Risk reduction through better acute stroke treatment

Insurance companies are constantly on the lookout for innovative ways to reduce risk and reduce costs. From underwriting continuing education for insured physicians to providing discounts to hospitals that have implemented risk reduction measures, forward-thinking insurers know that small investments in safety today can reap significant future rewards.

Yet even as these creative strategies become more common, there are many areas of untapped potential, with one of the biggest opportunities for risk reduction in acute stroke treatment.

Stroke is the leading cause of serious, long-term disability and the third-leading cause of death in the United States. On average, a stroke occurs every 45 seconds, and someone dies of stroke every three minutes. This translates into an estimated 700,000 U.S. residents who have a new or recurrent stroke each year, accounting for more than 1 million hospitalizations and about 163,000 deaths.

Improving treatment

The reality is that proven treatment protocols and drug therapies dramatically reduce the sequelae of acute stroke. For example, tissue plasminogen activator (tPA) is a thrombolytic "clot-busting" drug that has been proven to dissolve the blood clots that cause most heart attacks and strokes. When appropriate, prompt treatment with tPA can significantly reduce the consequences of stroke and reduce permanent disability.

Unfortunately, these promising advances are having little impact on treatment of stroke. In fact, less than 10% of eligible candidates receive thrombolytic therapy. For the vast majority of people, a stroke will simply run its course, causing death or long-term disability.

The real culprit is time. Current research supports the administration of tPA only during the three-hour window following the onset of symptoms. This means that for patients to receive tPA, they must arrive at the hospital soon after their symptoms begin. An effective course of treatment actually starts with the EMS provider and kicks into high gear at the first point of hospital contact. Hospital staff must be ready to rapidly evaluate the patient and perform brain imaging with interpretation as soon as the patient arrives. This must be immediately followed by tPA, if the patient is eligible, or other appropriate interventions. When you break this down even further, the goal for "door-to-needle" time is just 30 to 60 minutes.

To facilitate and acknowledge the tremendous effort required to achieve this level of capability, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has begun awarding a certificate of distinction for primary stroke centers, recognizing centers that make exceptional efforts to foster better outcomes for stroke care. JCAHO awards certification for one year to primary stroke centers that successfully demonstrate compliance with consensus-based national standards, effective use of established clinical practice guidelines to manage and optimize care and an organized approach to performance measurement and improvement. Maintaining certification after the first year requires evidence of updates to clinical practice guidelines, continuing standards compliance and performance improvement.

The benefits of certification are clearly spurring hospitals to action. Reduced morbidity and mortality among patients, fewer stroke complications, improved long-term outcomes, and increased patient satisfaction are all compelling reasons to make the investment. Some states, such as Florida and Texas, have even mandated that suspected stroke patients be brought only to certified emergency departments.

Certification challenge

While many hospitals have taken steps to achieve certification, few have successfully completed the process, and this failure is minimizing the impact of the JCAHO certification program on acute stroke patients. Why is this vision proving so difficult to realize?

Even the most efficient hospitals can face significant obstacles in completing the stroke center certification process. The same roadblocks come up: disconnects between hospital administrators and medical professionals; lack of agreement among various medical specialties; lack of cooperation from local EMS providers; and bottlenecks in processing patients quickly through a stroke evaluation. Frequently, hospitals just don't have experience designing and executing fail-safe systems of time management.