services Division (ISD). Cerebrovascular Disease Admissions in Scotland; episodes, continuous inpatient stays, number of patients and estimated costs in the patient pathway of care for the financial years 2002/03 to 2007/08 inclusive. File Reference IR2008-01983 in response to a request by Craig J. NHS Quality Improvement Scotland 13 August 2008. 16. Health Service Journal. Fast Thinking: Stroke Care 18-20. 12 March 2009 17. Caso V., Paciaroni M., Venti M., Palmerini F. et al. Determinant of outcome in patients eligible for thrombolysis for ischaemic stroke. Vasc Health Risk Manag 2007; 3(5): 749-54 18. Murphy D. Information Services Division (ISD). Cerebrovascular Disease Admissions & Mortality in Scotland; first ever occurrence of cerebrovascular disease that has resulted in a hospital admission or that has resulted in death without admission as a unique once only event. File Reference IR2008-02372 in response to a request by Wallace G. NHS Quality Improvement Scotland 1 October 2008. 19. Murphy D. Information Services Division (ISD). Cerebrovascular Disease Unique First Ever Admissions for Stroke or TIA in Scotland: Linked database results for prior admission history, readmission and survival for the years 31 March 2006, 2007 and 2008. File Reference IR2008-02372 in response to a request by Wallace G. NHS Quality Improvement Scotland 1 October 2008. 20. Hacke W., Donnan G., Fieschi C., Kaste M., von Kummer R., Broderick JP et al. Association of outcomes with early stroke treatment: pooled analysis of ATLANTIS, ECASS and NINDS rt-PA stroke trials. Lancet 2004; 363 768-74. 46 9 APPENDICES Appendix 1 Key recommendations The following recommendations were highlighted by the guideline development group as being clinically very important and to be prioritised for implementation. Each recommendation was then assessed as to whether it is a material change to current practice and likely to have a material resource impact. If so, then the recommendation is considered in this report. A brief commentary is provided for those recommendation judged not to have a material impact on resource use. SIGN 108 recommendation Emergency medical services should be redesigned to facilitate rapid access to specialist stroke services. Stroke patients requiring admission to hospital should be admitted to a stroke unit staffed by a co-ordinated multidisciplinary team with a special interest in stroke care. All patients with suspected stroke should have brain imaging immediately on presentation. All patients with non-disabling acute stroke syndrome/TIA in the carotid territory who are potential candidates for carotid surgery should have carotid imaging. Patients admitted with stroke within 4.5 hours of definite onset of symptoms, who are considered suitable, should be treated with 0.9 mg/kg (up to maximum 90 mg) intravenous rt-PA. For individuals aged up to 60 years who suffer an acute MCA territory ischaemic stroke complicated by massive cerebral oedema, surgical decompression by hemicraniectomy should be offered within 48 hours of stroke onset. Low-dose aspirin (75 mg daily) and dipyridamole (200 mg modified release twice daily) should be prescribed after ischaemic stroke or TIA for secondary prevention of vascular events. 47 Commentary Included in report Included in report Included in report Included in report Included in report Included in report Not included in report as this is current practice http://www.isdscotland.org/isd/servlet/File Buffer?namedFile=QOF_Scot_200405_to_ 200708_indicators_lookup.xls&pContentDi spositionType=attachment SIGN 108 recommendation Clopidogrel (75mg daily) monotherapy should be considered as an alternative to combination aspirin and dipyridamole after ischaemic stroke or TIA for secondary prevention of vascular events. A statin should be prescribed to patients who have had an ischaemic stroke, irrespective of cholesterol level. Statin therapy after haemorrhagic stroke is not routinely recommended unless the risk of further vascular events outweighs the risk of further haemorrhage. Commentary Not included in report as this is current practice http://www.isdscotland.org/isd/servlet/File Buffer?namedFile=QOF_Scot_200405_to_ 200708_indicators_lookup.xls&pContentDi spositionType=attachment Not included in report as this is current practice http://www.isdscotland.org/isd/servlet/File Buffer?namedFile=QOF_Scot_200405_to_ 200708_indicators_lookup.xls&pContentDi spositionType=attachment Not included in report as this is current practice All patients with carotid artery territory stroke Included in report (without severe disability, mRS ≤2) or transient ischaemic attack should be considered for carotid endarterectomy as soon as possible after the index event. Carotid endarterectomy (on the internal carotid Included in report artery ipsilateral to the cerebrovascular event) should be considered in all: • male patients with a carotid artery stenosis of 50–99% (by NASCET method) • female patients with a carotid artery stenosis of 70–99%. For all patients, carotid endarterectomy should Included in report be performed as soon as the patient is stable and fit for surgery, ideally within two weeks of event. Information should be offered to patients and carers in a variety of formats, including easy access. Care givers should be offered ongoing practical information and training individualised for the needs of the person for whom they are caring. 48 Judged not to require material additional resources or present system redesign Judged not to require material additional resources or present system redesign Appendix 2 Acknowledgements Authors (NHS Quality Improvement Scotland) Mr George M Wallace Ms Joyce Craig Senior Project Cost Accountant Lead Health Economist Authors’ acknowledgements We would like to thank all colleagues who contributed to the development of the report, provided responses to questionnaires and assisted in quality assuring the assumptions and pathways in individual NHS boards. In particular we would like to thank: Guideline development group members: Dr Anthony Byrne Ms Hazel Fraser Professor Peter Langhorne Dr Keith Muir Dr Scott Ramsay Dr Giles Roditi Dr Paul Syme Stroke Consultant, Stirling Royal Infirmary Lead MCN Nurse for Stroke, NHS Fife Professor of Geriatric Medicine, Glasgow Royal Infirmary Consultant Neurologist, Southern General Hospital, Glasgow Stroke Consultant, St John’s Hospital, Livingstone Consultant Radiologist, Glasgow Royal Infirmary Consultant Physician, Borders General Hospital, Melrose NHSScotland colleagues: Dr Mark Barber Ms Katrina Brennan Ms Denise Brown Dr George Crooks Professor Martin Dennis Ms Anne Duthie Dr Andrew Farrall Dr James Godfrey Mr Christian Goskirk Dr Ian Hay Dr Christine McAlpine Ms Pamela Mclauchlan Ms Morag Medwin Mr David Murphy Ms Stephanie Phillips Mr David Potter Ms Camilla Young Lead Clinician Stroke, NHS Lanarkshire Stroke MCN Manager, NHS Lanarkshire Stroke MCN Manager, NHS Ayrshire & Arran Medical Director, Scottish Ambulance Service Professor of Stroke Medicine, University of Edinburgh Service Development Manager, Scottish Centre for Telehealth Consultant Neuroradiologist, Royal Infirmary Edinburgh Lead Clinician Stroke, NHS Ayrshire & Arran Stroke MCN Manager, NHS Highland Lead Clinician Stroke, NHS Dumfries & Galloway Lead Clinician Stroke, NHS Greater Glasgow and Clyde Director of Finance, Scottish Ambulance Service Stroke MCN Manager, NHS Lothian Information Services Division Acting GM PPU, Scottish Ambulance Service Stroke MCN Manager, NHS Dumfries & Galloway Stroke MCN Manager, NHS Greater Glasgow and Clyde 49 Appendix 3 Resource impact assessment process Stage 1: Draft guideline at consultation stage Stage 2: Identify those recommendations likely to have a material resource impact Stage 3: Identify key cost drivers for each material recommendation and gather information on potential clinical benefits, pathways and cost evidence Stage 4: Develop model to estimate clinical benefits and associated resources and costs – incorporate sensitivity analysis Stage 5: Develop national clinical and resource impact report Stage 6: Determine links between national bodies and each NHS board and develop cost template where required Stage 7: Internal review with chair of the SIGN guideline development group and NHS Quality Improvement Scotland Stage 8: Circulate report and template to chair of guideline development group and others for peer review; update report based on feedback and any changes following consultations Stage 9: Final sign-off Stage 10: Publication, dissemination and impact assessment 50 Appendix 4.1 ICD-10 codes for stroke or TIA G45 G45.0 G45.1 G45.2 G45.3 G45.4 G45.8 G45.9 I61 I61.0 I61.1 I61.2 I61.3 I61.4 I61.5 I61.6 I61.8 I61.9 I62 I62.0 I62.1 I62.9 I63 I63.0 I63.1 I63.3 I63.4 I63.6 I63.8 I63.9 I64 Source: Transient cerebral ischaemic attacks and related syndromes Excludes: neonatal cerebral ischaemia (P91.0) Vertebro-basilar artery syndrome Carotid artery syndrome (hemispheric) Multiple and bilateral precerebral artery syndromes Amaurosis fugax Transient cerebral ischaemic attacks and related syndromes Other transient cerebral ischaemic attacks and related syndromes Transient cerebral ischaemic attack, unspecified Intracerebral haemorrhage Excludes: sequelae of intracerebral haemorrhage (I69.1) Intracerebral haemorrhage in hemisphere, subcortical Intracerebral haemorrhage in hemisphere, cortical Intracerebral haemorrhage in hemisphere, unspecified Intracerebral haemorrhage in brain stem Intracerebral haemorrhage in cerebellum Intracerebral haemorrhage, intraventricular Intracerebral haemorrhage, multiple localised Other intracerebral haemorrhage Intracerebral haemorrhage, unspecified Other nontraumatic intracranial haemorrhage Excludes sequelae of intracranial haemorrhage (169.2) Subdural haemorrhage (acute)(nontraumatic) Nontraumatic extradural haemorrhage Intracranial haemorrhage (nontraumatic), unspecified Cerebral infarction Excludes: sequelae of cerebral infarction (I69.3) Cerebral infarction due to thrombosis of precerebral arteries Cerebral infarction due to embolism of precerebral arteries Cerebral infarction due to thrombosis of cerebral arteries Cerebral infaction due to embolism of cerebral arteries Cerebral infarction due to cerebral venous thrombosis, nonpyogenic Other cerebral infarction Cerebral infarction, unspecified Stroke, not specified as haemorrhage or infarction Cerebrivascular accident NOS Excludes: sequelae of stroke (I69.4) International Statistical Classification of Diseases and Related Health Problems. Tenth Revision Volume 1. World Health Organisation, Geneva 1992 51 Appendix 4.2 ICD-10 codes for other cerebrovascular diseases I65 I65.0 I65.1 I65.2 I65.3 I65.8 I65.9 I66 I66.0 I66.1 I66.2 I66.3 I66.4 I66.8 I66.9 I67 I67.0 I67.1 I67.2 I67.3 I67.4 I67.5 I67.6 I67.7 I67.8 I67.9 I69 I69.0 I69.1 I69.2 I69.3 I69.4 I69.8 Source: Occlusion and senosis of precerebral arteries, not resulting in cerebral infarction Excludes: when causing cerebral infarction (I63.