CINCINNATI—The vast majority of Americans live within an hour’s drive of a hospital able to treat acute stroke, but only 4 percent receive recommended treatment in the key hours after stroke, researchers from the University of Cincinnati (UC) reported today.
The research was presented at the American Heart Association/American Stroke Association’s annual International Stroke Conference 2014 in San Diego. The conference is the world’s largest meeting dedicated to the science and treatment of cerebrovascular disease.
Results were presented by Opeolu Adeoye, MD, an associate professor in the UC Department of Emergency Medicine and the Department of Neurosurgery, Division of Neurocritical Care. He is a member of the UC Neuroscience Institute, one of four institutes of UC Health and the UC College of Medicine. Collaborating institutions were the University of Alabama Birmingham and the University of Pennsylvania.
"To our knowledge, this is the first report on the geographic access of the U.S. population to all acute care hospitals that actually deliver IV and endovascular therapy for acute stroke,” Adeoye says. Previous studies had focused on access to Primary Stroke Centers, which are hospitals that meet AHA/ASA and Joint Commission standards to support better outcomes for stroke care.
Using data from 2011, the researchers determined access to care as defined by populations that could reach capable hospitals within 60 minutes via ambulance or helicopter. Capable hospitals were those that offered intravenous delivery of the clot-busting drug tPA (tissue plasminogen activator) or performed any endovascular therapy for acute ischemic stroke.
Intravenous therapy delivers tPA through a vein in the arm and is the only emergency stroke treatment proven to improve outcomes. (UC researchers played a leading role in developing and testing of tPA in the late 1980s and mid-1990s.) It must be given within 4.5 hours of symptom onset and has been shown to be time-dependent, with faster start of treatment leading to better recovery.
Endovascular therapy involves inserting a catheter directly into a blocked artery in the brain to deliver clot-busting drugs or use a device to remove the clot.
The researchers determined that 81 percent of the U.S. population could reach a hospital that can deliver IV tPA by ground within an hour, while 56 percent could reach a hospital that can perform endovascular therapy.
But out of 370,351 hospital discharges for acute ischemic stroke, only 14,926 (4 percent) received IV tPA. Another 1,889 (0.5 percent) had endovascular therapy.
"While many Americans live near hospitals that can treat acute stroke, actual stroke treatment rates remain extremely low,” Adeoye says. He notes that factors that contribute to low acute stroke treatments rates include patient factors such as ineligibility for acute therapies and delay in seeking medical attention and system factors such as poor public education for stroke warning signs, delays by pre-hospital personnel, triage to hospitals less likely to deliver acute stroke therapy and delays in emergency department/in-hospital delays.
Adeoye said optimization of regional stroke systems across the United States is needed to ensure that eligible patients are delivered to appropriate hospitals and that they receive treatment.
"We found that one in five of all acute ischemic stroke discharges in Fiscal Year 2011 were from hospitals that did not give any tPA during that year,” he says.
"These findings are critical evidence of room for improvement in the current system of stroke triage and care delivery in the United States.”
Immediate steps that could be taken, Adeoye said, include public education to inform patients with possible stroke to call 9-1-1, better training for EMS personnel and better planning by hospitals that do not currently provide acute stroke care for rapid transport of patients to capable hospitals.
"It is our hope that hospitals and pre-hospital systems will work together to improve stroke outcomes,” Adeoye says.
The Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality funded the study.