An estimated 700,000 U.S. residents have a new or recurrent stroke each year, and about 163,000 of them die. An estimated 5.4 million Americans are stroke survivors and stroke is the leading cause of serious, long-term disability, according to statistics compiled by the American Heart Association.
The statement, issued today, and published in the online edition of Stroke: Journal of the American Heart Association, describes current practices among stroke care providers as "inadequate." It recommends stroke care providers work at a state or regional level as part of a system that will analyze data from a range of health providers to determine what is working and seek to apply those findings across the region to improve each patient's experience, said Lee H. Schwamm, M.D., a neurologist at Massachusetts General Hospital in Boston and chairman of the American Heart Association/American Stroke Association committee that drafted the statement. The stroke systems of care would strive to give each patient seamless transitions from one stage of care to the next with the highest quality at each step, he said.
"There is increasing recognition that stroke care is fragmented in this country with many different groups and institutions providing stroke care independently, whether for prevention, acute treatment or rehabilitation," he said. "If you are the patient, what you want to see is an integrated team of providers starting with the person who answers the phone when you call 9-1-1 all the way through to the time you come home having recovered from your stroke."
One aim of the systems approach is to overcome geopolitical boundaries that might interfere with stroke care, Schwamm said. Stroke support can be delivered to smaller, underserved facilities by relying more heavily on telemedicine-enabled consultations that overcome the boundaries of time and distance, and help rural hospitals tap into urban resources.
Physicians can use "TeleStroke" consults on stroke patients with hospitals in small communities using high-speed videoconferencing and imaging links that can transmit interactive clinical and brain scan data directly to physician's office.
Because many who experience a stroke will be unable to call for help on their own, prevention includes community education programs to increase stroke systems and help the public understand the symptoms of stroke. One example is the two-year-old public service campaign by the American Stroke Association and the Ad Council that uses television ads, featuring celebrities, to alert viewers to the symptoms and damage caused by stroke.
The drug tissue plasminogen activator (tPA) is a clot buster used for ischemic stroke, which is caused by blocked arteries in the brain. The drug is approved for use during a three-hour window of symptom onset before brain damage becomes irreversible. For patients to receive tPA, they must get to a hospital soon after their symptoms begin. Hospital staff must be able to rapidly evaluate the patient and perform the brain imaging and interpretation that will rule out other conditions such as seizure disorders, brain infections, brain swelling, tumors or hemorrhagic stroke (bleeding in the brain), Schwamm said.
Many rural hospitals lack the support needed to give tPA, such as immediate access to radiologists and neurologists who can image the brain and interpret the results. Telemedicine can make that happen. "Treating patients early with tPA reduces disability, which saves money. A cost-benefit analysis suggests that you save $4,000 for every patient treated with tPA," Schwamm said.
Arthur Pancioli, M.D., an associate professor at the University of Cincinnati (Ohio) and vice chairman of the department of emergency medicine, said tPA use for ischemic stroke is one of several recent advances in stroke treatment. Some hemorrhagic strokes can be treated effectively with surgery or catheter-based treatments that reduce disability from that condition, and remarkable advances also have been made in secondary prevention and rehabilitation in recent years, he said.
"That's why we need a system to better implement the advances that have been achieved," he said. "We tend to fixate on our own arena as either clinicians or administrators. We can each sharpen our own tools to advance stroke care, but until the many tools in the toolbox work together, we aren't optimizing our collective skills. That's what stroke systems will do."
Among suggestions in the blueprint, health professionals should identify the acute stroke treatment capabilities and limitations of all hospitals in a state or region and make that information available to primary care providers, emergency services and the public.
"This is a non-partisan document," Schwamm said. "It is not about making the teaching hospitals even more comprehensive in their stroke care. This is about equal access for all citizens to high-quality stroke care. It's critical to leverage technology to make the stroke expertise available to all, regardless of their geography or economic circumstances. If you're poor and live near a poor hospital, you shouldn't be deprived of high-quality stroke care just because your hospital can't afford or can't attract a dedicated on-site stroke neurologist."
This blueprint ideally will promote greater efficiency of care as well as the more effective application of acute treatment and secondary prevention -- such as getting people on cholesterol-lowering drugs; controlling high blood pressure, diabetes and weight; and telling them of the importance of quitting smoking and increasing exercise. This should lower the total burden of recurrent disease and disability, he said. Similar quality improvement strategies would be applied throughout the care system, including rehabilitation.
The American Stroke Association's quality improvement program Get With The Guidelines–Stroke helps hospitals ensure patients are consistently treated and discharged according to evidence-based medicine by providing tools that shows how well the staff is meeting stroke treatment goals. A stroke system could magnify such quality improvement measures by expanding them to the regional level, Schwamm said.
"This is the first time that anyone has undertaken such a comprehensive analysis of the core components of this chain of prevention, survival and recovery," he said. "And this is just the beginning. This establishes a framework for stroke systems of care, but more work is needed to outline the performance measures by which we should judge the success of interventions for each area identified in this blueprint."
Creating stroke systems of care will be easier if U.S. Congress passes the Stroke Treatment and Ongoing Prevention Act, known as the STOP Stroke Act, Schwamm said. The House version passed by unanimous consent last June, but Congress didn't complete action on the measure before adjourning for the year. The legislation, which is expected to be reintroduced early in the 109th Congress, would:
- create a grant program to help states ensure that patients have access to quality stroke prevention, treatment and rehabilitation services;
- create a national public awareness campaign about stroke warning signs and stroke prevention;
- support the Coverdell Stroke Registry and Clearinghouse to collect data and share best practices; and
- create a grant program to educate medical professionals in newly developed diagnostic approaches, technologies and therapies.
Co-authors are: Joe Acker, E.M.T.-P., M.P.H., M.S.; Larry B. Goldstein, M.D.; Richard D. Zorrowitz, M.D.; Timothy J. Shephard, Ph.D.; C.N.R.N.; C.N.S.; Peter Moyer, M.D.; M.P.H.; Mark Gorman, M.D.; Clay Johnston, M.D.; Ph.D.; M.P.H.; Pamela W. Duncan, Ph.D.; Phillip Gorelick, M.D.; Jeffery Frank, M.D.; Steven K. Stranne, M.D., J.D.; Renee Smith, M.P.A.; William Federspiel; Katie B. Horton, R.N., J.D.; Ellen Magnis, M.B.A.; and Robert J. Adams, M.D.
NR05 – 1009 (Circ/SCHWAMM)