-) Occlusion and stenosis of vertebral artery Occlusion and stenosis of basilar artery Occlusion and stenosis of carotid artery Occlusion and stenosis of multiple and bilateral precerebral arteries Occlusion and stenosis of other precerebral artery Occlusion and stenosis of unspecified precerebral artery Occlusion and stenosis of cerebral arteries, not resulting in cerebral infarction Excludes: when causing cerebral infarction (163.-) Occlusion and stenosis of middle cerebral artery Occlusion and stenosis of anterior cerebral artery Occlusion and stenosis of posterior cerebral artery Occlusion and stenosis of cerebellar arteries Occlusion and stenosis of multiple and bilateral cerebral arteries Occlusion and stenosis of other cerebral artery Occlusion and stenosis of unspecified cerebral artery Other cerebrovascular diseases Excludes: sequelae of the listed conditions (I69.8) Dissection of cerebral arteries, nonruptured Cerebral aneurysm, nonruptured Cerebral atherosclerosis Progressive vascular leukoencephalopathy Hypertensive encephalopathy Moyamoya disease Nonpyogenic thrombosis of intracranial venous system Cerebral arteritis, not elsewhere classified Other specified cerebrovascular diseases Cerebrivascular disease, unspecified Sequelae of cerebrovasular disease Sequelae of subarachnoid haemorrhage Sequelae of intracerebral haemorrhage Sequelae of other non traumatic intracranial haemorrhage Sequelae of cerebral infarction Sequelae of stroke, not specified as haemorrhage or infarction Sequelae of other and unspecified cerebrovascular diseases International Statistical Classification of Diseases and Related Health Problems. Tenth Revision Volume 1. World Health Organisation, Geneva 1992 52 Appendix 5.1 Incidence of first ever hospital admission for stroke and TIA for year ending 31 March 2007 Population statistics mid year estimate provided by GRO as at 30 June 2006 Age group analysis % of total population % reduction in population groups Total 0 - 44 population years 5,116,900 2,941,253 57.5% 45 - 54 years 713,310 13.9% 55 - 64 years 624,369 12.2% 12.5% 65 - 74 years 455,744 8.9% 27.0% 75 - 84 years 287,021 5.6% 37.0% 85+ years 95,203 1.9% 66.8% Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 1,625 65 142 284 437 465 232 1,625 0.32 65 0.02 142 0.20 284 0.45 437 0.96 465 1.62 232 2.44 I61 SMR01 Database ISD Intracerebral GRO Mortality Records - I61 Haemorrhage Total Cases Incidence 782 127 909 0.18 46 7 53 0.02 75 10 85 0.12 103 19 122 0.20 184 23 207 0.45 231 40 271 0.94 143 28 171 1.80 SMR01 Database ISD I62 - Intracranial GRO Mortality Records - I62 Haemorrhage Total Cases Incidence 416 50 466 0.09 36 1 37 0.01 24 1 25 0.04 66 3 69 0.11 93 8 101 0.22 136 14 150 0.52 61 23 84 0.88 SMR01 Database ISD GRO Mortality Records - G45 GRO Mortality Records - I63 GRO Mortality Records - I69 Total Cases Incidence 3,440 7 95 554 4,096 0.80 129 240 475 830 0 1 130 0.04 3 0 243 0.34 6 8 489 0.78 10 38 878 1.93 1,143 1 25 195 1,364 4.75 623 6 51 312 992 10.42 SMR01 Database ISD GRO Mortality Records - I64 Total Cases Incidence 2,432 900 3,332 0.65 59 2 61 0.02 129 7 136 0.19 271 16 287 0.46 548 72 620 1.36 831 316 1,147 4.00 594 487 1,081 11.35 75 - 84 years 1.62 1.47 8.75 10.22 11.84 85+ years 2.44 2.68 21.77 24.45 26.89 465 421 2,511 232 255 2,073 12.8% 21.3% 20.0% 41.0% 465 367 1,975 232 204 1,223 2,807 1,659 Stroke Inpatient admission & GRO mortality Classifications records with no previous history of CBV in (ICD 10) the year to 31 March 2007 SMR01 Database ISD G45 - Transient GRO Mortality Records - Added to I63 Ischaemic Attack Total Cases Incidence I63 - Cerebral Infarction I64 Inconclusive Stroke Total 0 - 44 45 - 54 55 - 64 65 - 74 population years years years years 0.32 0.02 0.20 0.45 0.96 Incidence of TIA 0.27 0.03 0.15 0.31 0.68 Incidence of Haemorrhagic Stroke 1.45 0.06 0.53 1.24 3.29 Incidence of Cerebral Infarcts Incidence of First Ever Stroke 1.72 0.10 0.69 1.55 3.96 Incidence of First Ever CBV Event 2.04 0.12 0.88 2.00 4.92 Predicted number of first ever cerebrovascular events 1,625 65 142 284 437 Predicted TIA's 1,375 90 110 191 308 Predicted Haemorrhagic Strokes Predicted Ischaemic Strokes 191 379 776 1,498 7,428 % of first ever cerebrovascular events not admitted - death in the community 12.9% 8.9% 10.0% 11.5% 10.1% % Haemorrhagic Stroke Deaths % Ischaemic Stroke Deaths 20.9% 1.6% 2.6% 3.9% 8.0% Number of patients admitted to Scottish hospitals in the year to 31 March 2007 1,625 65 142 284 437 Number of TIA's Admitted 1,198 82 99 169 277 Number of Haemorrhagic Admitted 5,879 188 369 746 1,378 Number of Ischaemic Infarcts Admitted Total Number of Admissions 8,702 335 610 1,199 2,092 Events calculated from data collected Source ISD19 53 Appendix 5.2 Survival rates for stroke and TIA after a first ever hospital admission for year ending 31 March 2007 Number of TIA's Number of haemorrhagic strokes Number of ischaemic strokes Total Admissions Total population 1,625 1,198 5,879 8,702 TIA Survival rate Haemorrhagic stroke Survival rate Ischaemic strokes Survival rate Outcome - Month 1 numbers survived 1,600 65 140 98.5% 100.0% 98.6% 736 55 73 61.4% 67.1% 73.7% 4,918 177 344 83.7% 94.1% 93.2% Original admissions Comparator Infarct Analysis - Known Deaths Comparator Infarct Analysis - Predicted Deaths 961 954 0 - 44 years 65 82 188 335 11 7 45 - 54 years 142 99 369 610 55 - 64 years 284 169 746 1,199 25 19 65 - 74 years 437 277 1,378 2,092 75 - 84 years 465 367 1,975 2,807 85+ years 232 204 1,223 1,659 282 99.3% 114 67.5% 705 94.5% 435 99.5% 177 63.9% 1,227 89.0% 456 98.1% 219 59.7% 1,635 82.8% 222 95.7% 98 48.0% 830 67.9% 41 52 151 158 340 364 393 355 282 99.3% 108 63.9% 690 92.5% 425 97.3% 161 58.1% 1,162 84.3% 444 95.5% 194 52.9% 1,492 75.5% 209 90.1% 73 35.8% 675 55.2% 281 98.9% 105 62.1% 672 90.1% 414 94.7% 157 56.7% 1,124 81.6% 433 93.1% 175 47.7% 1,393 70.5% 190 81.9% 65 31.9% 593 48.5% 276 97.2% 102 60.4% 653 87.5% 405 92.7% 150 54.2% 1,076 78.1% 403 86.7% 160 43.6% 1,276 64.6% 170 73.3% 57 27.9% 521 42.6% Outcome - Month 3 numbers survived TIA Survival rate Haemorrhagic stroke Survival rate Ischaemic strokes Survival rate 1,565 96.3% 661 55.2% 4,535 77.1% 65 100.0% 54 65.9% 177 94.1% 140 98.6% 71 71.7% 339 91.9% Outcome - Month 6 numbers survived TIA Survival rate Haemorrhagic stroke Survival rate Ischaemic strokes Survival rate 1,522 93.7% 624 52.1% 4,293 73.0% 65 100.0% 53 64.6% 174 92.6% 139 97.9% 69 69.7% 337 91.3% Outcome - Month 12 numbers survived TIA Survival rate Haemorrhagic stroke Survival rate Ischaemic strokes Survival rate 1,458 89.7% 591 49.3% 4,024 68.4% Source ISD19 54 65 100.0% 53 64.6% 170 90.4% 139 97.9% 69 69.7% 328 88.9% Appendix 5.3 Re-admission rates for stroke and TIA after a first ever hospital admission for year ending 31 March 2007 Stroke Number of patients readmitted at 3, 6 & Classifications 12 months following a first ever (ICD 10) hospitalisation for a CBV event SMR01 - Original admittance 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 65 142 284 437 465 232 133 173 240 3 3 7 6 7 10 16 20 23 35 47 63 54 68 94 19 28 43 % Readmission at 12 months 14.8% 10.8% 7.0% 8.1% 14.4% 20.2% 18.5% SMR01 - Original admittance 782 46 75 103 184 231 143 33 53 75 5 5 5 2 3 4 3 7 9 7 10 21 11 17 23 5 11 13 % Readmission at 12 months 9.6% 10.9% 5.3% 8.7% 11.4% 10.0% 9.1% SMR01 - Original admittance 416 36 24 66 93 136 61 45 52 56 3 4 4 4 5 5 7 10 12 15 16 17 10 11 12 6 6 6 % Readmission at 12 months 13.5% 11.1% 20.8% 18.2% 18.3% 8.8% 9.8% SMR01 - Original admittance 3,440 129 240 475 830 1,143 623 227 358 542 7 11 18 21 30 40 37 55 73 55 91 136 75 116 188 32 55 87 % Readmission at 12 months 15.8% 14.0% 16.7% 15.4% 16.4% 16.4% 14.0% SMR01 - Original admittance 2,432 59 129 271 548 831 594 161 241 339 8 9 10 11 16 18 22 31 43 47 68 91 47 75 114 26 42 63 13.9% 16.9% 14.0% 15.9% 16.6% 13.7% 10.6% SMR01 - Readmission at 3 months I61 Intracerebral SMR01 - Readmission at 6 months Haemorrhage SMR01 - Readmission at 12 months SMR01 - Readmission at 3 months I62 - Intracranial SMR01 - Readmission at 6 months Haemorrhage SMR01 - Readmission at 12 months I64 Inconclusive Stroke 0 - 44 years 1,625 SMR01 - Readmission at 3 months G45 - Transient SMR01 - Readmission at 6 months Ischaemic Attack SMR01 - Readmission at 12 months I63 - Cerebral Infarction Total population SMR01 - Readmission at 3 months SMR01 - Readmission at 6 months SMR01 - Readmission at 12 months SMR01 - Readmission at 3 months SMR01 - Readmission at 6 months SMR01 - Readmission at 12 months % Readmission at 12 months Readmission summary for cerebral infarcts at 12 months Transient Ischaemic Attack Haemorrhagic stroke (I61 & I62) Ischaemic stroke (I63 & I64) Readmission summary for infarcts at 3 months Comparator Infarct Analysis - Known Readmissions Comparator Infarct Analysis - Predicted Readmissions Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 14.8% 10.9% 15.0% 10.8% 11.0% 14.9% 7.0% 9.1% 15.7% 8.1% 12.4% 15.5% 14.4% 13.7% 16.5% 20.2% 9.5% 15.3% 18.5% 9.3% 12.3% 388 409 15 11 32 19 59 48 102 100 122 155 58 77 Source ISD19 55 Appendix 5.4 Prior admission of patients who had a first