Locate New Stroke Centers by Need, Not Economics

March 10, 2015

Dramatically increasing the number of comprehensive stroke centers (CSCs) capable of endovascular treatment is not the ideal way to improve access to best stroke care, a new study suggests, but rather careful consideration of where each center is located is the key to maximize the population that could benefit from them.

The study, published online in Neurology on March 4, was conducted by a team led by Michael T. Mullen, MD, University of Pennsylvania, Philadelphia.

The development of new CSCs is particularly topical given the host of new studies showing the benefit of endovascular therapy for patients with a stroke caused by a large artery occlusion. As this benefit is extremely time sensitive, patients have to be able to get to a center capable of delivering such treatment very fast, and more hospitals are applying for certification to become CSCs.

"Our results highlight the need for population-based planning in developing systems of stroke care," Dr Mullen commented to Medscape Medical News. "Unfortunately this is not how the system is developing in the US, as in most cases it is the administrators in each individual hospital who decide whether or not to go for certification as a CSC.

"These decisions are made on market forces and economic considerations, rather than population need, and allowing such a system to continue will not be as effective as systems planned using data-driven methods," he said.

Stroke Belt Worst Served?

For the current study, Dr Mullen and colleagues created models on where CSCs may be best placed by population need, with the existing primary stroke centers used as potential candidates to become the new comprehensive centers.

They found that even if the new comprehensive centers are optimally located throughout the United States, 37% of the US population would still be unable to access such a facility within 60 minutes by ground transportation. However, this percentage decreased significantly if all hospitals with an emergency department were considered as candidates to become a CSC.

They also found a large degree of variability across the United States in access to care if new compressive stroke centers are selected from existing primary stroke centers. The Southeast part of the United States, known as the "Stroke Belt" — where there is the highest proportion of potential stoke patients — has the lowest access to expert stroke care.

"Ironically, we found that one factor that predicted not having a CSC nearby was living in an area of the US with the greatest need for stroke care," said coauthor Brendan Carr, MD, Thomas Jefferson University, Philadelphia, Pennsylvania.

In an accompanying editorial, Adam G. Kelly, MD, University of Rochester, New York, and John Attia, MD, University of Newcastle, Australia, emphasize that timely access to primary stroke centers should be the first priority and that comprehensive centers should then be added in a coordinated, stepwise manner guided by regional needs.

In an interview with Medscape Medical News, Dr Kelly elaborated that more primary stroke centers need to be established in areas of great need, particularly in the Stroke Belt. "Once hospitals in areas of need have reached this status, they may be more likely to eventually move towards a comprehensive stroke center designation. And a major benefit of enhanced primary stroke center access or telemedicine services is that a decision can then be more effectively made about whether a patient is appropriate for transfer to a nearby comprehensive center."

For their models, Dr Mullen and colleagues allowed a maximum of 20 CSCs per state. But they found that the marginal increase in population access with each subsequent comprehensive center fell dramatically, and population access often plateaued before all candidate hospitals were used.

"This suggests significant geographic clustering of candidate hospitals [primary stroke centers], reducing the efficiency f potential systems," they say.

Noting that CSCs are resource intensive in terms of both physicians and equipment and that certification requires a minimum volume of cases, they suggest that the number of actual centers is likely to be much lower than 20 per state. "Given finite resources, it is critically important to locate CSCs in a way that maximizes population access," they stress.

Dr Mullen commented: "When looking at which hospitals should become a compressive stroke center, health planners need to think about the burden of disease in that area and develop a system of care that meets the need of their population. We are hopeful that work like ours may encourage this to happen."

He added that it probably would not be possible to ensure ground access within 1 hour to everyone in the United States. "The US is a big place with large rural areas. The system needs to include telemedicine and air transfers in areas a long way from a comprehensive stroke center."

US System Problematic

In their editorial, Dr Kelly and Dr Attia reiterate Mullen and colleagues' concerns about whether the service will evolve in the best way. The editorialists write: "Unfortunately, in the US health care system, it seems unlikely that determining the quantity and location of CSC hospitals would be done purely on a population health basis.

"In a fee-for-service model of care in which endovascular stroke procedures are highly reimbursed, in a market system with competition between hospitals to obtain the largest share of a finite number of procedures, and in which CSC designation is made by nongovernmental agencies, CSC status may be determined more by financial motives than a sense of national utilitarianism."

Dr Kelly commented to Medscape Medical News that it was "unclear" whether any organization was taking on responsibility for the location of new comprehensive stroke centers. He stressed the importance of tracking patient outcomes from these facilities. "If we want real value out of the system, we need to see better outcomes in order to justify the high costs of these centers."

He pointed out that in addition to patients eligible for endovascular therapy, those with large strokes or intracerebral hemorrhages, or patients with subarachnoid hemorrhage from ruptured aneurysms, would also be better treated at a comprehensive stroke center. But he added that numbers of these patients are limited and dividing them across a larger number of centers may result in lower quality of care.

"It also remains to be seen what number of comprehensive centers we as a country can support with the expected number of vascular neurologists, endovascular neurosurgeons, neurocritical care providers, et cetera, needed," he added.

This research was supported by a grant from the Agency for Healthcare Research and Quality. Dr Kelly is a faculty member at an institution currently designated as a comprehensive stroke center.

Neurology. Published online March 4, 2015. Abstract   Editorial


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