Lee H. Schwamm, M.D., FAHA, FANA, Executive Vice Chairman, Neurology Department, and Director, Comprehensive Stroke Center and Center for TeleHealth, Massachusetts General Hospital; Professor of Neurology, Harvard Medical School
A February 6 article in the Wall Street Journal, “A Breakthrough Stroke Treatment Can Save Lives – If It’s Available” raised awareness of barriers that hinder patient access to thrombectomy, but these six aspects should have been included:
- We need a big-picture approach to tackle the barriers that prevent thrombectomy from being available and accessible to patients who need it.
When a person has a stroke, the intertwined systems that are involved include emergency medical dispatch, response and transport; acute care and subacute care hospitals; and rehabilitation and recovery centers. Coordinating these resources into an integrated stroke system of care is paramount to improving patient access to appropriate facilities and critical treatments, and to ensuring seamless transition between providers. This integration requires participation from all stakeholders so that solutions are locally or regionally customized.
- The comprehensive approach that we need (see #1) starts with scientific evidence that is translated into guidelines and put into practice.
The American Heart Association/American Stroke Association funds research, publishes clinical guidelines, implements quality improvement programs and advocates for stroke systems of care. These activities are critical for collecting data and generating evidence to quantify impact. For example:
- Our acute stroke guidelines released in January 2018 expanded the eligible time window for thrombectomy to up to 24 hours, which is expected to be a game-changer for many patients.
- The Get With the Guidelines-Stroke quality improvement program has more than 2,000 participating hospitals that contribute valuable information to help drive research that informs strategies to improve outcomes.
- Reliable, accurate data are critical and must be interpreted correctly to ultimately determine the best investments to achieve optimal stroke outcomes. The Wall Street Journal article cited statistics highlighting variation by metropolitan region in the percent of Medicare “clot-caused” (i.e., ischemic) stroke patients who received thrombectomy. Though informative, the data were not adjusted for population density, patient characteristics or the proportion of patients for whom the procedure would have been indicated. These caveats should have been included alongside the reporting of the data.
- Hospital certification and recognition provide key support for the translation of knowledge into practice.
Partnering with The Joint Commission (the nation’s largest independent healthcare evaluator), the AHA/ASA certifies hospitals as stroke centers of varying capability. Certification requires hospitals to make significant investments, such as staffing skilled personnel and tracking post-discharge outcomes. Thrombectomy-Capable Stroke Center is a new level of certification designed to increase thrombectomy access in communities without comprehensive stroke centers.
- Telestroke is a promising, evidence-based solution for patients at the vast majority of hospitals that cannot perform thrombectomy. Telestroke allows a neurologist to remotely provide expert advice on acute stroke management and transfer of patients to hospitals that perform advanced stroke care. A new two-year Federal budget resolution includes provisions that authorize reimbursement for telemedicine-enabled stroke care for all Medicare recipients (previously, this coverage was available only to Medicare patients in rural areas), which will expand access to these services everywhere.
- Treatment delivery should be consistent with the National Academy of Medicine’s six domains of healthcare quality – safe, timely, efficient, effective, patient-centered and equitable. In light of existing healthcare inequities, we must be vigilant in ensuring that the benefits of thrombectomy are experienced equally across economic, racial and ethnic groups. Social determinants of health (e.g., race, income, environment, social supports and education) influence access to acute care and to post-stroke recovery resources, and can be potent contributors to disparities in stroke outcomes.
As a leading cause of death and adult disability, we can’t rest in our determination to treat and beat stroke. Improving stroke systems of care is a critical piece of this mission.