ever admittance for stroke or TIA for year ending 31 March 2007 Stroke Prior admissions identified for conditions Classifications likely to be contra indicated for (ICD 10) thrombolysis & carotid surgery Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years SMR01 - Original admittance 1,625 65 142 284 437 465 232 SMR01 - Liver Complications G45 - Transient SMR01 - Type 1 Diabetes Ischaemic Attack SMR01 - Type 2 Diabetes 12 35 206 1 0 4 1 5 12 2 8 30 3 15 68 5 5 71 0 2 21 15.6% 7.7% 12.7% 14.1% 19.7% 17.4% 9.9% SMR01 - Original admittance 782 46 75 103 184 231 143 I61 SMR01 - Liver Complications Intracerebral SMR01 - Type 1 Diabetes Haemorrhage SMR01 - Type 2 Diabetes 31 10 66 5 0 1 10 4 8 10 2 10 5 2 18 1 2 23 0 0 6 13.7% 13.0% 29.3% 21.4% 13.6% 11.3% 4.2% SMR01 - Original admittance 416 36 24 66 93 136 61 SMR01 - Liver Complications I62 - Intracranial SMR01 - Type 1 Diabetes Haemorrhage SMR01 - Type 2 Diabetes 11 4 38 2 0 0 4 0 1 4 0 5 0 1 10 1 3 19 0 0 3 12.7% 5.6% 20.8% 13.6% 11.8% 16.9% 4.9% SMR01 - Original admittance 3,440 129 240 475 830 1,143 623 SMR01 - Liver Complications SMR01 - Type 1 Diabetes SMR01 - Type 2 Diabetes 35 93 475 1 3 7 5 7 26 13 18 63 11 35 138 4 22 172 1 8 69 17.5% 8.5% 15.8% 19.8% 22.2% 17.3% 12.5% SMR01 - Original admittance 2,432 59 129 271 548 831 594 SMR01 - Liver Complications SMR01 - Type 1 Diabetes SMR01 - Type 2 Diabetes 34 63 335 1 5 4 6 5 18 6 9 36 13 21 104 6 18 125 2 5 48 17.8% 16.9% 22.5% 18.8% 25.2% 17.9% 9.3% % Total Complications Admitted % Total Complications Admitted % Total Complications Admitted I63 - Cerebral Infarction % Total Complications Admitted I64 Inconclusive Stroke % Total Complications Admitted Complications summary by CBV event Transient Ischaemic Attack Haemorrhagic Stroke Cerebral Infarcts Complications summary by intervention Contraindicated for Thrombolysis Possible contraindications for carotid surgery Total population 15.6% 13.4% 17.6% Total population 0 - 44 years 7.7% 9.8% 11.2% 0 - 44 years 45 - 54 years 12.7% 27.3% 18.2% 45 - 54 years 55 - 64 years 14.1% 18.3% 19.4% 55 - 64 years 65 - 74 years 19.7% 13.0% 23.4% 65 - 74 years 75 - 84 years 17.4% 13.4% 17.6% 75 - 84 years 85+ years 9.9% 4.4% 10.9% 85+ years 3.8% 5.3% 6.2% 6.2% 5.8% 2.5% 1.3% 13.6% 5.9% 11.0% 12.5% 17.1% 15.1% 9.5% Source ISD19 56 Appendix 5.5 Incidence of stroke and TIA resulting in a first ever hospital admission by NHS board for year ending 31 March 2007 Age Analysis of First Ever in a lifetime Stroke - Number of Cases Stroke Event G45 Transient Ischaemic Attack Total ICH Total Infarcts Total Number of Stokes Total CBV Events 0 - 44 years 65 90 191 281 346 45 - 54 years 142 110 379 489 631 55 - 64 years 284 191 776 967 1,251 65 - 74 years 437 308 1,498 1,806 2,243 75 - 84 years 465 421 2,511 2,932 3,397 85+ Total years population 232 1,625 255 1,375 2,073 7,428 2,328 8,803 2,560 10,428 Age Analysis of First Ever in a lifetime Stroke - Incidence per 1000 of the Population Stoke Event G45 Transient Ischaemic Attack Total ICH Total Infarcts Total Number of Stokes Total CBV Events 0 - 44 years 0.02 0.03 0.06 0.10 0.12 45 - 54 years 0.20 0.15 0.53 0.69 0.88 55 - 64 years 0.45 0.31 1.24 1.55 2.00 65 - 74 years 0.96 0.68 3.29 3.96 4.92 75 - 84 years 1.62 1.47 8.75 10.22 11.84 85+ Total years population 2.44 0.32 2.68 0.27 21.77 1.45 24.45 1.72 26.89 2.04 75 - 84 years 10.22 10.05 10.20 10.72 9.76 10.04 11.35 85+ Total years population 24.45 1.72 25.52 1.75 23.92 1.52 27.06 1.68 24.63 1.61 23.59 1.96 25.14 1.95 75 - 84 years 10.22 10.63 9.84 10.43 10.27 8.74 8.89 85+ Total years population 24.45 1.72 21.49 1.71 22.97 1.78 24.22 1.63 23.12 1.99 27.04 1.90 20.79 1.46 Health Board Analysis of Contribution to First Ever Stroke Incidence Population Ranking Comparator 1 2 3 4 5 6 Health Board Scotland Greater Glasgow & Clyde Lothian Lanarkshire Grampian Tayside Ayr 0 - 44 years 0.10 0.12 0.06 0.09 0.11 0.12 0.12 45 - 54 years 0.69 0.90 0.58 0.78 0.70 0.50 0.60 55 - 64 years 1.55 1.76 1.58 1.68 1.20 1.76 1.88 65 - 74 years 3.96 4.46 3.50 4.32 3.66 4.07 3.58 Health Board Analysis of Contribution to First Ever Stroke Incidence Population Ranking Comparator 7 8 9 10 11 12 Health Board Scotland Fife Highlands Forth Valley Dumfries Borders Islands 0 - 44 years 0.10 0.08 0.07 0.10 0.07 0.09 0.08 45 - 54 years 0.69 0.57 0.55 0.74 0.42 0.74 0.30 Source ISD19 57 55 - 64 years 1.55 1.28 1.27 1.41 1.63 1.15 0.73 65 - 74 years 3.96 4.27 3.86 3.79 3.64 3.83 2.54 Appendix 5.6 Predicted mortality for patients with first admission of ischaemic stroke for year ending 31 March 2007 Original Admissions Number of FES - TIA's Admitted Number of FES - Haemorrhagic Admitted Number of FES - Infarcts Admitted Total Admissions Total population 1,625 1,198 5,879 8,702 0 - 44 years 65 82 188 335 45 - 54 years 142 99 369 610 55 - 64 years 284 169 746 1,199 65 - 74 years 437 277 1,378 2,092 75 - 84 years 465 367 1,975 2,807 85+ years 232 204 1,223 1,659 Predictive Outcome Model (Adapted from OCSP 1986) - Identifying the Four Subtypes of Infarction Cryptogenic Stroke - Not Included Cryptogenic Stroke - Patients Excluded Clinically Identifiable Subtypes of Cerebral Infarction LACI - Lacunar Infarcts TACI - Total Anterior Circulation Infarcts PACI - Partial Anterior Circulation Infarcts POCI - Posterior Circulation Infracts 5% 293 40% 75 20% 74 10% 75 5% 69 0% 0 0% 0 Total population 25% 17% 34% 24% Subtotal 0 - 44 years 5% 5% 85% 5% 100% 45 - 54 years 35% 10% 40% 15% 100% 55 - 64 years 25% 15% 35% 25% 100% 65 - 74 years 25% 15% 35% 25% 100% 75 - 84 years 24% 17% 34% 25% 100% 85+ years 25% 25% 25% 25% 100% LACI - Lacunar Infarcts TACI - Total Anterior Circulation Infarcts PACI - Partial Anterior Circulation Infarcts POCI - Posterior Circulation Infracts 1,384 975 1,885 1,345 6 6 96 6 103 30 118 44 168 101 235 167 327 196 458 327 474 336 672 495 306 306 306 306 Total Infarcts excluding Cryptogenic Stroke 5,589 114 295 671 1,308 1,977 1,224 75 - 84 years 4% 60% 11% 14% 85+ years 8% 65% 22% 21% 19 202 74 69 24 199 67 64 364 340 355 393 Outcome of Infarct Analysis Predictive Outcome Model (Adapted from OCSP 1986) - 30 Day Mortality Clinically Identifiable Subtypes of Cerebral Total 0 - 44 45 - 54 55 - 64 65 - 74 Infarction population years years years years LACI - Lacunar Infarcts 4% 2% 2% 2% 4% TACI - Total Anterior Circulation Infarcts 50% 25% 25% 25% 25% PACI - Partial Anterior Circulation Infarcts 11% 5% 5% 5% 11% POCI - Posterior Circulation Infracts 14% 7% 7% 7% 14% Application of OCSP Mortality Rate at 6 Months - Applied in Scotland in the First 30 Days of Admission LACI - Lacunar Infarcts 62 0 2 3 13 TACI - Total Anterior Circulation Infarcts 484 2 8 25 49 PACI - Partial Anterior Circulation Infarcts 214 5 6 12 50 POCI - Posterior Circulation Infracts 195 0 3 12 46 Predicted No of Deaths in the First Month Known No of Deaths in the First Month 954 961 7 11 19 25 52 41 158 151 Predictive Outcome Model (Adapted from OCSP 1986) - Recurrent Strokes Readmitted in the First 3 Months Number of Infarction Subtypes Survived at 1 Total 0 - 44 45 - 54 Month population years years LACI - Lacunar Infarcts 1,322 6 101 TACI - Total Anterior Circulation Infarcts 491 5 23 PACI - Partial Anterior Circulation Infarcts 1,671 91 112 POCI - Posterior Circulation Infracts 1,150 6 41 Application of OSCP Recurrent Stroke Rates LACI - Lacunar Infarcts 2% 1% 1% TACI - Total Anterior Circulation Infarcts 4% 2% 2% PACI - Partial Anterior Circulation Infarcts 14% 11% 12% POCI - Posterior Circulation Infracts 11% 8% 9% Predicted Number of Patients to be readmitted as a result of Recurrent Stroke LACI - Lacunar Infarcts 24 0 1 TACI - Total Anterior Circulation Infarcts 18 0 0 PACI - Partial Anterior Circulation Infarcts 237 10 13 POCI - Posterior Circulation Infracts 131 0 4 Predicted Readmissions at 3 Months 409 11 19 Known Readmissions at 3 Months 388 15 32 58 55 - 64 years 165 76 223 155 65 - 74 years 314 147 408 281 75 - 84 years 455 134 598 426 85+ years 282 107 239 242 1% 2% 13% 10% 2% 4% 14% 11% 2% 4% 15% 12% 2% 4% 16% 12% 2 2 29 16 48 59 6 6 57 31 100 102 9 5 90 51 155 122 6 4 38 29 77 58 Appendix 5.7 Predicted mortality and disability for patients with first admission of ischaemic stroke for year ending 31 March 2007 Original Admissions Number of FES - TIA' s Admitted Number of FES - Haemorrhagic Admitted Number of FES - Infarcts Admitted Total Admissions Total population 1,625 1,198 5,879 8,702 0 - 44 years 65 82 188 335 45 - 54 years 142 99 369 610 55 - 64 years 284 169 746 1,199 65 - 74 years 437 277 1,378 2,092 75 - 84 years 465 367 1,975 2,807 85+ years 232 204 1,223 1,659 Predictive Outcome Model (Adapted from OCSP 1986) - Identifying Disability in the Four Subtypes of Infarction Cryptogenic Stroke - Not Included Cryptogenic Stroke - Patients Excluded Clinically Identifiable Subtypes of Cerebral Infarction LACI - Lacunar Infarcts TACI - Total Anterior Circulation Infarcts PACI - Partial Anterior Circulation Infarcts POCI - Posterior Circulation Infracts 5% 293 40% 75 20% 74 10% 75 5% 69 0% 0 0% 0 Total population 25% 17% 34% 24% Subtotal 0 - 44 years 5% 5% 85% 5% 100% 45 - 54 years 35% 10% 40% 15% 100% 55 - 64 years 25% 15% 35% 25% 100% 65 - 74 years 25% 15% 35% 25% 100% 75 - 84 years 24% 17% 34% 25% 100% 85+ years 25% 25% 25% 25% 100% LACI - Lacunar Infarcts TACI - Total Anterior Circulation Infarcts PACI - Partial Anterior Circulation Infarcts POCI - Posterior Circulation Infracts 1,384 975 1,885 1,345 6 6 96 6 103 30 118 44 168 101 235 167 327 196 458 327 474 336 672 495 306 306 306 306 Total Infarcts excluding Cryptogenic Stroke 5,589 114 295 671 1,308 1,977 1,224 Outcome of Infarct Analysis Predictive Outcome Model (Adapted from OCSP 1986) - Death & Disability Rates at 30 Days Clinically Identifiable Subtypes of Cerebral Total 0 - 44 45 - 54 Infarction population years years Mortality Rate Detailed in Infarct Analysis & Readmission 4% 2% 2% LACI - Lacunar Infarcts 50% 25% 25% TACI - Total Anterior Circulation Infarcts 11% 5% 5% PACI - Partial Anterior Circulation Infarcts POCI - Posterior Circulation Infracts 14% 7% 7% Application