TRANSCRIPT

2023-02 HS-STATEWIDE STROKE SYSTEM

August 22, 2023

9:00 a.m. – 12:00 p.m.

MARY BRENNAN: Good morning. My name is Mary Brennan, and I am the Regulatory Aﬀairs

Oﬃcer for the Department of Health and Human Services. We are on the record today for

MOAHR rule case number 2023-02 HS Statewide Stroke System. If you haven't signed in for this

session, please do so before you leave today.

I would like to introduce our subject mater expert for this hearing star�ng to my le�. Emily?

EMILY BERQUIST: Emily Berquist, State Division Administrator, Systems of Care - Stroke and

STEMI

MARY BRENNAN: Thank you. Aaron?

AARON BROWN: Good morning, Aaron Brown, Systems of Care Coordinator.

MARY BRENNAN: Thank you. Katelyn?

KATELY SCHLABLE: Good morning. Katelyn Schlable, Department Manager, Systems of Care -

Stroke and STEMI.

MARY BRENNAN: Thank you. And last but not least, Eileen?

EILEEN WORDEN: You know me. Eileen Worden, Sec�on Manager. Systems of Care - Stroke and

STEMI

MARY BRENNAN: Thank you. Some housekeeping maters: the restrooms are out the door,

take a le�, go down the ramp and make another quick le�. If you would like to give tes�mony,

please come up and speak at the podium. I will ask you to spell your name for purposes of the

rule package. Your tes�mony will be recorded for purposes of a transcript. If you do not want to

make a public comment, but just ask ques�ons, you may do so, but the ques�ons and answers

will not become part of the record unless you want them to be.

For your convenience, I have placed two items on the board behind me. The ﬁrst is the email

box to send comments in the event of a 3:00 a.m. epiphany and you forgot to tell us. That is

MDHHS-Adminrules-all one word- at michigan.gov. The second is the rule status website at the

Administra�ve Rules Division LARA website: Htps://ars.apps.lara.state.mi.us.

If there are no ques�ons, let’s begin. If anyone wishes to make a comment, please come

forward.

DR. ALEX CHEBL: Good morning, Ms. Brennan, Ms. Worden, and the Michigan Department of

Health and Human Services EMS Systems of Care Sec�on. My name is Dr. Alex Chebl, A-L-E-X C-

H-E-B--L and I am tes�fying on behalf of the American Heart Associa�on and the American

Stroke Associa�on. I am the Director of the Harris Complex Stroke at Henry Ford Health, and the

Director of the Stroke and Vascular Neurology Division at Henry Ford Hospital, um, in the

Department of Neurology where I’ve been since 2018. Prior to that I was Medical Director of

Bap�st Health Louisville, as well as the University of Louisville. I am a fellowship trained vascular

interven�onal and neurological care neurologist. I’ve authored mul�ple manuscripts, scien�ﬁc

ar�cles, book chapters in the subject of stroke. I have lectured na�onally and interna�onally

and I’m an ac�ve member of the Society of Vascular (inaudible) Neurology, where I was the

founding Vice President, as well as a member of the American Heart Associa�on and American

Stroke Associa�on. Most importantly, I am a passionate advocate for stroke preven�on and

treatment. Thank you for allowing me to speak today on the systems of care statewide stroke

system proposed rules.

The American Heart Associa�on will be celebra�ng 100, it’s 100^thyear in 2024. The associa�on

is one of the na�on’s largest voluntary health care organiza�ons with more than 35 million

volunteers and supporters that seek to be a relentless force for (inaudible) of longer, healthier

lives by preven�on of stroke, and cardiovascular disease.

Stroke is the ﬁ�h leading cause of death and leading cause of adult disability in the United

States. Worldwide, it is among the leading causes of death. In an eﬀort to reduce the burden of

stroke, by improving the quality of care delivered to stroke pa�ents, stroke registries have been

developed to measure and track acute stroke care. Clinical registries, which are databases of

health informa�on, on speciﬁc clinical condi�ons, procedures, or popula�ons, are used to

capture data and clinically important events (inaudible) par�cular popula�on or condi�on. They

can be integrated in our electronic health records to directly support evalua�on of care delivery

and pa�ent outcomes. Basically, they help us evaluate the quality of care we deliver and to

improve that care. The American Heart Associa�on and American Stroke Associa�on strongly

support eﬀorts to enact a robust stroke systems of care framework in Michigan that addresses

both stroke registries and facility designa�on. In this tes�mony I will be providing comments on

behalf of the Associa�ons and will provide speciﬁc change recommenda�ons through

submission of writen tes�mony.

