Decade of Efforts Helps AHA/ASA Meet Goal of 25% Reduction in Stroke, CV Events

Susan Jeffrey

March 04, 2010

March 4, 2010 — A new report chronicles the systematic changes that were required to achieve a remarkable reduction of 25% in stroke, heart disease, and cardiovascular risk since the American Heart Association/American Stroke Association (AHA/ASA) committed to this goal a decade ago.

"What I've seen through this 10-year lens is a really systematic approach to advocacy, to organizing healthcare providers, and to using almost a kind of manufacturing model approach to workflow," Lee Schwamm, MD, from the Massachusetts General Hospital in Boston, cochair of the writing committee on the report, told Medscape Neurology.

Increasing delivery of tissue plasminogen activator for the treatment of stroke, for example, has required reorganization of entire hospital systems, emergency medical response systems, and imaging systems within hospitals, he said. "That took the kind of organization that I think only a nonprofit advocacy group like the AHA could accomplish, by bringing people together on neutral territory and encouraging collaboration," he said.

Dr. Lee Schwamm

Their journey might also serve as a blueprint for other organizations looking to improve healthcare delivery, Dr. Schwamm noted. "It's a very nice paradigm for how to organize a broad collaboration of stakeholders and really make progress."

The report was published online February 24 in Stroke. The document also acknowledges the efforts of many partner organizations, including the American Academy of Neurology, the American College of Chest Physicians, the American College of Emergency Physicians, the Brain Attack Coalition, the Centers for Disease Control and Prevention, National Committee for Quality Assurance, The Joint Commission, National Quality Forum, National Stroke Association, Veterans Affairs Department, Department of Defense, and the World Stroke Organization, among others.

25% Reduction by 2010

In 1998, the AHA committed to the ambitious goal of reducing coronary heart disease, stroke, and cardiovascular risk by 25% by the year 2010, and to underline their commitment to stroke reduction, they formed the ASA at that time.

"In fact, that goal was met early, at the end of 2009, so that's really an amazing accomplishment," Dr. Schwamm said.

"The American Stroke Association and its many partners has spent the last decade methodically, thoughtfully, and effectively changing the care delivery system for stroke in this country," the study authors write.

Among the accomplishments, they note, are nonindustry funding of stroke research second only to the federal government; the development of Stroke, the first scientific journal focused solely on stroke research; work with The Joint Commission to develop the primary stroke centers certification program; creation of Get With the Guidelines-Stroke (GWTG-Stroke), an in-hospital quality improvement program; and successful advocacy for increased stroke reimbursement for Medicare and Medicaid.

Dr. Schwamm has been involved in the GWTG-Stroke initiative, which is part of why he was asked to chair the writing committee for this paper. He points to some developments of particular interest in the new report.

"What we've seen with GWTG-Stroke is that sustained focus on hospital-level quality improvement really pays off and that you can focus on more than 1 measure at the same time," he said. "Conventional wisdom was that you could only do 1 thing at a time in order to do it well. Here, there are actually 7 things that people are doing at a time and doing year after year increasingly well."

So well in fact that the results convinced Medicare that they need to start thinking about requiring hospitals to report on the quality of stroke care, he added.

"Last year's Medicare ruling identified 8 stroke measures that would be reported by all hospitals for payment in 2012, which means they will be collected in 2011, and there are now electronic versions of these measures being created and vetted," Dr. Schwamm said. "I'm pretty confident that beginning in 2011 many more US hospitals are going to start collecting this data, not just the ones in our GWTG-S quality program, but hospitals across the US. When this starts to happen, then the public will know, 'how does my hospital perform on these measures?' and 'what is my hospital doing to improve its performance?'; I believe that’s the ultimate step in empowering the public."

Another interesting development has been the use of new kinds of information technology to understand how to attack the problem, he said. "GIS mapping — geospatial information mapping — has turned out to be a very powerful tool to identify disparities in care, based on geographic factors or patient characteristics, such as race/ethnicity, age, or socioeconomic means. Now, because we can overlay this information onto maps of the US, along with regional death rates and the location of stroke centers, we can identify regions of the country that need special attention and resources."

For example, he said, it might appear that there are a lot of stroke centers in the Northeast, but there is also high population density and a lot of patients in the Northeast. "When you look at a map absent those other key geospatial variables, you might think stroke care is disproportionately distributed in this country," Dr. Schwamm points out. Many areas with fewer stroke centers also have very lower population density, he added, "so maybe we're doing better than it first appears."

Dr. Schwamm has disclosed no relevant financial relationships. Disclosures for coauthors are outlined in the paper.

Stroke. Published online February 24, 2010.