of OCSP Disability Rates at 30 Days - mRS of between 3 and 5 34% 20% 20% LACI - Lacunar Infarcts 45% 30% 40% TACI - Total Anterior Circulation Infarcts 33% 20% 20% PACI - Partial Anterior Circulation Infarcts POCI - Posterior Circulation Infracts 24% 10% 10% Application of OCSP Disability Rates at 30 Days - mRS of between 0 and 2 61% 78% 78% LACI - Lacunar Infarcts 5% 45% 35% TACI - Total Anterior Circulation Infarcts 55% 75% 75% PACI - Partial Anterior Circulation Infarcts POCI - Posterior Circulation Infracts 61% 83% 83% Total Allocation between Infarct Groups 100% 100% 100% 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 2% 25% 5% 7% 4% 25% 11% 14% 4% 60% 11% 14% 8% 65% 22% 21% 30% 50% 25% 15% 35% 70% 30% 25% 35% 40% 40% 25% 40% 35% 40% 30% 68% 25% 70% 78% 100% 61% 5% 59% 61% 100% 61% 0% 49% 61% 100% 52% 0% 38% 49% 100% Predictive Outcome Model (Adapted from OCSP 1986) - Allocation Split of Dependence at 30 Days Number of Infarction Subtypes having an mRS Total of between 0 and 2 population LACI - Lacunar Infarcts 846 48 TACI - Total Anterior Circulation Infarcts 1,041 PACI - Partial Anterior Circulation Infarcts POCI - Posterior Circulation Infracts 823 Total Allocation between Infarct Groups 2,758 0 - 44 years Number of Infarction Subtypes having an mRS Total of between 3 and 5 population LACI - Lacunar Infarcts 475 443 TACI - Total Anterior Circulation Infarcts 630 PACI - Partial Anterior Circulation Infarcts POCI - Posterior Circulation Infracts 327 Total Allocation between Infarct Groups 1,875 0 - 44 years 5 3 72 5 85 1 2 19 1 23 45 - 54 years 80 11 89 37 216 55 - 64 years 114 25 165 130 434 65 - 74 years 199 10 270 199 678 75 - 84 years 289 0 329 302 920 85+ years 159 0 116 150 425 45 - 54 years 21 12 24 4 61 55 - 64 years 50 51 59 25 185 65 - 74 years 114 137 137 82 471 75 - 84 years 166 134 269 124 693 85+ years 122 107 122 92 444 Predictive Outcome Model (Adapted from OCSP 1986) - Age Related Ratio between Dependency & Independency Dependency Ratio Totals for Scotland Total population 40% 0 - 44 years 21% 59 45 - 54 years 22% 55 - 64 years 30% 65 - 74 years 41% 75 - 84 years 43% 85+ years 51% Appendix 6.1 Estimated first hospital admissions for stroke or TIA Population statistics mid year estimate provided by GRO as at 30 June 2007 Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years Age group analysis % of total population % reduction in population groups 5,144,200 2,938,670 57.1% 728,462 14.2% 631,455 12.3% 13.3% 457,382 8.9% 27.6% 289,941 5.6% 36.6% 98,290 1.9% 66.1% Incidence of stroke that has resulted in a first ever hospital admission Stroke Information from data collected in 3 Classifications year incidence studies for Scotland (ICD 10) Incidence calculated for 2006 G45 - Transient Incidence calculated for 2007 Ischaemic Attack Incidence calculated for 2008 Average Incidence for Period Incidence calculated for 2006 I61 Incidence calculated for 2007 Intracerebral Incidence calculated for 2008 Haemorrhage Average Incidence for Period Incidence calculated for 2006 I62 - Intracranial Incidence calculated for 2007 Haemorrhage Incidence calculated for 2008 Average Incidence for Period Incidence calculated for 2006 I63 - Cerebral Incidence calculated for 2007 Incidence calculated for 2008 Infarction Average Incidence for Period Incidence calculated for 2006 I64 Incidence calculated for 2007 Inconclusive Incidence calculated for 2008 Stroke Average Incidence for Period Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 0.30 0.32 0.31 0.31 0.18 0.18 0.17 0.18 0.08 0.09 0.09 0.09 0.84 0.80 0.75 0.80 0.68 0.65 0.66 0.66 0.03 0.02 0.02 0.02 0.02 0.02 0.02 0.02 0.01 0.01 0.01 0.01 0.05 0.04 0.05 0.05 0.02 0.02 0.02 0.02 0.20 0.20 0.23 0.21 0.12 0.12 0.13 0.12 0.05 0.04 0.05 0.04 0.35 0.34 0.31 0.33 0.18 0.19 0.22 0.20 0.47 0.45 0.48 0.47 0.24 0.20 0.20 0.21 0.11 0.11 0.11 0.11 0.88 0.78 0.75 0.80 0.55 0.46 0.53 0.51 0.83 0.96 0.87 0.89 0.42 0.45 0.43 0.43 0.22 0.22 0.25 0.23 2.19 1.93 1.80 1.97 1.37 1.36 1.36 1.36 1.47 1.62 1.52 1.54 1.02 0.94 0.87 0.95 0.44 0.52 0.46 0.48 4.97 4.75 4.22 4.65 4.37 4.00 3.93 4.10 2.61 2.44 2.30 2.45 1.61 1.80 1.49 1.63 0.73 0.88 0.84 0.82 10.54 10.42 9.84 10.26 11.95 11.35 10.84 11.38 Prevalence of first every CBV event that has resulted in outright mortality with no hospital admission record Information from data collected in 3 Stroke year incidence studies for Scotland Classifications GRO Mortality Records Haemorrhagic Prevalence calculated for 2006 Stroke Prevalence calculated for 2007 Community Prevalence calculated for 2008 Average Prevalence for Period Mortality Prevalence calculated for 2006 Ischaemic Stroke Prevalence calculated for 2007 Community Prevalence calculated for 2008 Mortality Average Prevalence for Period Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 13.6% 12.9% 12.2% 12.9% 21.4% 20.9% 20.7% 21.0% 7.4% 8.9% 8.7% 8.3% 3.0% 1.6% 1.9% 2.2% 15.8% 10.0% 19.7% 15.2% 2.7% 2.6% 1.8% 2.4% 11.7% 11.5% 12.2% 11.8% 5.3% 3.9% 4.4% 4.5% 11.7% 10.1% 8.3% 10.0% 10.2% 8.0% 10.2% 9.5% 15.8% 12.8% 11.4% 13.3% 22.2% 21.3% 20.8% 21.4% 15.6% 20.0% 16.2% 17.2% 41.3% 41.0% 40.2% 40.8% Events calculated from data collected on Total 0 - 44 45 - 54 55 - 64 65 - 74 75 - 84 85+ the probability of a first ever hospital population years years years years years years admission 0.31 0.02 0.21 0.47 0.89 1.54 2.45 Incidence of TIA 0.27 0.03 0.17 0.32 0.67 1.42 2.45 Incidence of Haemorrhagic Stroke 1.46 0.07 0.53 1.32 3.33 8.75 21.64 Incidence of Ischaemic Stroke Incidence of first ever admisson - stroke 1.73 0.10 0.70 1.64 4.00 10.17 24.09 Incidence of first ever admission - CBV 2.04 0.13 0.91 2.11 4.89 11.70 26.54 Predicted number of cerebrovasclar events likely to lead to a first hospital admission 1,612 73 152 295 406 446 241 Predicted TIA's 1,378 96 121 204 305 412 241 Predicted Haemorrhagic Strokes Predicted Ischaemic Strokes 7,605 199 386 832 1,525 2,536 2,127 Prevalance of cerebrovascular events that will not be admitted - death in the community 12.9% 8.3% 15.2% 11.8% 10.0% 13.3% 17.2% % Haemorrhagic Stroke Deaths % Ischaemic Stroke Deaths 21.0% 2.2% 2.4% 4.5% 9.5% 21.4% 40.8% Number of CBV events due for a first ever admission to Scottish hospitals in the year to 31 March 2009 1,612 73 152 295 406 446 241 Number of TIA's 1,201 88 103 180 274 357 199 Number of Haemorrhagic 5,997 194 377 794 1,380 1,992 1,259 Number of Ischaemic Infarcts Number of First Ever Admissions 8,811 355 632 Source ISD19 60 1,269 2,061 2,795 1,699 Appendix 6.2 Estimated survival rates for patients following a first admission to hospital for stroke or TIA Predicted first ever hospital admissions as a result of stroke or CBV event Number of FES - TIA's Number of FES - Haemorrhagic Number of FES - Infarcts Total Admissions Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 1,612 1,201 5,997 8,811 73 88 194 355 152 103 377 632 295 180 794 1,269 406 274 1,380 2,061 446 357 1,992 2,795 241 199 1,259 1,699 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 98.8% 100.0% 100.0% 99.6% 79.5% 67.1% 86.3% 77.6% 95.8% 94.1% 95.1% 95.0% 100.0% 98.6% 100.0% 99.5% 70.3% 73.7% 63.7% 69.3% 94.2% 93.2% 94.7% 94.0% 100.0% 99.3% 99.0% 99.4% 73.5% 67.5% 74.6% 71.9% 94.2% 94.5% 93.3% 94.0% 100.0% 99.5% 98.0% 99.2% 68.5% 63.9% 65.6% 66.0% 89.5% 89.0% 88.3% 88.9% 100.0% 98.1% 98.4% 98.8% 57.8% 59.7% 61.2% 59.6% 81.1% 82.8% 80.9% 81.6% 100.0% 95.7% 96.0% 97.2% 50.3% 48.0% 52.1% 50.1% 70.3% 67.9% 70.7% 69.6% 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 72 69 185 326 0 20 10 30 151 71 354 577 1 32 22 55 293 129 747 1,169 2 51 48 100 403 181 1,228 1,811 3 93 153 249 441 213 1,625 2,278 5 144 367 516 234 100 877 1,211 7 99 383 489 8.4% 8.7% 7.9% 12.1% 18.5% 28.8% 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 98.8% 100.0% 100.0% 99.6% 77.3% 64.6% 77.9% 73.3% 92.2% 90.4% 93.6% 92.1% 96.4% 97.9% 98.2% 97.5% 67.3% 69.7% 54.9% 64.0% 91.7% 88.9% 92.1% 90.9% 96.5% 97.2% 97.7% 97.1% 62.4% 60.4% 68.8% 63.9% 87.5% 87.5% 87.6% 87.5% 93.1% 92.7% 95.0% 93.6% 57.6% 54.2% 56.6% 56.1% 78.4% 78.1% 80.0% 78.9% 87.9% 86.7% 88.5% 87.7% 42.2% 43.6% 47.8% 44.5% 63.3% 64.6% 65.1% 64.3% 73.0% 73.3% 82.3% 76.2% 32.4% 27.9% 36.5% 32.3% 40.2% 42.6% 49.1% 44.0% 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 72 65 179 316 0 24 15 39 148 66 343 557 4 37 34 75 286 115 695 1,096 8 65 99 172 380 154 1,088 1,622 26 120 292 438 391 159 1,281 1,831 55 198 711 964 183 64 554 801 57 135 706 898 11.1% 11.9% 13.6% 21.3% 34.5% 52.8% Average survial rates following a first Stroke Total ever admisson for stroke or TIA outcome Classifications population at 1 month Survival rates in 2006 99.9% Transient Survival rates in 2007 98.5% Ischaemic Attack Survival rates in 2008 98.3% 98.9% Average contribution for period Survival rates in 2006 64.3% Haemorrhagic Survival rates in 2007 61.4% Stroke Survival rates in 2008 65.0% 63.6% Average contribution for period Survival rates in 2006 84.0% Survival rates in 2007 83.7% Ischaemic Stroke Survival rates in 2008 83.5% 83.7% Average contribution for period Predicted number of first ever admissons Total as a result of stroke or TIA event likely to population survive at 1 month Number of FES - TIA's 1,595 Number of FES - Haemorrhagic 762 Number of FES - Infarcts 5,015 Total numbers survived at 1 month 7,372 Number of FES - TIA's 18 Number of FES - Haemorrhagic 439 Number of FES - Infarcts 982 Total mortality at 1 month 1,439 Total rate of mortality at 1 month 16.3% Average survial rates following a first Stroke Total ever admisson for stroke or TIA outcome Classifications population at 1 year Survival rates in 2006 89.8% Transient Survival rates in 2007 89.7% Ischaemic Attack Survival rates in 2008 92.5% 90.7% Average contribution for period Survival rates in 2006 52.2% Haemorrhagic Survival rates in 2007 49.3% Stroke Survival rates in 2008 54.1% 51.9% Average contribution for period Survival rates in 2006 68.2% Survival rates in 2007 68.4% Ischaemic Stroke Survival rates in 2008 70.9% 69.2% Average contribution for period Predicted number of first ever admissons Total as a result of stroke or TIA