Treatment after stroke includes reducing risk of recurrence

Each year roughly 700,000 Americans suffer a new or recurrent stroke, a condition that arises when blood flow to the brain is disrupted. Nearly a quarter of those incidents are fatal, making stroke the third-leading cause of death behind diseases of the heart and cancer.

Despite its prevalence, treating stroke remains a challenge, but the problem does not lie in a lack of knowledge about what to do. Rather, experts say, the problem lies in a fragmented system of care and convoluted incentive practices.

"There is a lot that we already know how to do," says Lee Schwamm, MD, associate professor of neurology at Harvard Medical School and director of Acute Stroke Services at Massachusetts General Hospital. "Unfortunately, there's a big gap between what we know and what we're doing."

Treating stroke patients is expensive. The American Stroke Assn. (ASA) estimates Americans will spend about $58 billion on stroke-related medical and disability costs this year.

To curtail those costs, payers in recent years have experimented with financial incentives, such as reducing in-patient length of stay and making reimbursement criteria more stringent.

"The irony is that these financial pressures don't seem to be saving cost overall," says David Matchar, MD, director and professor of medicine at the Center for Clinical Health Policy Research at Duke University Medical Center. In a paper presented at the International Stroke Conference in February, Dr. Matchar traced how financial incentives helped reduce hospital, physician and rehabilitation costs between 1991 and 2000 but resulted in a nearly equal increase in skilled nursing costs.

"We see from our cost studies that squeezing the balloon on the acute care side only leads to expansion on the long-term care side," he says. "If we truly want to improve stroke outcomes we must address these perverse financial pressures."

If a move by the Centers for Medicare and Medicaid Services (CMS) is a harbinger, reimbursement practices may be on the brink of change. Last summer, CMS created a new Diagnosis Related Group (DRG) that increases reimbursement levels for hospitals using clot-busting drugs to treat acute ischemic stroke patients. DRG 559 reimburses hospitals $11,578-up from previous reimbursement levels of between $4,000 and $6,000.

But misaligned financial incentives-although they exacerbate the problems associated with stroke care-are only part of the problem.

According to policy recommendations released last year by the ASA's Task Force on the Development of Stroke Systems, "the fragmented approach to stroke care that exists in most regions of the United States fails to provide an effective integrated system for stroke prevention, treatment and rehabilitation because of inadequate linkages and coordination among the fundamental components of stroke care."

Comprised of experts in stroke prevention, emergency medical services, acute stroke treatment, stroke rehabilitation and health policy development, the task force concluded that an effective system should coordinate and promote patient access to all stages of care including: primary prevention; community education; notification and response of emergency medical services; acute stroke treatment; sub-acute stroke treatment; and secondary prevention, rehabilitation and continuous quality-improvement activities.

Such a system would function according to the same principles that guide local and regional trauma care systems with enhanced communication among hospitals and emergency medical services, clear transport protocols, strategies for treating and transporting patients in remote areas and integrated rehabilitation services already in place.

The ASA isn't the only organization looking at developing a system of care. In 2001, the Centers for Disease Control and Prevention launched the Paul Coverdell National Acute Stroke Registry. Eight state-based prototypes were developed to measure delivery of care from emergency response to discharge from a hospital over a three year period.

At the end of the demonstration period, results showed large gaps between the recommended treatment guidelines and actual hospital practices.

Recognizing that intensive quality improvement was needed to close those gaps, the CDC in 2004 provided four state registry projects with funding to monitor and improve the quality of acute stroke care in sample hospitals.

Over the long term, the CDC hopes to use data collected from the Georgia, Illinois, Massachusetts and North Carolina registries to guide quality improvement interventions at the hospital level.