Implementation of Stroke Pathways to Reduce Length of Stay, Cost, Readmissions, and Mortality

Introduction: Acute stroke is a major contributor to healthcare costs. In 2012, es-timated direct costs associated with stroke was $71B, which is projected to double to $184B by 2030. As healthcare evolves and reimbursements decrease, cost control in disease specific populations is critical. In January 2017, length of stay (LOS) peaked at 5.25 days, as did variable and total cost/case. In fiscal year 2017 the 30-day readmission rate was 9% and the mortality rate was 12%. Compliance with stroke ad-mission order sets was at 55%. Methods: A multidisciplinary committee was formed in February 2017 to develop standardized, evidence-based clinical pathways for three populations: Ischemic stroke (IS) treated with IV tPA, TIA/IS without IV tPA, and intracerebral hemorrhage. The team met biweekly to standardize clinical pathways, decrease time to follow-up imaging, focus on physician order set utilization, and control costs. A comprehensive education program for all clinical staff was completed; official implementation of the pathways was in November 2017. Pathways are discussed in stroke multidisciplinary rounds and rapid discharge rounds daily to ensure compliance and identify opportunities for improvement. We reviewed a retrospective financial report of all in-hospital cases coded as MS-DRG 61-69 from 12/2017 through 11/2018 and compared it the 1/2017 report. Results: A total of 83 cases where available for 1/2017 and of 1623 for 1/2017 through 11/2018. There was a reduced LOS by 10% (4.74 days), reduced variable cost/case by 24% ($5,958), reduced total cost/case by 23% ($13,790), reduced the 30-d re-admission rate to 6%, and reduced the mortality rate to 7%. Case mix index was 6% higher at 1.2753 (vs. 1.2055 previously). Order set compliance improved to 91% (Table). Discussion: Standardization of stroke clinical pathways led to improved order set compliance, almost ¼ reduction in variable and total costs per case, shortened LOS, and reduced mortality and readmission rates