event likely to population survive at 1 year Number of FES - TIA's 1,462 Number of FES - Haemorrhagic 622 Number of FES - Infarcts 4,140 6,224 Total numbers survived at 1 year Number of FES - TIA's 151 Number of FES - Haemorrhagic 579 Number of FES - Infarcts 1,857 2,587 Total mortality at 1 year Total rate of mortality at 1 year 29.4% 61 Appendix 6.3 Estimated re-admission rates for patients following a first admission to hospital for stroke or TIA Predicted first ever hospital admissions as a result of stroke or CBV event Total population 65 - 74 years 75 - 84 years 85+ years Number of FES - TIA's 1,612 73 152 295 406 Number of FES - Haemorrhagic 1,201 88 103 180 274 Number of FES - Infarcts 5,997 194 377 794 1,380 Total Admissions 8,811 355 632 1,269 2,061 Incidence of First Ever Stroke with No Previous Admission History b/fwd from Incidence Summary 446 357 1,992 2,795 241 199 1,259 1,699 Stroke Annual readmission rates calculated from Total Classifications first ever stroke presentations population 0 - 44 years 45 - 54 years 55 - 64 years 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 15.9% 16.3% 14.8% 15.6% 10.6% 11.8% 10.9% 11.1% 16.3% 15.8% 15.0% 15.7% 15.4% 3.6% 10.8% 9.9% 19.0% 15.9% 11.0% 15.3% 19.1% 19.3% 14.9% 17.8% 15.2% 15.2% 7.0% 12.5% 13.6% 14.9% 9.1% 12.5% 20.6% 17.2% 15.7% 17.8% 17.8% 15.3% 8.1% 13.7% 13.2% 15.3% 12.4% 13.7% 18.0% 15.9% 15.5% 16.5% 13.8% 16.1% 14.4% 14.8% 11.4% 8.9% 13.7% 11.4% 17.4% 18.1% 16.5% 17.3% 16.5% 18.3% 20.2% 18.4% 8.9% 10.3% 9.5% 9.6% 16.5% 15.3% 15.3% 15.7% 16.7% 19.4% 18.5% 18.2% 4.2% 11.2% 9.3% 8.2% 11.8% 12.7% 12.3% 12.3% Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 252 133 940 1,325 7 13 35 55 19 13 67 99 41 25 131 196 60 31 239 330 82 34 313 429 44 16 155 215 First ever event Recurrent events Total events 1,557 1,545 1,625 1,576 1,185 1,165 1,198 1,183 6,334 6,112 5,879 6,108 247 252 240 246 126 137 131 131 1,033 965 881 960 1,804 1,797 1,865 1,822 1,311 1,302 1,329 1,314 7,367 7,077 6,760 7,068 Average readmission rates for stroke and Total TIA from prior years population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years Transient Ischaemic Attack Haemorrhagic Stroke Ischaemic Stroke 13.7% 18.6% 22.1% 8.7% 25.6% 25.0% 10.9% 21.0% 25.1% 12.0% 22.9% 23.2% 12.9% 19.1% 24.4% 16.1% 16.0% 22.1% 15.9% 13.8% 17.3% Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 220 222 1,321 1,763 6 23 49 78 17 22 95 134 35 41 184 260 52 52 336 440 72 57 440 569 38 27 217 282 Readmission rate for 2005 Transient Readmission rate for 2006 Ischaemic Attack Readmission rate for 2007 Average readmission rate - current year Readmission rate for 2005 Haemorrhagic Readmission rate for 2006 Readmission rate for 2007 Stroke Average readmission rate - current year Readmission rate for 2005 Readmission rate for 2006 Ischaemic Stroke Readmission rate for 2007 Average readmission rate - current year Predicted Additional Admissions from Recurrent Stroke in the Current Year Number of FES - TIA's Number of FES - Haemorrhagic Number of FES - Infarcts Total Admissions Annual readmission rates calculated from Stroke total admissions & first ever stroke Classifications presentations Readmission rate for 2005 Transient Readmission rate for 2006 Ischaemic Attack Readmission rate for 2007 Average readmission from prior years Readmission rate for 2005 Haemorrhagic Readmission rate for 2006 Readmission rate for 2007 Stroke Average readmission from prior years Readmission rate for 2005 Readmission rate for 2006 Ischaemic Stroke Readmission rate for 2007 Average readmission from prior years Predicted additional admissions from recurrent stroke from prior years Number of FES - TIA's Number of FES - Haemorrhagic Number of FES - Infarcts Total Admissions 62 Recurrent % Total actual event from Additional admissions a prior recurrence year 2,040 236 15.2% 2,011 214 13.9% 2,061 196 12.1% 2,037 215 13.7% 1,544 233 19.7% 1,498 196 16.8% 1,561 232 19.4% 1,534 220 18.6% 8,706 1,339 21.1% 8,339 1,262 20.6% 8,198 1,438 24.5% 8,414 1,346 22.1% Appendix 6.4 Estimated prior admission rates for patients later admitted for stroke or TIA for the first time Predicted first ever hospital admissions as a result of stroke or CBV event Stroke Classifications Total population 65 - 74 years 75 - 84 years 85+ years Number of FES - TIA's 1,612 73 152 295 406 Number of FES - Haemorrhagic 1,201 88 103 180 274 Number of FES - Infarcts 5,997 194 377 794 1,380 Total Admissions 8,811 355 632 1,269 2,061 Incidence of First Ever Stroke with No Previous Admission History b/fwd from Incidence Summary 446 357 1,992 2,795 241 199 1,259 1,699 Annual Complication Rates by CBV Event Total Calculated from First Ever Stroke population Presentations 0 - 44 years 45 - 54 years 55 - 64 years 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years Complications arising in 2006 Transient Complications arising in 2007 Ischaemic Attack Complications arising in 2008 Average Contribution 13.8% 15.6% 16.1% 15.2% 3.6% 7.7% 8.6% 6.6% 8.7% 12.7% 11.3% 10.9% 15.3% 14.1% 16.9% 15.4% 19.3% 19.7% 20.8% 19.9% 14.8% 17.4% 14.9% 15.7% 8.0% 9.9% 15.0% 11.0% Complications arising in 2006 Haemorrhagic Complications arising in 2007 Stroke Complications arising in 2008 Average Contribution 14.1% 13.4% 16.1% 14.5% 4.5% 9.8% 7.4% 7.2% 10.9% 27.3% 22.5% 20.2% 19.6% 18.3% 20.2% 19.4% 19.1% 13.0% 18.8% 16.9% 14.0% 13.4% 16.0% 14.4% 7.8% 4.4% 9.4% 7.2% Complications arising in 2006 Ischaemic Stroke Complications arising in 2007 Complications arising in 2008 Average Contribution 16.9% 17.6% 17.2% 17.2% 19.8% 11.2% 11.8% 14.2% 18.9% 18.2% 18.2% 18.4% 17.5% 19.4% 17.1% 18.0% 21.2% 23.4% 25.0% 23.2% 17.2% 17.6% 16.8% 17.2% 9.5% 10.9% 10.1% 10.2% 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 5 6 28 39 10.9% 17 21 69 107 16.9% 46 35 143 223 17.6% 81 46 320 447 21.7% 70 52 342 464 16.6% 26 14 128 169 9.9% 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years Predicted number of admissions included Total in First Ever Stroke likely to have population complications Number of FES - TIA's 244 Number of FES - Haemorrhagic 174 Number of FES - Infarcts 1,030 Number of Admissions 1,449 16.4% % of Total Admissions Intervention Annual Complication Rates by Total Anticipated Intervention Calculated from population FES Presentations Contraindication Rate in 2006 Thrombolysis Contraindication Rate in 2007 Ischaemic Stroke Contraindication Rate in 2008 Only Average Rate of Contraindication 3.5% 3.8% 3.7% 3.7% 10.9% 5.3% 4.9% 7.1% 6.9% 6.2% 8.9% 7.4% 3.6% 6.2% 4.0% 4.6% 4.7% 5.8% 5.8% 5.4% 2.8% 2.5% 3.0% 2.8% 1.0% 1.3% 0.7% 1.0% Carotid Surgery Contraindication Rate in 2006 TIA and Contraindication Rate in 2007 Ischaemic Stroke Contraindication Rate in 2008 Only Average Rate of Contraindication 12.9% 13.6% 13.2% 13.2% 6.9% 5.9% 5.8% 6.2% 9.8% 11.0% 8.4% 9.7% 13.3% 12.5% 12.8% 12.9% 16.2% 17.1% 18.5% 17.3% 14.2% 15.1% 13.4% 14.2% 8.3% 9.5% 10.0% 9.3% Source ISD19 63 Appendix 6.5 Estimated admission rates for patients who have attended a neurovascular outpatient clinic Predicted Admissions to Scottish Total Hospitals in the Year to 31st March 2009 population 55 - 64 years 65 - 74 years 75 - 84 years 85+ years 1,612 252 220 2,085 1,201 133 222 1,556 5,997 940 1,321 8,258 73 7 6 86 88 13 23 125 194 35 49 278 152 19 17 188 103 13 22 138 377 67 95 539 295 41 35 370 180 25 41 245 794 131 184 1,109 406 60 52 518 274 31 52 358 1,380 239 336 1,955 446 82 72 600 357 34 57 448 1,992 313 440 2,745 241 44 38 323 199 16 27 243 1,259 155 217 1,631 Total Admissions 11,898 488 865 1,725 2,831 3,793 2,196 Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years Number of Ischaemic Events Admitted 10,343 364 727 1,480 2,473 3,345 1,954 Outpatient Attendance from SSCAS RAO & Transient Monocular Blindness Non Cerebrovascular Events TIA and Minor Stroke Attendances 9,598 1,075 2,822 5,701 338 38 99 201 675 76 198 401 1,373 154 404 816 2,295 257 675 1,363 3,104 348 913 1,844 1,813 203 533 1,077 Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years Independency Ratio First Ever Stroke Independency Ratio Recurrent Stroke 60% 45% 79% 59% 78% 59% 70% 53% 59% 44% 57% 43% 49% 37% No of TIA's Admitted No of FES - Infarcts Admitted No of Recurrent Strokes Admitted No of Neurovascular OP Attendees 2,085 3,572 1,024 5,701 86 153 49 201 188 294 95 401 370 557 166 816 518 815 255 1,363 600 1,137 322 1,844 323 616 136 1,077 Total number of patients who subject to further investigation may be suitable for Carotid Surgery without complications 12,382 489 978 1,909 2,951 3,903 2,152 Total population 0 - 44 years 45 - 54 years 55 - 64 years 65 - 74 years 75 - 84 years 85+ years Dependency Ratio First Ever Stroke Dependency Ratio Recurrent Stroke 40% 55% 21% 41% 22% 41% 30% 47% 41% 56% 43% 57% 51% 63% No of FES - Infarcts Admitted No of Recurrent Strokes Admitted 2,425 1,237 41 34 82 67 237 149 566 321 855 431 643 235 Total number of patients who subject to further investigation may be suitable for Thrombolysis assuming that they arrive on time without complications 3,662 75 150 386 886 1,286 879 Independency Analysis of Ischaemic Strokes & CBV Events mRS < = 2 25% 45 - 54 years Number of FES - TIA's Number of Recurrent TIA's CY Number of Recurrent TIA's PY Total number of TIA Admitted Number of FES - Haemorrhagic Number of Recurrent Heamorrhagic CY Number of Recurrent Heamorrhagic PY Total number of Haemorrhagic Strokes Number of FES - Infarcts Number of Recurrent Infarcts CY Number of Recurrent Infarcts PY Total number of Infarcts Admitted Predicted Outpatients Attending Neurovascular Clinics 93% 11% 29% 59% 0 - 44 years Dependency Analysis of Ischaemic Strokes mRS 3 - 5 64 214,869 1,821 8.47 4,170,592 0.44 AMBULANCE CAR SERVICE Patient Journeys ( Incl. Escorts ) Total Cost £' 000 Cost per P.J. ( £ ) Total Mileage Cost per Mile ( £ ) 89 270 3,034 17,038 163 9.57 429,414 0.38 126,094 2,676 21.22 1,056,647 2.53 44,132 10,699 242.43 1,167,762 9.16 Ayrshire and Arran 16 49 3,063 4,043 59 14.59 158,683 0.37 50,264 979 19.48 463,115 2.11 12,342 6,114 495.38 515,291 11.87 Borders 41 126 3,073 5,167 106 20.51 