In the United States, we see nearly 800,000 strokes each year—amounting to a new or recurrent stroke occuring every 40 seconds. Fortunately, with notable improvements in care, many more people are surviving strokes than in the past. Stroke survival, however, brings its own set of demands on the health care delivery system, with many patients needing extensive support from physicians, therapists, and family members.
Current efforts around developing certified Comprehensive Stroke Centers (written about earlier this week on The Pipeline) are focused on enhancing acute and post-acute care for stroke, but with much of the health care dialogue centered on population care management, a focus on stroke prevention may become a more realistic goal for the delivery system.
An article published last week in BMJ Open suggests that the possibility of reducing the incidence of stroke can be realized through improved management of known risk factors. While the study arrives at its conclusion in a weak manner, the story is compelling.
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At the end of September, the Joint Commission released proposed requirements for certification as a Comprehensive Stroke Center. These new requirements build off of the exisiting certification program for Primary Stroke Centers (PSCs), which was launched in 2003 and has seen impressive growth since its inception.
To date, more than 800 hospitals nationwide have achieved this distinction, which signals a dedication to providing evidenced-based care for stroke patients in an efficient and high-quality manner. The Comprehensive Stroke Center program will certify hospitals that can provide advanced therapies for acute stroke patients, but can also provide enhanced long-term management of these patients. Assuming the final rules closely resemble the current proposed guidelines, it's possible that not many hospitals will be able to meet the extensive requirements. Few hospitals should be engaged in providing advanced stroke services, especially considering the intensity of resources needed and the complexity of care required.
The Joint Commission developed the proposed requirements along with The American Heart Association (AHA) and the American Stroke Association (ASA). Similar to PSC certification, the proposed requirements follow the Brain Attack Coalition’s recommendations—in this case the “Recommendations for Comprehensive Stroke Centers” that were first published in 2005—and provide detailed specifications on the capabilities, technology, physicians, and services needed to be considered a comprehensive program by the joint commission. A detailed account of the requirements can be found on the Joint Commission's website, but here we'd like to highlight some of the key aspects needed.
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Since the initial publication of primary stroke center recommendations in 2000, there have been significant advancements in the standard of care for stroke patients in terms of diagnosis and treatment. To that end, the Brain Attack Coalition (BAC) has recently issued revised recommendations for primary stroke centers.
The updated guidelines take into account the efficacy and importance of stroke teams, stroke units, the use of intravenous tissue plasminogen activator (tPA), and imaging advances. Primary stroke centers (PSCs), proficient in providing acute care for stroke patients and administering the clot busting drug IV-tPA, can be distinguished from their counterpart comprehensive stroke centers (CSCs), which cater to more complex stroke cases and offer advanced interventional treatments.
The revised recommendations, based on extensive literature review and experience of PSCs, encompass numerous aspects of stroke care, with the key points summarized below.
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New data published in the New England Journal of Medicine suggest the use of intracranial stenting for secondary prevention of stroke in patients with atherosclerotic intracranial stenosis may be inferior, and even more dangerous than an aggressive drug regimen. The Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial, which compared Stryker's intracranial Wingspan stent against a combination of aspirin, clopidogrel, and the management of primary and secondary risk factors for stroke was completed prior to completing its full enrollment of 764 patients because of the heightened risk for patients receiving the stent.
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Results from the largest randomized clinical trial to date regarding rehabilitation after stroke were published in the May 26th issue of the New England Journal of Medicine. The study called Locomotor Experience Applied Post-Stroke or LEAPS investigated approximately 408 patients recruited from 6 inpatient rehabilitation sites in California and Florida. Approximately two months after having a stroke, all of the participants were assigned to one of three treatment groups: home exercise with a physical therapist, body-weight-supported treadmill training at two months after the stroke (early locomotor training), or body-weight-supported treadmill training at six months after the stroke (late locomotor training). All participants received three sessions per week (90 minutes' duration) for a total to 30 to 36 sessions overall.
Given more than four million stroke survivors experience difficulties in walking, the primary outcome to be measured was improvements in the functional level of walking approximately one year after the stroke (metrics such as walking speed, balance, falls). The investigators hypothesized that locomotor training, especially early locomotor training, would be superior to a home exercise program.
At approximately one year, increased functional walking ability was observed in 52% of all participants. However, interestingly, no significant differences in improvement were found between early locomotor training and home exercise or between late locomotor training and home exercise. On the other hand, compared with the home exercise group, each of the locomotor training groups reported a higher frequency of dizziness or faintness during treatment.