In 2003, the American Heart Associa�on and American Stroke Associa�on launched yet with the

guidelines stroke, a performance improvement program for hospitals using a stroke registry to

support its aims. Get With the Guidelines-Stroke collects pa�ent level data on characteris�cs,

diagnos�c tes�ng treatments, adherence to quality measures, and in-hospital outcomes in

pa�ents hospitalized with (inaudible) stroke and trans schema�c atack or warning stroke.

Collec�on of comprehensive con�nuous stroke data supports data analysis and involvement for

interven�on to improve stroke care. Currently, over 3, 850 hospitals na�onwide par�cipate with

Get with the Guidelines-Stroke including 80 in the State of Michigan. And data has been

collected from over 10 million pa�ent encounters for stroke, including nearly 250,000 in

Michigan. We advise, under sec�on 1(n), that MDHHS ensure data can be exported to the state

database and allow exporta�on of state data to get with the guideline stroke. This would be

similar to the na�onal trauma databank. In Sec�on 330.251, the Associa�ons recommend

changes to the deﬁni�ons of accredita�on and cer�ﬁca�on as the designa�on is used for the

powers and du�es of the Department. The language for accredita�on and cer�ﬁca�on and

veriﬁca�on could cause confusion.

For the deﬁni�on of disciplinary ac�on, we suggest including EMS agencies, as they may also fail

to comply with the Code. The regional stroke advisory council and the statewide stroke care

advisory subcommitee both pose ambiguity around their membership. For instance, is the

American Heart Associa�on considered a consumer under the regional stroke advisory council?

For both the council and the subcommitee we recommend the deﬁni�on include, inclusive of

exper�se in the speciﬁc ﬁeld such as professional organiza�on, with exper�se in stroke systems

of care. The State trauma commitee has representa�on from Level 1 and 2 trauma hospitals

cer�ﬁed by the American College of Surgery. At a minimum, we suggest a Level 1 CSC, or Level

2 TSC cer�ﬁed, and Level 3 PSC or Level 4 ASR. CSC IS comprehensive stroke center, TSC is

thrombectomy stroke center, PSC is primary stroke center, and ASR is acute stroke ready. And,

let’s see, Level 4, administra�ve representa�on should be allowable.

Addi�onally, considera�on should be given about a stroke nurse coordinator and get with the

guidelines registrar, similar to the trauma commitee. Under R 330.254(1)(a), the American

Heart Associa�on recommends the removal of the phrase “all-inclusive”. This would indicate

primary preven�on through rehabilita�on which can be construed as beyond the scope and

capabili�es of the Bureau. “All-inclusive” is used in trauma regula�ons but does this include sub-

acute and rehabilita�on? Would preven�on and risk reduc�on consider things like hypertension

smoking and stroke screenings?

In Sec�on 1(e), AHA recommends the statement be modiﬁed because Michigan may have its

own cer�ﬁca�on accredited or /accredita�on based on the deﬁni�on of veriﬁca�on used

previously. The trauma rules, for instance, reference the American College of Surgeons. Sec�on

1(i) states “to develop a statewide process for a statewide stroke center.” This is similar to

trauma but could create an issue(s). In Sec�on (1)(n), there is a typo. It should likely read “the

establishment of the regional stroke system does limit , does not limit the transfer or transport

stroke pa�ents between in regions of the State.

In Sec�on 2, we recommend including the inclusion of EMS. For Sec�on 4, AHA believe some of

the ac�vi�es suggested are not an eﬃcient, cost-eﬀec�ve, and do not incorporate na�onal

standards like developing another registry and not adop�ng na�onal cer�ﬁca�on standards.

The state is already funded through Coverdell (Grant). And we believe this is a duplica�on of

eﬀorts.