209,763 0.51 49,581 1,124 22.67 714,432 1.57 16,429 7,562 460.28 845,670 8.94 Dumfries & Galloway 4 13 3,250 18,334 127 6.93 313,668 0.40 143,431 2,358 16.44 896,470 2.63 40,455 7,754 191.67 886,108 8.75 Fife 38 116 3,053 39,996 278 6.95 616,010 0.45 95,874 1,989 20.75 582,627 3.41 27,342 4,803 175.66 487,676 9.85 Forth Valley 217 679 3,129 6,210 61 9.82 159,664 0.38 90,566 2,911 32.14 727,165 4.00 53,490 14,104 263.68 1,472,866 9.58 Grampian 462 1,390 3,009 18,772 295 15.71 656,885 0.45 383,231 6,903 18.01 2,238,765 3.08 150,552 24,502 162.75 1,725,264 14.20 Glasgow & Clyde 1,300 4,096 3,151 41,428 274 6.61 500,820 0.55 77,172 1,894 24.54 1,139,976 1.66 39,179 19,151 488.81 1,861,851 10.29 Highland 44 135 3,068 37,353 216 5.78 529,751 0.41 140,313 3,484 24.83 898,469 3.88 65,299 11,106 170.08 1,075,616 10.33 Lanarkshire 29 88 3,034 10,249 61 5.95 178,030 0.34 181,011 4,249 23.47 788,098 5.39 88,300 15,066 170.62 1,476,701 10.20 Lothian 378 1,204 3,185 165 3 18.18 5,818 0.52 2,075 55 26.51 26,716 2.06 1,758 743 422.64 69,915 10.63 Orkney 250 803 3,212 - 3,243 112 34.54 78,623 1.42 1,684 470 279.10 78,519 5.99 Shetland 65 27 83 3,074 14,078 146 10.37 358,962 0.41 130,790 3,002 22.95 1,002,814 2.99 40,070 11,718 292.44 1,146,873 10.22 Tayside 379 1,214 3,203 2,036 32 15.72 52,971 0.60 3,457 124 35.87 15,070 8.23 3,076 1,889 614.11 222,951 8.47 Western Isles This is an ISD Scotland National Statistics release 25th November 2008 Source: ISD http://www.isdscotland.org/isd/4434.html Excel File R910 http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=Costs_R910_2008.xls&pContentDispositionType=inline 3,274 10,266 3,136 1,477,102 31,860 21.57 10,629,438 3.00 PATIENT TRANSPORT SERVICE (excludes Ambulance Car Service) Patient Journeys ( Incl. Escorts ) Total Cost £' 000 Cost per P.J. ( £ ) Total Mileage Cost per Mile ( £ ) PATIENT AIR TRANSPORT SERVICE Missions Total Cost £' 000 Cost per Mission ( £ ) 584,108 135,681 232.29 13,033,062 10.41 Scotland ACCIDENT & EMERGENCY Incidents Total Cost £' 000 Cost per Incident ( £ ) Total Mileage Cost per Mile ( £ ) ROAD AMBULANCE SERVICE Board R910: THE SCOTTISH AMBULANCE SERVICE April 2007 - March 2008 Appendix 7.1 Costs for the Scottish Ambulance Service A2 A2 A2 A2 A2 A1 A1 A2 A2 A2 A2 A2 A3 A2 A3 A3 A3 A2 A2 A2 A1 A3 A3 A1 A2 A1 A2 A2 A2 A3 A2 A3 A3 1,602,537 68,603 43,739 22,417 41,827 45,554 78,270 74,557 49,536 68,786 33,963 42,639 72,114 17,209 31,071 7,367 7,696 12,309 62,524 60,520 48,612 65,258 22,818 3,310 105,827 52,253 50,620 25,359 52,601 31,197 8,545 35,880 13,399 9,206 1,498,710 65,150 40,482 22,417 39,093 42,954 73,321 73,519 48,047 66,935 31,918 41,244 68,100 15,044 29,032 6,352 6,366 9,668 60,224 58,520 48,004 61,512 21,943 3,310 103,955 44,335 49,736 24,650 50,835 30,012 7,326 35,880 13,399 7,861 72 62 73 75 83 59 67 69 69 71 79 67 60 59 100 84 50 85 62 52 69 68 92 96 107 49 100 47 69 43 88 65 56 73 Total £ £ 30 32 28 50 18 18 18 23 27 29 25 16 25 35 48 80 49 34 30 30 33 23 35 92 54 21 31 17 34 19 28 37 43 96 Gross Attendance Cost per Allocated 102 94 102 125 100 77 86 92 95 99 104 83 85 94 148 164 99 119 92 82 102 91 127 188 161 70 131 64 103 62 116 102 99 170 £ Other ACT £ Income Income -2 -1 0 0 0 -2 -3 -3 -7 -15 -1 -1 -6 -1 -1 -1 -1 -1 0 -2 0 -6 -3 -5 0 -1 -1 0 0 - -7 -4 -5 -2 -2 -1 -7 -9 -8 -4 -4 -4 -8 -4 -12 -6 -1 -4 -6 -6 -14 -6 -2 -1 -25 -13 -4 -10 -6 -5 -6 -10 -1 -1 Cost per Attendance Total Costs £ Net 93 89 96 123 98 75 77 80 84 89 85 78 75 84 135 158 98 114 85 75 88 84 125 187 130 54 122 54 97 56 110 91 98 169 Index Group 100 96 104 133 106 81 83 87 91 96 92 84 81 91 146 171 106 124 92 81 95 91 135 202 140 59 132 58 104 60 119 99 105 182 66 Source: ISD http://www.isdscotland.org/isd/4434.html Excel File R044 Macros Enabled http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=Costs_R044_2008.xls&pContentDispositionType=inline Totals or Averages Crosshouse Hospital The Ayr Hospital Borders General Queen Margaret Hospital Victoria Kirkcaldy West Hospitals Glasgow Royal Infirmary Southern General (SGH) Royal Alexandra Hospital Inverclyde Royal Hospital Stobhill, Glasgow Victoria Infirmary, Glasgow Vale of Leven, Alexandria Raigmore, Inverness Lorn & Islands District G.H. Caithness General Belford Wishaw General Monklands Hospital Hairmyres, East Kilbride Aberdeen Royal Infirmary Dr. Gray's, Elgin Balfour, Kirkwall Edinburgh Royal Infirmary St. John's at Howden Ninewells Perth Royal Infirmary Stirling Royal Infirmary Falkirk Royal Infirmary Western Isles, Stornoway D&G Royal Infirmary Galloway Community Hospital Gilbert Bain, Lerwick Cost per Attendance A A B F F G G G G G G G G H H H H L L L N N R S S T T V V W Y Y Z Total Direct and Classification New Patients Total Attendances 25th November 2008 This is an ISD Scotland National Statistics release * If menu is not active, change macro security settings using Tools, Macro, Security - set security level to Medium and re-open the report. * Use drop-down menu to select specialties Hospital, Board Cipher Number of Hospitals: 86 Accident & Emergency April 2007 - March 2008 R044: SPECIALTY GROUP COSTS - CONSULTANT OUTPATIENTS Appendix 7.2 Costs for attendance at an A&E department A A B F F G G G G G G G G H H H L L L N N R S S S T T T V V W Y Z A2 A2 A2 A2 A2 A1 A1 A2 A2 A2 A2 A2 A3 A2 A3 A3 A2 A2 A2 A1 A3 A3 A1 A1 A2 A1 A2 A3 A2 A2 A3 A2 A3 248,808 7,701 6,980 4,948 6,406 6,710 16,125 13,701 17,792 9,557 8,620 5,999 7,997 5,406 7,695 364 758 8,634 7,350 7,410 20,233 2,960 15,770 14,119 8,529 9,356 3,669 3,597 6,208 6,165 771 5,651 - Attendances Net cost per Attendance Group £ Index 115.46 116.56 115.71 150.12 151.22 125.23 124.52 111.11 139.50 132.47 107.87 126.04 76.90 86.84 36.20 200.42 211.73 102.26 103.69 102.93 97.63 89.13 98.78 135.89 55.53 155.42 132.02 165.11 169.09 131.70 304.02 72.12 - CT Scanner 100 101 100 130 131 108 108 96 121 115 93 109 67 75 31 174 183 89 90 89 85 77 86 118 48 135 114 143 146 114 263 62 - Magnetic Resonance Imaging Attendances Net cost per Attendance Group £ Index 96,525 228.59 3,831 125.99 3,145 163.40 2,386 88.86 5,741 250.45 8,782 229.98 3,614 200.85 12,743 252.18 2,915 239.47 1,802 195.00 29 204.28 1,393 168.95 787 156.97 3,998 604.39 2,670 169.87 1,851 161.97 2,372 159.76 4,211 153.26 6,996 177.84 9,746 244.80 15 99.40 4,372 236.18 2,341 258.38 2,144 255.73 1 304.81 4,726 237.56 100 55 71 39 110 101 88 110 105 85 89 74 69 264 74 71 70 67 78 107 43 103 113 112 133 104 - 398,069 19,999 9,250 6,029 14,116 8,349 16,830 35,472 8,531 12,996 8,234 9,889 9,880 3,950 12,520 2,167 1,655 13,818 13,609 12,556 21,784 5,143 645 41,752 13,536 18,482 13,533 7,068 3,250 10,877 7,919 1,569 10,486 1,761 Attendances Net cost per Attendance Group £ Index 52.87 38.96 38.86 41.50 37.81 31.31 64.15 52.35 65.73 62.41 50.82 60.73 36.23 40.91 78.84 135.33 200.48 45.56 47.89 58.13 66.38 25.34 199.41 47.68 63.11 25.05 31.19 38.55 39.33 77.33 60.43 100.57 68.30 114.27 100 74 73 78 72 59 121 99 124 118 96 115 69 77 149 256 379 86 91 110 126 48 377 90 119 47 59 73 74 146 114 190 129 216 25th November 2008 Ultrasonics * If menu is not active, change macro security settings using Tools, Macro, Security - set security level to Medium and re-open the report. * Use drop-down menu to select specialties This is an ISD Scotland National Statistics release 67 Source: ISD http://www.isdscotland.org/isd/4434.html Excel File R120 Macros Enabled http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=Costs_R120_2008.xls&pContentDispositionType=inline Totals or Averages Crosshouse Hospital The Ayr Hospital Borders General Queen Margaret Hospital Victoria Kirkcaldy West Hospitals Glasgow Royal Infirmary Southern General (SGH) Royal Alexandra Hospital Inverclyde Royal Hospital Stobhill, Glasgow Victoria Infirmary, Glasgow Vale of Leven, Alexandria Raigmore, Inverness Caithness General Belford Wishaw General Monklands Hospital Hairmyres, East Kilbride Aberdeen Royal Infirmary Dr. Gray's, Elgin Balfour, Kirkwall Edinburgh Royal Infirmary Western General, Edinburgh St. John's at Howden Ninewells Perth Royal Infirmary Stracathro Stirling Royal Infirmary Falkirk Royal Infirmary Western Isles, Stornoway D&G Royal Infirmary Gilbert Bain, Lerwick Hospital, Board Cipher and Classification Number of Hospitals: 43 R120: RADIOLOGY SERVICES April 2007 - March 2008 Appendix 7.3 Costs per event for CT, MRI and ultrasound diagnostics A2 A2 A2 A2 A2 A1 A1 A2 A2 A2 A2 A2 A3 A2 A3 A3 A3 A2 A2 A2 A1 A3 A3 A1 A1 A2 A1 A2 A3 A2 A2 A3 A2 A3 A3 232,509 12,850 14,050 7,506 1,451 2,889 13,651 5,567 188 17,089 9,985 2,823 1,153 2,720 4,626 1,914 859 1,116 9,072 7,672 7,420 6,257 13,721 324 1,860 37,579 1,220 7,260 2,383 465 7,636 7,237 2,579 4,565 477 2,226 83,798 3,375 2,731 2,974 649 779 3,426 1,327 7 4,102 3,722 1,034 406 1,064 1,472 457 354 402 1,252 1,444 1,056 1,578 3,152 131 992 33,244 539 1,920 923 163 1,783 1,487 559 1,133 141 474 96 61 63 113 150 130 177 159 173 119 105 94 138 118 136 165 140 111 76 81 86 128 60 98 79 25 176 229 216 436 129 119 92 50 35 219 Total £ £ 36 25 30 82 49 31 46 27 39 16 26 19 35 9 28 88 30 29 90 55 64 43 23 48 41 7 93 89 30 136 49 49 14 18 20 37 Gross Attendance Cost per Allocated 132 86 93 195 199 161 223 186 211 135 131 113 173 127 163 252 171 140 166 136 150 171 83 146 120 32 269 318 246 572 178 168 105 67 55 257 £ -13 -3 -3 -21 -3 -3 -23 -27 -32 -2 -1 -6 -18 0 -12 -7 -15 -10 -41 -26 -24 -34 -3 -46 -19 -1 -17 -75 -100 -110 -17 -20 -1 -2 -2 -1 Other ACT £ Income Income -9 -2 -2 -2 -59 -31 -7 -25 -13 -3 -3 -11 -1 -7 -1 -2 -9 -6 0 -6 0 -4 0 -6 -20 -2 -2 0 0 - Cost per Attendance Total Costs £ Net 110 83 91 171 193 157 141 128 172 108 117 105 152 115 150 239 155 127 116 104 126 131 80 100 97 32 246 223 146 462 159 146 104 65 53 255 Index Group 100 76 82 156 176 143 129 117 157 98 107 95 138 105 137 217 141 116 106 95 115 120 73 91 88 29 224 203 133 421 145 133 95 59 48 232 68 Source: ISD http://www.isdscotland.org/isd/4434.html Excel File R044 Macros Enabled http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=Costs_R044_2008.xls&pContentDispositionType=inline Totals or Averages Crosshouse Hospital