Despite the high incidence of stroke, there remain a limited number of studies examining post-stroke rehabilitation and recovery. This study presents strong evidence to the importance of initiating physical therapy for stroke patients, with over half observing improvements within the year. This study also proves that physical therapy at home can be just as effective as more expensive, locomotor training solutions such as robot-assisted treadmill steppers. Also, not only was the home-based program found to be cheaper, it was also accompanied by fewer risks. As hospitals continue to evaluate best practices on post-stroke care, physical therapy/rehab will undoubtedly remain an important piece, with the optimal methods of delivery being the primary question to be addressed.
The physician expertise required to provide neuroendovascular care for stroke patients remains significant, resting primarily in the domain of neurointerventional radiologists. Given the high incidence of stroke (upwards of 800,000 patients per year) and the relative shortage of qualified neuro interventionalists (roughly 400 to 500), there remains an acute demand for trained specialists to perform advanced interventions. The idea of adding cardiologists as part of a multidisciplinary team for stroke treatment/management has been investigated and was echoed at the Cardiovascular Research Technologies (CRT) 2011 conference held last week. Dr. Christopher White, Chairman of Cardiology at the Ochsner Health System, emphasized the key role cardiologists can play in stroke care delivery. Dr. White explains that most cardiologists can be directly involved in the treatment process and perform rescue interventions as "carotid stent operators". Cardiologists can work in tandem with neurologists/neurosurgeons, who will serve as "quarterbacks" in the actual treatment process, particularly in navigating the cerebral arterial anatomy.
From a provider perspective, this idea holds merit. The addition of cardiologists as part of a "stroke team" would likely be an attractive option for most hospitals. The relatively larger number of cardiologists could alleviate some of the resource crunch currently faced on the recruiting front. Given the high salaries charged by most neuro interventionalists, hiring cardiologists may also serve as a cheaper alternative. And from a societal perspective, the window of time to treat patients with acute stroke can be extended if such therapies are more widely available. While adding cardiologists to the mix may not be the answer to the acute shortage of care providers for stroke, it is certainly an interesting one. Even if the current stroke care provision model is not altered any time soon, as health care delivery continues to shift towards a multidisciplinary approach, the resulting impact on stroke care will nonetheless be important to observe.
The phrase "time is brain" resonates throughout our industry as clinicians know they have a limited number of hours to achieve a successful intervention for stroke patients. Typically, patients presenting to the emergency department with stroke-like symptoms are often given a non-contrast CT and also CT angiography to rule out hemorrhage or other lesions that may appear to cause ischemic events, and also to diagnose infarcts (tissue death caused by an obstruction). After initial stroke diagnosis, an MRI is commonly performed to assess the extent of ischemic damage. CT imaging for stroke patients has many distinct advantages for use in the ED, including wide availability, speed of image acquisition, and relatively low cost. However, CT has become the assumed standard rather than being clinically proven as such. New advances in MR imaging are causing some researchers to rethink how stroke patients should be treated upon presenting with symptoms.
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In TI, the management of stroke patients has increasingly become our most requested project in the Neuroscience vertical. While our work began a few years ago with a technology-focus, helping hospitals looking to invest in a biplane angiography suite offer interventional stroke treatments, our focus has shifted to include analysis of the continuum of care for stroke patients, including building regional stroke networks. On that topic, some important positive data on "drip and ship," a method of utilizing stroke networks to enhance stroke patient care, were recently released in the journal, Stroke.
Despite mounting evidence that IV-tPA improves clinical outcomes for stroke patients, national utilization remains low, with a mere one to five percent of ischemic stroke patients receiving IV-tPA. This low utilization rate is largely the result of a tight time window for treatment and a shortage of stroke specialists to provide emergent consultations. To combat these challenges, many hospitals and health systems have developed stroke networks of care, facilitated by telephone or telemedicine, in which regional stroke centers serve as the hub to outlying hospitals lacking stroke expertise.
A recently published article in Stroke by Dr. Lee Schwamm and his stroke team at Massachusetts General Hospital provides evidence suggesting that that "drip and ship" is a safe and feasible method to shorten time to IV-tPA treatment. Clinical outcomes for "drip and ship" patients and patients who received IV tPA at a regional stroke center were comparable, with no significant differences in treatment complications (i.e. hemorrhage), mortality, and discharge outcomes between the two groups.
For more information on how TI can help with your stroke strategy through our Stroke Care Gap Analysis, please contact me at WynnP@advisory.com.
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