|Richaed E. Latchaw, MD|
Stroke is the number three cause of death in the United States, and the leading cause of adult disability. There is no question that it is our medical and ethical duty to provide the most advanced diagnosis and treatment for this devastating disease. It is also our duty to make significant investments into research to discover and evaluate new forms of treatment for cerebrovascular disease. However, those are societal goals. The new treatment paradigms being proposed for the diagnosis and treatment of acute stroke, including the establishment of primary and comprehensive stroke centers,1 are costly. These costs come at a time when the financial health of our medical system is being questioned. Hospital administrators take a very sanguine look at any new program, with the expectation that the financial outcome of the program will exceed the costs of resource utilization. The current financial paradigm for stroke care places a high burden on the acute care hospital, while the benefits are often more long-term and are realized by society. In addition, the current reimbursement patterns for both the physician and the institution dealing with acute stroke treatment are less than ideal. However, there is some suggestion that the spin-offs of a stroke center may enhance its financial viability.
The treatment of acute stroke using tissue plasminogen activator (tPA) is the result of a number of recent medical and institutional advances. First, there was the discovery of a class of pharmaceuticals, the thrombolytics, which are very effective for dissolving thrombus. The use of these agents started with acute myocardial infarction and progressed to their use in other vascular territories. Second, the techniques of selective intra-arterial catheterization, particularly for the cerebral circulation, were developed in the middle 1980s. These techniques make it possible to selectively infuse a thrombolytic drug directly into a thrombus. Third, imaging methods to evaluate cerebral perfusion and tissue damage have been developed over the past 2 decades to help us select patients who are more likely to respond to lytic therapy with fewer complications. Last, the ability to rapidly respond to the acute stroke patient has been enhanced by utilizing knowledge and techniques applied via the Emergency Medical System and hospitals for trauma patients.
Failure to treat
Unfortunately, very few acute stroke patients are being treated today with intravenous thrombolysis. Of the 750,000 new stroke cases per year in the United States, approximately 2% receive tPA.2 What are the factors that are inhibiting the use of this highly effective therapy? Could these same factors inhibit the desire to establish a stroke center?
The most important factors in the low utilization of tPA are logistical and educational. A patient with an acute stroke must arrive in the emergency department within 3 hours of symptom onset to qualify for the intravenous administration of tPA. The 3- hour time window is actually more like 2 hours, since even under ideal circumstances it will take about an hour to complete the examination, blood test, and head CT scan needed before one can administer tPA. (Although some institutions perform intra-arterial thrombolysis up to 6 hours after stroke onset, this is an unapproved technique with an off-label use of an approved drug.) Therefore, the use of IV tPA for acute stroke requires almost immediate recognition of the symptoms by the patient or a family member, and by the physician, which is not common, given society’s current level of knowledge regarding stroke. Hence, most patients arrive too late to be treated with IV tPA. Another limitation is the reimbursement rates for the treating physician, which are extremely low. This discourages many physicians from taking time away from their busy practices to spend the many hours needed to evaluate and treat acute stroke patients.
The Stroke Team approach
One approach for improving the delivery of in-hospital stroke care is to establish acute stroke teams. Ideally, such teams should include physicians, nurses, technicians, and coordinators. These teams should be available on a 24/7 basis, which means additional salary support for the staff. Imaging resources include CT at a minimum, with magnetic resonance and angiographic capabilities required in the comprehensive stroke center. All acute stroke patients, whether they receive tPA or not, should be cared for in a stroke unit type of setting. Numerous studies have shown that such units reduce mortality, prevent complications, and improve outcome.3 After all of these resource commitments, studies have shown that the savings to the hospital with the use of intravenous tPA, relative to more standard treatment, are relatively small, particularly when the cost of tPA (approximately $2,200 per treatment) is considered.4 Earlier return to a functional state is a savings that accrues to society in general, rather than directly to the acute care hospital or the treating physicians.
Why would a hospital administrator wish to develop a program with increased expenses and minimal financial return? There are several factors that make the development of stroke centers viable and justified. Stroke is a very common disorder. In most hospitals it is among the top 10 DRG diseases seen. Therefore, it makes sense for the hospital to provide optimal care for a disease that affects such a large percentage of their business. Second, by utilizing stroke units, care protocols, as well as tPA, hospitals may be able to reduce length of stay and in-hospital complications, thereby reducing their costs and perhaps even making a modest profit. Third, many hospitalized patients with other diseases (cardiac disorders, peripheral arterial disease) will develop strokes or transient ischemic attacks (TIAs), and require rapid therapy. Last, acute ischemic stroke is only one portion of the broad spectrum of cerebrovascular disease. Chronic vascular disease presenting with repeated strokes or TIAs may require evaluation and treatment of the extracranial circulation. Nontraumatic intracranial hemorrhage accounts for 20% of the gamut of the stroke syndrome, which will require evaluation and treatment of the underlying aneurysm, arteriovenous malformation, or hypertension. Once an institution acquires the human and physical resource base to become known for its expertise in the treatment of the entire gamut of cerebrovascular disorders, the referrals will grow rapidly.
The systems approach
Another way to improve the efficiency and financial viability of resource utilization in the management of cerebrovascular disease might be to take a systems approach. In many cities and regions, hospitals are part of larger medical systems. Certain hospitals within a system might be designated the stroke center facilities, with the majority of the patients with cerebrovascular disease, especially acute stroke, brought to those facilities. This approach is currently used for trauma centers and has proven successful in many locations.
The stroke center is a paradigm program: it requires the mobilization and coordination of many disciplines of medical excellence, the acquisition of numerous diagnostic resources, and the capability of rapid response. To put those parameters in place requires a major commitment, but once established they offer the potential of providing programs that the competition will find hard to beat.
Richard E. Latchaw, MD, is professor of radiology and neurological surgery, chief of neuroradiology, University of Pittsburgh, and Mark J. Alberts, MD, is associate professor, and director, Stroke Acute Care Unit, division of neurology, Duke University Medical Center, Durham, NC.
- Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the establishment of primary stroke centers. JAMA. 2000;283:3102-3109.
- Alberts MJ. tPA in acute ischemic stroke: United States experience and issues for the future. Neurology. 1998;51(suppl):S53-S55.
- . Stroke Unit Trialists’ Collaboration. Collaborative systemic review of the randomised trials of organised inpatient (stroke unit) care after stroke. BMJ. 1997; 314:1151-1159.
- Fagan SC, Morgenstern LB, Petitta A, et al, for the NINDS rt-PA Stroke Study Group. Cost-effectiveness of tissue plasminogen activator for acute ischemic stroke. Neurology. 1998;50:883-890.