The Ayr Hospital Borders General Queen Margaret Hospital Victoria Kirkcaldy West Hospitals Glasgow Royal Infirmary Southern General (SGH) Royal Alexandra Hospital Inverclyde Royal Hospital Stobhill, Glasgow Victoria Infirmary, Glasgow Vale of Leven, Alexandria Raigmore, Inverness Lorn & Islands District G.H. Caithness General Belford Wishaw General Monklands Hospital Hairmyres, East Kilbride Aberdeen Royal Infirmary Dr. Gray's, Elgin Balfour, Kirkwall Edinburgh Royal Infirmary Western General, Edinburgh St. John's at Howden Ninewells Perth Royal Infirmary Stracathro Stirling Royal Infirmary Falkirk Royal Infirmary Western Isles, Stornoway D&G Royal Infirmary Galloway Community Hospital Gilbert Bain, Lerwick Cost per Attendance A A B F F G G G G G G G G H H H H L L L N N R S S S T T T V V W Y Y Z Total Direct and Classification New Patients Total Attendances 25th November 2008 This is an ISD Scotland National Statistics release * If menu is not active, change macro security settings using Tools, Macro, Security - set security level to Medium and re-open the report. * Use drop-down menu to select specialties Hospital, Board Cipher Number of Hospitals: 62 General Medicine April 2007 - March 2008 R044: SPECIALTY GROUP COSTS - CONSULTANT OUTPATIENTS Appendix 7.4 Costs for a stroke consultant outpatient attendance A2 A2 A2 A2 A1 A1 A2 A2 A3 A3 A1 A1 A2 A2 32,623 1,727 1,919 1,018 1,601 2,496 3,856 2,284 1,874 234 88 5,102 5,759 2,567 2,098 12,681 911 462 431 821 1,005 1,459 1,001 840 69 35 2,901 1,902 469 375 98 67 88 83 70 88 124 103 92 55 71 96 120 74 104 Total £ £ 35 42 14 25 11 42 27 25 87 33 32 33 44 27 36 Gross Attendance Cost per Allocated 133 109 102 108 81 130 150 128 179 88 103 129 165 101 140 £ Other ACT £ Income Income -5 0 0 -7 -21 -3 -1 -2 -2 -2 -7 -2 -2 -14 -5 -2 -2 -5 -27 0 -10 -8 -11 -19 -22 -17 -16 Cost per Attendance Total Costs £ Net 114 104 102 105 79 118 102 125 168 78 90 108 136 82 122 69 Source: ISD http://www.isdscotland.org/isd/4434.html Excel File R044 Macros Enabled http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=Costs_R044_2008.xls&pContentDispositionType=inline Totals or Averages Crosshouse Hospital The Ayr Hospital Queen Margaret Hospital Victoria Kirkcaldy West Hospitals Glasgow Royal Infirmary Southern General (SGH) Raigmore, Inverness Caithness General Belford Aberdeen Royal Infirmary Edinburgh Royal Infirmary Stirling Royal Infirmary Falkirk Royal Infirmary Cost per Attendance A A F F G G G H H H N S V V Total Direct and Classification New Patients Total Attendances Index Group 100 91 89 92 69 104 89 110 147 68 79 95 119 72 107 25th November 2008 This is an ISD Scotland National Statistics release * If menu is not active, change macro security settings using Tools, Macro, Security - set security level to Medium and re-open the report. * Use drop-down menu to select specialties Hospital, Board Cipher Number of Hospitals: 14 Vascular Surgery April 2007 - March 2008 R044: SPECIALTY GROUP COSTS - CONSULTANT OUTPATIENTS Appendix 7.5 Costs for a consultant vascular surgeon outpatient attendance A2 A2 A2 A2 A2 A1 A1 A2 A2 A2 A2 A2 A3 A2 A3 A3 A3 A2 A2 A2 A1 A3 A3 A1 A1 A2 A1 A2 A3 A2 A2 A3 A2 A3 A3 A A B F F G G G G G G G G H H H H L L L N N R S S S T T T V V W Y Y Z 5837 2627 2958 6526 104 8725 7291 3793 6857 3810 4613 5242 361 5774 1428 1102 1479 5003 3883 4453 7598 2673 880 10201 5901 816 7423 3282 384 4516 865 879 3542 36 1087 3.5 5.0 2.8 4.3 1.0 3.7 4.9 5.6 3.6 4.3 3.3 4.4 2.1 3.9 3.7 3.0 3.3 5.0 4.6 4.9 3.6 4.6 4.3 3.7 5.8 1.2 5.6 2.8 0.9 4.0 6.4 5.1 4.2 1.4 3.9 4.2 174 £ 97 238.7 288.4 528.1 314.7 1177.5 251.0 317.1 510.9 386.3 283.1 333.7 410.8 253.0 303.4 296.2 216.8 289.1 216.8 338.3 280.5 428.5 314.9 1165.1 537.8 753.9 523.7 429.5 333.7 460.8 406.9 331.2 393.3 411.6 108.4 241.3 572 702 229 508 293 382 404 776 368 670 467 671 1150 478 425 447 570 418 515 616 420 650 749 655 609 181 785 352 7 548 277 612 494 197 1054 148 257 192 164 86 159 183 232 140 244 115 140 723 110 30 82 101 145 126 155 123 55 147 269 487 139 196 105 31 150 44 213 92 20 79 95 311 79 159 50 70 88 134 50 70 81 74 83 63 14 47 95 40 30 115 207 130 169 52 110 58 151 39 15 99 112 53 140 36 62 £ 383.7 £ Other Care £ AHP Direct Cost per Case Direct 530 Pharmacy and £ Nursing Dental Medical 32 74 4 24 12 14 17 16 53 38 21 18 136 1 2 5 6 2 7 54 8 38 8 2 1 1 20 12 3 20 1 26 17 £ Theatre 530 522 587 506 535 565 529 501 629 385 384 739 258 491 206 205 379 641 409 461 697 392 121 486 525 687 900 346 903 382 466 568 654 371 195 542 £ 92 153 130 19 204 258 287 94 126 178 124 145 159 44 92 67 95 95 132 73 48 110 126 25 279 113 220 132 132 33 70 69 62 138 Laboratory Total £ Case 770 858 494 765 648 517 733 734 424 580 681 650 547 583 1017 651 753 773 626 857 680 617 1189 923 985 920 1021 520 1248 633 715 567 671 724 1270 729 Cost per Allocated * If menu is not active, change macro security settings using Tools, Macro, Security - set security level to Medium and re-open the report. * Use drop-down menu to select specialties £ 2477 3166 2113 2571 2822 2162 2529 3191 2145 2397 2260 2826 3294 2187 1987 1696 2285 2306 2143 2588 2687 2232 3643 3040 3635 2542 3764 1810 2887 2372 2089 2441 2551 1526 2989 2611 Gross £ ACT -44 -18 -104 -15 -7 -17 -24 -68 -53 -117 -83 -21 -43 -101 -15 -15 -12 -11 -22 -21 -10 -64 -1 -81 -82 -85 -79 -1 -13 -13 -58 -22 -3 - Income £ Other -112 -88 -226 -49 -59 -151 -136 -170 -29 -11 -136 -189 -9 -81 -81 -33 -64 -121 -188 -124 -250 -123 -22 -254 -225 -224 -159 -69 -217 -250 -138 -65 -141 -41 -48 -149 Income Net 2347 2974 1871 2515 2746 1987 2324 2968 1998 2303 2102 2594 3184 2091 1891 1650 2210 2162 1935 2454 2373 2109 3622 2705 3328 2234 3526 1740 2670 2109 1937 2318 2388 1482 2941 304 318 280 291 1608 242 217 310 260 311 310 273 1130 264 180 264 327 149 193 231 274 239 538 352 314 509 287 311 547 270 117 231 254 279 380 70 223 171 175 179 667 139 150 131 117 135 203 147 260 151 274 216 228 154 135 174 187 134 277 250 170 748 183 185 1317 156 111 111 161 521 327 526 489 455 470 2276 381 367 441 376 445 513 419 1390 414 454 480 555 302 328 405 462 373 815 603 484 1257 470 496 1863 426 228 342 415 800 707 Average Average Variable Cost Overhead Cost Total Cost per Day Per Day Per Day £ £ £ £ 2418 274 174 449 Total Costs Cost per Case 25th November 2008 This is an ISD Scotland National Statistics release Source: ISD http://www.isdscotland.org/isd/4434.html Excel File R040 Macros Enabled http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=Costs_R040_2008.xls&pContentDispositionType=inline Totals or Averages Stroke Hospitals: Crosshouse Hospital The Ayr Hospital Borders General Queen Margaret Hospital Victoria Kirkcaldy West Hospitals Glasgow Royal Infirmary Southern General (SGH) Royal Alexandra Hospital Inverclyde Royal Hospital Stobhill, Glasgow Victoria Infirmary, Glasgow Vale of Leven, Alexandria Raigmore, Inverness Lorn & Islands District G.H. Caithness General Belford Wishaw General Monklands Hospital Hairmyres, East Kilbride Aberdeen Royal Infirmary Dr. Gray's, Elgin Balfour, Kirkwall Edinburgh Royal Infirmary Western General, Edinburgh St. John's at Howden Ninewells Perth Royal Infirmary Stracathro Stirling Royal Infirmary Falkirk Royal Infirmary Western Isles, Stornoway D&G Royal Infirmary Galloway Community Hospital Gilbert Bain, Lerwick Average and Classification 133558 Length of Stay Specialty Discharges Hospital, Board Cipher Number of Hospitals: 41 General Surgery April 2007 - March 2008 R040: SPECIALTY GROUP COSTS - INPATIENTS IN ALL SPECIALTIES (EXC LONG STAY) Appendix 7.6 Mean variable cost per day (excluding overheads and theatre costs) in a surgical ward A2 A2 A2 A2 A2 A1 A1 A2 A2 A2 A2 A2 A3 A2 A3 A3 A3 A2 A2 A2 A1 A3 A3 A1 A1 A2 A1 A2 A3 A2 A2 A3 A2 A3 A3 A A B F F G G G G G G G G H H H H L L L N N R S S S T T T V V W Y Y Z 11864 9694 8153 6510 9444 11950 13982 9201 9730 7595 8518 11651 4745 8734 1467 1679 1221 11115 11983 9640 12466 4249 1101 18649 5871 9328 14736 7843 24 9144 395 1600 6052 11 1052 260608 4.9 4.9 5.5 5.0 2.9 5.2 5.3 4.9 5.0 5.2 2.8 4.1 5.8 4.1 6.3 4.6 5.8 4.5 3.7 4.5 5.4 6.2 4.6 2.5 3.6 5.6 4.9 4.8 1.1 3.6 21.7 9.1 4.9 12.7 5.3 74.4 62.7 315.1 78.7 119.4 296.5 126.6 272.7 150.6 203.8 195.0 188.6 216.1 222.8 337.2 278.1 317.1 171.2 166.8 216.0 86.2 254.4 299.9 336.8 355.4 274.2 237.7 143.4 634.7 217.3 200.6 391.6 384.8 789.9 615.6 207.8 £ 568 564 681 860 405 560 515 627 617 554 401 666 695 501 805 630 1326 498 372 417 426 1033 777 371 434 727 599 394 6 443 1834 1398 626 1708 932 £ 182 319 268 256 102 155 166 238 214 148 96 145 178 163 31 152 170 158 107 94 458 161 98 54 160 151 232 179 15 145 225 170 206 158 123 179 £ 89 95 94 158 114 142 85 106 76 74 47 56 83 118 14 50 103 43 86 70 226 97 221 44 76 108 113 55 109 69 194 247 157 112 95 95 9 17 11 8 33 9 11 8 9 12 15 42 8 16 2 1 1 4 2 3 55 3 8 17 2 1 1 8 25 4 22 7 24 £ 2 4 314 4 5 28 7 1 0 2 211 9 9 3 11 £ 102 72 53 91 255 195 304 156 105 104 184 109 118 106 85 166 158 167 107 64 54 26 48 56 215 129 145 136 136 64 119 112 68 129 £ 591 687 706 733 519 675 488 623 359 516 448 527 387 588 1008 663 1116 531 459 757 442 621 998 439 441 691 584 389 779 462 1833 1239 681 1893 1101 562 £ 1625 1821 2073 2172 1359 2095 1582 2181 1583 1616 1333 1776 1684 1716 2406 1890 3127 1572 1351 1725 1746 2230 2502 1274 1523 2024 1985 1291 2004 1485 4452 3542 2204 4779 2963 1736 Gross £ ACT -39 -20 -30 -14 -13 -28 -245 -68 -36 -35 -42 -47 -15 -34 -7 -15 -5 -9 -9 -9 -5 -62 -1 -44 -47 -40 -36 0 -7 -7 -131 -17 -21 - Income £ Other -97 1523 1662 1835 2118 1309 1749 1451 1988 1537 1565 1187 1674 1644 1653 2309 1828 3041 1502 1285 1627 1517 2151 2467 1041 1344 1858 1842 1249 1969 1325 4310 3282 2072 4684 2921 188 198 204 279 274 207 181 280 235 201 264 281 215 258 174 251 328 214 225 192 200 245 320 241 253 208 256 180 808 237 114 222 281 219 343 71 119 141 128 147 180 130 92 128 72 99 160 129 66 143 161 144 191 117 125 167 82 100 217 176 124 123 119 81 719 127 85 137 138 149 208 308 340 332 426 454 337 273 408 307 300 424 410 281 401 336 395 519 331 350 358 282 345 538 417 377 331 374 261 1528 364 199 359 420 368 550 Average Average Variable