These are the best of times and the worst of times. We have successfully decoded the human genome, yet the 13 trauma centers that serve Los Angeles County had to threaten to close down before county supervisors would reconsider their financial support — a sum that has plummeted from $9 million 10 years ago to $1.5 million this year — to supplement care of the uninsured patients who make up 30% to 40% of those treated in the trauma system. (The county thinks the state should pay; the state thinks the county should pay; and they would both prefer the federal government to pay.) We are considering adding prescription drug benefits to the Medicare program, yet reimbursement for screening mammograms is so skimpy that programs are closing and radiology residents are steering a wide berth around the subspecialty of breast imaging (see Peter Pesavento’s story).

As advances in science and medicine result in ever higher standards of care, we, as a society, will have to reassess our health care priorities. To do this, we need a middle ground, a sober environment in which to consider our choices, somewhere between the hurly-burly of presidential politics and the closed door sessions at the Health Care Financing Administration. We need a place to decide, now that science has produced the miracle of thrombolytics, whether there will be a comprehensive stroke center (see Judith Gunn Bronson’s story) in every community, or, in lieu of that, a primary stroke center, such as described by Alberts et al,[1] as a frontline defense against the deadly, debilitating effects and the societal burdens of stroke.

The authors recommended the use of written protocols for emergency care of patients with ischemic and hemorraghic stroke, initial diagnostic tests, and use of medication, including but not limited to intravenous tPA. Depending on their infrastructure and current staffing levels, hospitals should expect to spend an additional $8,000-$200,000 annually, a more realistic sum for the community hospitals that receive the lion’s share of stroke victims than that required for a comprehensive stroke center. “Consider that stroke is a very common disease,” notes lead author Mark J. Alberts, MD, who is with the Division of Neurology, Duke University Medical Center, Durham, NC. “Typically it is in the top 10 on most hospital discharge DRG categories. It is the third leading cause of death and the leading cause of adult disability: each year there are probably 700,000-750,000 strokes that occur. It is hard to imagine a hospital being in the business of patient care that can avoid taking care of stroke patients. Since you can’t avoid it, it makes more sense to me to develop systems to provide the care in a compassionate, efficient manner that would be financially viable.”

Physicians must play a role in educating the community and its elected officials on the dangers of stroke as well as what can be done to minimize its effects. According to an article in the Los Angeles Times, many of that city’s physicians and nurses who testified before the county supervisors were shocked that the state legislature was unaware of the fragile state of the county trauma system. “The fact that we need to educate our legislators is a shame,” said Vijay S. Kaushik, MD, a commissioner and cardiologist at Martin Luther King Jr/Drew Medical Center. Nonetheless, it is a fact: Legislators must be educated.

Does your hospital have an organized stroke center or, at a minimum, written protocols for dealing with stroke? If not, I suggest you find the nearest hospital that does and program its number into your speed dial. You could recommend the same to the board of directors.

Cheryl Proval

References:

  1. Alberts MJ,Hademenos G, Latchaw RE, et al. Recommendations for the establishment of primary stroke centers. JAMA. 2000;23:3102-3109.