Few Receive Best Acute Stroke Care Despite Good Access

February 21, 2014

More than 80% of people in the United States live within an hour's drive of a hospital that is able to give thrombolytic therapy to patients with acute stroke, but despite this, only 4% of these patients actually receive such treatment, new data shows.

The data come from a study presented by Opeolu Adeoye, MD, from the University of Cincinnati, Ohio, at last week's American Stroke Association (ASA) International Stroke Conference (ISC) 2014.

A shocking finding from the study was that 63% of US hospitals had not given a single dose of tissue plasminogen activator (tPA) during the year of the study — 2011 — even though these hospitals treated 20% of all stroke patients.

Referring to the ASA's FAST campaign (which stands for Face, Arms, Speech, Time) on how to recognize stroke and access help, Dr. Adeoye recommended that "H" be added to tell patients to go to the right hospital.

"Patients do not seem to be going to appropriate hospitals in a timely fashion," Dr. Adeoye told Medscape Medical News. "Many hospitals are not geared up for giving tPA, and the fact that these hospitals are treating 20% of stroke patients is hugely concerning."

Dr. Opeolu Adeoye

The study was set up to assess where the US population lives relative to hospitals able to deliver acute intravenous tPA. The researchers used the Medicare database and data from all fee-for-service hospitals in the United States. They used population census data to analyze where hospitals were in relation to the US population.

The study found that within an hour's driving time, 81% of patients could reach a hospital capable of administering tPA; 66% could get to a primary stroke center, and 56% could access a hospital capable of performing endovascular therapy.

However, of 370,351 discharges with ischemic stroke as the primary diagnosis, just 14,926 patients (4%) received tPA and 1889 (0.5%) had endovascular therapy.

Fast-Track Systems Not in Place

Dr. Adeoye noted that the hospitals not giving tPA do not have a system in place to fast-track stroke patients, which entails fast triage, computed tomography (CT), and the availability of a radiologist and neurologist, he explained. "On arrival, the triage nurse needs to recognize stroke, then ensure the patient gets an emergency CT scan, which is evaluated immediately by a radiologist and the results communicated speedily to a neurologist. This is not happening routinely."

He recommended that everyone find out where their nearest stroke center is. This information should be available on the hospital's Web site. "Family members should then tell paramedics which hospital to take the patient to, or ask them to go to the nearest stroke-certified hospital. In addition, all paramedics should be trained to recognize stroke and automatically take these patients to the stroke center."

Dr. Adeoye said the problem can be attributed to systems of care. "When stroke patients enter the ER [emergency room], they are not bleeding or screaming so they can easily be put in a corner and staff may not realize what is happening. Everybody needs to recognize that this is happening. From the patient care point of view, everything breaks down to the level of the person at the front desk. And they may not have the right knowledge of stroke, or do not put it into practice. We need to tackle this problem urgently."

The Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality funded the study.

International Stroke Conference (ISC) 2014. Abstract 99. Presented February 13, 2014.

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