Cost Overhead Cost Total Cost Per Day Per Day per Day £ £ £ £ 1600 225 122 348 Net Cost per Case -82 -129 -223 -40 -22 -101 -63 -157 -11 -9 -99 -87 -6 -56 -82 -57 -77 -61 -57 -92 -167 -78 -36 -189 -131 -125 -107 -42 -35 -153 -135 -129 -115 -74 -42 Income Total Costs 25th November 2008 This is an ISD Scotland National Statistics release Source: ISD http://www.isdscotland.org/isd/4434.html Excel File R040 Macros Enabled http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=Costs_R040_2008.xls&pContentDispositionType=inline Totals or Averages Stroke Hospitals: Crosshouse Hospital The Ayr Hospital Borders General Queen Margaret Hospital Victoria Kirkcaldy West Hospitals Glasgow Royal Infirmary Southern General (SGH) Royal Alexandra Hospital Inverclyde Royal Hospital Stobhill, Glasgow Victoria Infirmary, Glasgow Vale of Leven, Alexandria Raigmore, Inverness Lorn & Islands District G.H. Caithness General Belford Wishaw General Monklands Hospital Hairmyres, East Kilbride Aberdeen Royal Infirmary Dr. Gray's, Elgin Balfour, Kirkwall Edinburgh Royal Infirmary Western General, Edinburgh St. John's at Howden Ninewells Perth Royal Infirmary Stracathro Stirling Royal Infirmary Falkirk Royal Infirmary Western Isles, Stornoway D&G Royal Infirmary Galloway Community Hospital Gilbert Bain, Lerwick Case £ 552 Laboratory £ 4.6 Theatre Cost per Other Care AHP Direct Pharmacy and Dental Average Nursing Medical Specialty Total and Classification Direct Cost per Case Hospital, Board Cipher Length Allocated Discharges of Stay Number of Hospitals: 36 General Medicine April 2007 - March 2008 R040: SPECIALTY GROUP COSTS - INPATIENTS IN ALL SPECIALTIES (EXC LONG STAY) Appendix 7.7 Mean variable cost per day (excluding overheads and theatre costs) in a general medical ward A A B F F G G G G G G G G H H H L L L N N R S S S T T T V V W Y Y Z A2 A2 A2 A2 A2 A1 A1 A2 A2 A2 A2 A2 A3 A2 A3 A3 A2 A2 A2 A1 A3 A3 A1 A1 A2 A1 A2 A3 A2 A2 A3 A2 A3 A3 17 9 6 9 6 19 21 19 12 6 9 8 2 9 1 1 11 9 8 23 5 1 21 11 13 18 8 3 8 5 2 8 1 2 327 Theatres of Number 390 296 125 248 151 385 465 422 215 94 117 99 21 335 24 25 242 250 250 669 91 28 718 327 274 655 215 55 177 89 79 260 19 29 8,274 Week Per Hours 23 33 21 28 25 20 22 22 18 16 13 12 11 37 24 25 22 28 31 29 18 28 34 30 21 36 27 18 22 18 40 32 19 15 25 Per Week 100 91 130 82 109 99 80 88 88 71 62 51 49 42 147 95 101 87 110 124 115 72 111 135 117 83 144 106 73 87 71 157 128 73 58 Index 3,754 1,776 1,721 2,917 1,492 5,394 6,333 5,169 3,371 1,281 1,884 1,178 1,168 3,019 262 335 2,989 2,868 2,245 8,243 1,225 8,769 4,415 3,701 6,781 1,177 311 1,908 911 576 2,314 269 741 £000 95,598 Medical & Dental Group Per Theatre Theatre Hours Used 5,180 3,707 1,794 2,165 1,303 6,426 7,939 7,137 5,243 2,030 2,672 2,366 387 2,714 354 296 3,064 2,534 2,223 7,271 1,574 189 9,317 3,443 3,608 7,101 2,041 1,476 1,779 1,729 944 3,084 375 444 £000 109,961 Nursing Staff 50 378 113 727 408 37 2 113 178 87 2 2 28 851 35 70 1,900 35 6 1,033 334 49 208 75 109 681 - £000 7,918 Other 393 690 128 235 244 884 842 844 475 228 193 216 49 633 24 29 502 202 498 3,705 262 9 1,466 489 415 844 235 61 246 529 125 345 13 - £000 16,606 Drugs Direct Costs 71 23 351 88 384 443 387 205 24 8 38 78 10 1,266 23 40 17 49 45 519 551 3,395 1,728 51 2,616 795 104 12 4 0 £000 13,528 CSSD Supplies * If menu is not active, change macro security settings using Tools, Macro, Security - set security level to Medium and re-open the report. * Use drop-down menu to select specialties 5,068 4,188 760 2,710 2,178 6,069 5,679 7,312 2,452 2,088 1,058 2,013 309 3,793 179 81 3,129 1,959 3,427 3,035 1,655 113 13,081 3,234 2,144 4,149 1,546 534 76 22 334 4,764 106 198 £000 92,512 Other 4,644 2,459 1,914 2,479 2,256 5,934 4,726 2,902 4,791 1,976 2,503 1,131 819 2,681 511 378 4,149 3,267 3,658 8,356 1,978 291 10,184 4,098 4,609 6,178 2,396 2,701 688 1,976 306 - £000 101,891 Costs Allocated Total 19,159 13,221 6,781 11,321 8,265 25,187 25,908 23,682 16,534 7,698 8,350 6,983 2,770 14,957 1,387 1,230 13,849 10,879 12,097 33,030 7,245 602 42,853 15,679 14,483 29,482 9,455 5,183 6,834 4,062 2,879 13,175 1,074 1,383 £000 438,015 income) ACT (net of Expenditure £000 31 434 0 0 188 0 95 17 7 907 4 796 - 570 expenditure) theatre (netted in ACT Income 72 £ 945 859 1,042 878 1,055 1,257 1,071 1,079 1,477 1,570 1,375 1,356 2,516 859 1,107 929 1,100 835 930 950 1,535 414 1,147 923 1,015 865 846 1,800 744 874 698 975 1,110 911 1,018 Index Group Hour Used Theatre per Net Cost 93 84 102 86 104 123 105 106 145 154 135 133 247 84 109 91 108 82 91 93 151 41 113 91 100 85 83 177 73 86 69 96 109 90 100 25th November 2008 This is an ISD Scotland National Statistics release Source: ISD http://www.isdscotland.org/isd/4434.html Excel File R140 Macros Enabled http://www.isdscotland.org/isd/servlet/FileBuffer?namedFile=Costs_R140_2008.xls&pContentDispositionType=inline Totals or Averages Stroke Hospitals: Crosshouse Hospital The Ayr Hospital Borders General Queen Margaret Hospital Victoria Kirkcaldy West Hospitals Glasgow Royal Infirmary Southern General (SGH) Royal Alexandra Hospital Inverclyde Royal Hospital Stobhill, Glasgow Victoria Infirmary, Glasgow Vale of Leven, Alexandria Raigmore, Inverness Caithness General Belford Wishaw General Monklands Hospital Hairmyres, East Kilbride Aberdeen Royal Infirmary Dr. Gray's, Elgin Balfour, Kirkwall Edinburgh Royal Infirmary Western General, Edinburgh St. John's at Howden Ninewells Perth Royal Infirmary Stracathro Stirling Royal Infirmary Falkirk Royal Infirmary Western Isles, Stornoway D&G Royal Infirmary Galloway Community Hospital Gilbert Bain, Lerwick & Classification Hospital, Board Cipher Number of Hospitals: 38 Acute Sector Hospitals excl Long Stay April 2007 - March 2008 R140: THEATRE SERVICES Appendix 7.8 Costs per hour for theatre time inclusive of overheads, staff costs and consumables Appendix 7.9 Costs by function for hospitals in NHS Greater Glasgow and Clyde Hospitals in Greater Glasgow & Clyde with a CT Scanner for first level diagnosis for the exclusion of haemorrhagic stroke Glasgow Royal Southern Victoria Royal Western Alexandra General Infirmary Infirmary Infirmary Stobhill Hospital Hospital Name South South North North North Paisley Glasgow Glasgow Glasgow Glasgow Glasgow Renfrew Principal Location Hospital Classification Code A2 A2 A1 A1 A2 A2 Inverclyde Royal Hospital Greenock Inverclyde A2 Vale of Leven Alexandria Dumbarton A3 Inverclyde Royal Hospital Yes Yes Yes Yes No No Vale of Leven No Yes No Yes No No Southern General Yes Yes Yes Yes Yes Yes Victoria Infirmary No Yes Yes Yes No No Glasgow Royal Infirmary Yes Yes Yes Yes Yes No Western Infirmary Yes Yes Yes Yes Yes Yes Stobhill Yes Yes Yes Yes No No Royal Alexandra Hospital Yes Yes Yes Yes No No 6 0 3 3 5 1 6 0 4 2 4 2 4 2 2 4 Acute Stroke Unit Available Rehabilitation Stroke Unit Available If No Rehabilitation Unit are patients transferred Elsewhere Neurovascular Clinic Available Southern General Yes Yes n/a Yes Victoria Infirmary No Yes n/a Yes Glasgow Royal Infirmary Yes No Yes Yes Western Infirmary Yes No Yes Yes Stobhill Yes Yes n/a Yes Royal Alexandra Hospital Yes Yes n/a Yes Inverclyde Royal Hospital Yes Yes n/a Yes Vale of Leven No Yes n/a No Costs of Patient Transport: SAS Greater Glasgow & Clyde Accident & Emergency - Cost per Incident Patient Transport Service - Cost per Journey Ambulance Car Service - Cost per Journey Patient Air Transport Service - Cost per Mission Health Board Total 163 18 16 3,009 Southern General 163 18 16 3,009 Victoria Infirmary 163 18 16 3,009 Glasgow Royal Infirmary 163 18 16 3,009 Western Infirmary 163 18 16 3,009 Stobhill 163 18 16 3,009 Royal Alexandra Hospital 163 18 16 3,009 Inverclyde Royal Hospital 163 18 16 3,009 Vale of Leven 163 18 16 3,009 Costs associated with an initial diagnosis of Stroke in Greater Glasgow & Clyde Accident & Emergency - Consultant Clinic Costs CT Scanning - Cost Per Scan Event MRI Scanning - Cost Per Scan Event Ultrasound Scanning - Cost Per Scan Event Health Board Total 83 119 232 56 Southern General 84 140 252 66 Victoria Infirmary 75 77 169 36 Glasgow Royal Infirmary 80 111 201 52 Western Infirmary 77 125 230 64 Stobhill 78 126 204 61 Royal Alexandra Hospital 89 132 239 62 Inverclyde Royal Hospital 85 108 195 51 Vale of Leven 83 87 157 41 Inpatient costs per day in Greater Glasgow & Health Board Total Clyde excluding surgery and overheads Inpatient Costs per Day - General Medicine 233 Southern General 280 Victoria Infirmary 281 Glasgow Royal Infirmary 181 Western Infirmary 207 Stobhill 264 Royal Alexandra Hospital 235 Inverclyde Royal Hospital 201 Vale of Leven 215 Consultant outpatient costs per event in Greater Glasgow & Clyde Consultant Outpatients - General Medicine Consultant Outpatients - General Surgery Consultant Outpatients - Vascular Surgery Health Board Total 122 182 115 Southern General 172 127 125 Victoria Infirmary 152 125 0 Glasgow Royal Infirmary 128 96 102 Western Infirmary 141 110 118 Stobhill 105 70 0 Royal Alexandra Hospital 108 98 0 Inverclyde Royal Hospital 117 103 0 Vale of Leven 115 93 0 Surgical intervention costs for inpatients and Health Board Total outpatients in Greater Glasgow & Clyde Daycase Surgery - General Surgery 751 Inpatient Surgery - Cost Per Day's Stay 382 Theatre Costs - Per Hour 1,463 Southern General 928 310 1,079 Victoria Infirmary 840 273 1,356 Glasgow Royal Infirmary 720 217 1,071 Western Infirmary 755 242 1,257 Stobhill 680 310 1,375 Royal Alexandra Hospital 581 260 1,477 Inverclyde Royal Hospital 730 311 1,570 Vale of Leven 773 1,130 2,516 Current general service provision in the hospitals of Greater Glasgow & Clyde in relation to stroke pathway Accident & Emergency 24 Hour Coverage CT Scanning Facilities MRI Scanning Facilities Ultrasound Scanning Facilities Current Discharges for Carotid Endarterectomy Currently Delivering Thrombolytic Therapy Ranking out of 6 Estimated Number of Additional Hospital Transfers Current service provision for stroke in Greater Glasgow & Clyde Source: NHS Quality Improvement Scotland 73
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