Organizing Stroke Systems of Care
To the Editor:
I read with great interest the American Stroke Association (ASA) policy recommendation entitled Recommendations for the Establishment of Stroke Systems of Care.1 It is encouraging to see that this task force validates the recommendations from the 2 symposia sponsored by the National Institute of Neurological Disorders and Stroke held in 1997 and 2002.2,3⇓ There appears to be consensus on what systems need to be in place to optimally prevent and treat stroke. The challenge lies in effective implementation. Approximately 9 years after the Food and Drug Administration approved intravenous tissue plasminogen activator (IV tPA), the number of patients treated annually has not increased. It appears that simply agreeing on what should happen does not make it so.
The ASA’s Task Force set forth 5 general recommendations for stroke systems,1 but there is no clear description of who or what is organizing this comprehensive “systems” approach. The NINDS task force also emphasized the “need to link and coordinate the activities of providers, concluding that a stroke system should fundamentally be a single entity that is responsible for organizing the stroke system”3 without helping us understand who that “single entity” is. It is possible that we could fast-forward 9 more years and not have gained much ground.
As with all complex tasks, there is likely to be more than one successful approach. The “top down single entity” model is going to require state and/or federal leadership and support. Florida and New York appear to be headed in this direction. Another approach is to understand the critical elements producing successful outcomes in the “bottom up emergent” regional systems of care and reproduce them in like communities and regions.
The stroke team at the Mid America Brain and Stroke Institute (MABSI) at Saint Luke’s Hospital in Kansas City, Missouri has been active in organizing a systems approach to stroke treatment and prevention since 1993. In 2004, 513 patients with ischemic stroke were admitted to Saint Luke’s Hospital. Of those, 144 received tPA (28%). This was an increase of 80% over the previous year when 80 patients were treated. Seventy percent of the patients who received tPA were referred from one of 47 referring hospitals in the region, and half of the patients who received IV tPA had therapy initiated in the referring hospital, usually by an emergency medicine physician in consultation with the MABSI stroke team neurologist. Thirteen of the 47 referring hospitals were in the Kansas City metro area and 34 were within a 150-mile radius around the city. What is working for our region can certainly be replicated in other parts of Missouri and in other states, but we need to understand how and why the network succeeds.
There is a risk that the ASA Task Force Recommendations of 2005 may not drive the progress we need in stroke systems unless there is support for qualitative study of models that work, be they “top down” or “bottom up.”
Schwamm LH, Pancioli A, Acker JE, Goldstein LB, Zorowitz RD, Shephard TJ et al. Recommendations for the Establishment of Stroke Systems of Care. Stroke. 2005; 36: 690–703.
National Institute of Neurological Disorders and Stroke. National Institutes of Health. Rapid Identification and Treatment of Acute Stroke. NIH Publication No. 97-4239, August 1997.
National Institute of Neurological Disorders and Stroke. National Institutes of Health. Improving the Chain of Recovery for Acute Stroke in Your Communty. NIH Publication No. 03-5348, September, 2003.
We applaud the efforts of Dr Rymer’s group and those of many others across the United States who have worked so hard to improve the quality of acute stroke care in their communities. Such efforts have a significant impact in their region and offer considerable benefit to nearby patients. Although single hospital systems or communities have been able to organize and implement improvements in stroke care, including increased treatment with tissue plasminogen activator, broader changes are required to expand access and ensure the highest quality of stroke care across the spectrum of services. Ultimately, a stroke system of care will be successful through effective establishment of interconnected core components, including: (1) primary and primordial prevention; (2) community education; (3) notification and response of emergency medical services; (4) acute stroke treatment, including the hyperacute and emergency department phases; (5) subacute stroke treatment and secondary prevention; (6) rehabilitation; and (7) continuous quality improvement activities. Implementing this continuum of care is the best way to reduce mortality and improve quality of life for all stroke patients. The American Heart Association and American Stroke Association (AHA/ASA) have made a goal of reducing the burden and risk of heart disease and stroke by 25% by 2010. This commitment is reflected in a recent re-organization across the entire affiliate infrastructure that includes the development of specific state-level stroke goals based on the blueprint laid out in the Recommendations for the Establishment of Stroke Systems of Care.1
The AHA/ASA is partnering with its volunteer members and key organizations such as the Joint Commission on Accreditation of Healthcare Organizations, the Centers for Disease Control and Prevention, and State health departments and legislatures to form state-specific collaboratives to oversee the implementation of stroke systems of care. This process is playing out in different ways across the country: some states have chosen a DPH-based model (Mass, NY); others are pursuing state legislative models (Fla, NM, NC), and still others are leveraging federal programs like the Paul Coverdell National Acute Stroke Registry (Mass, NC, Ill, Ga). The leadership for implementation of system change will vary from state to state, and the stakeholders may be different, but as we have emphasized the locus of change should be at the state or regional level to be most effective at providing services to all citizens—not just those fortunate enough to live within the catchment area of large metropolitan hospitals. Geographically large states or those with significant rural populations will likely need to leverage access to specialists through the use of telemedicine, aeromedical transport, and interstate collaborations.
The effort to provide federal funds to support further implementation of systems at the state or regional level continues with the re-introduction in Congress of the STOP Stroke Act,2 a bill to “amend the Public Health Service Act to strengthen education, prevention, and treatment programs relating to stroke.” We urge all those interested in improving stroke care to enlist the support of their elected congressional representatives to pass this vital legislation.