Study Finds Sloppy Stroke Care
Ten years ago, a crucial study proved that a drug could limit the damage from one of nature's biggest train wrecks: a blood clot stuck inside the head.
The drug, TPA, was so powerful at dissolving blockages threatening to destroy regions of the brain that the first patient to get it, a 67-year-old man, regained the ability to walk and talk half an hour after it started flowing through his veins.
"The nurses at the bedside started crying. It was very dramatic," recalled Dr. William Barsan, who treated him.
TPA remains the sole drug approved for strokes. Yet only about 3 percent of victims get it.
Usually that's because they don't seek help until it's too late for the drug to do any good - three hours after symptoms start.
However, fresh research documents disturbing problems that keep this lifesaving treatment from reaching the roughly one in five stroke victims who do seek help in time. Studies presented at an American Stroke Association conference last week found that:
"It's like we've built a cascade of system failures here. Every place along the stream is another place something can go wrong," said Dr. Larry Goldstein, director of Duke University Medical Center's stroke program and member of a task force aimed at improving the situation.
The courts may provide added incentive to do so: Hospitals increasingly fear lawsuits if they fail to give the drug in time.
The consequences of missed opportunities are huge. Stroke is the third leading cause of death in the United States, behind heart disease and cancer. It's a chief reason for disability and forces many people to spend their final days in nursing homes, unable to walk, talk or see as they once could.
About 700,000 strokes occur each year, and nine out of 10 are due to a clot. Little could be done for them until doctors tried TPA, a medication used to dissolve clots causing heart attacks, for stroke.
The 1995 study, funded by the federal government, proved that it worked. Stroke victims treated with TPA were twice as likely to have a good outcome as those who were not. The Food and Drug Administration approved it for stroke the next year, and a move grew to treat strokes as "brain attacks," emergencies requiring swift treatment to prevent permanent damage.
Dr. Lee Schwamm, associate director of Massachusetts General Hospital's stroke program, called it a landmark event. "It signaled the end of therapeutic nihilism, the idea that if you were having a stroke it was just too bad, that you ought to go in a dark room and come out when it's over."
However, there is a dark side to this miracle-working medication. About 6 percent of stroke patients who get it develop bleeding in the brain, which is fatal half the time. This can be avoided by not giving it to those with bleeding ulcers, very high blood pressure or certain other conditions.
But many emergency room doctors have been afraid to give TPA without neurologists to back up their judgment, and most hospitals don't have neurologists in the ER.
Studies show the consequences.
Dr. Toby Gropen, neurology chief at Long Island College Hospital in Brooklyn, examined what happened at 14 New York hospitals participating in a state program to boost stroke care. They more than doubled TPA use, but from a mere 2.4 percent to 5.2 percent.
"We're moving in the right direction. It's a start," he said.
Schwamm studied more than 21,000 patients treated at 99 hospitals participating in the stroke association's "Get With the Guidelines" campaign. When it started, only one-third of the most ideal candidates for TPA were getting it. That improved to 61 percent a year later, but that meant four out of 10 still missed out.
Barsan, chief of emergency medicine at the University of Michigan, and the American College of Emergency Physicians surveyed 1,105 ER doctors on their willingness to use TPA.
"Even under ideal conditions where we told physicians, 'you've got a valid CAT scan which shows there's no bleeding, there aren't any snakes under the rocks,' 40 percent said they were unlikely or unwilling to treat those patients," he said.
There are problems before patients arrive, too. Dr. Brent Jarrell of Cabell Huntington Hospital in West Virginia studied how hospital operators and helplines in several states responded to hypothetical calls describing classic stroke symptoms.
"Roughly 25 percent of the people were referred back to their primary care doctor," he said. "The kind of the feeling, when you talk to them, is that they were trying to keep people away from the hospital."
One in five operators couldn't identify a single stroke warning sign.
Many efforts are under way to improve things. Last year, the Joint Commission for Accreditation of Healthcare Organizations started accrediting stroke centers meeting strict standards, such as seeing every patient within five minutes of arrival. So far, 88 hospitals in 28 states have earned the title and hundreds more are seeking it.
Some states -Florida, New York, Maryland and Massachusetts - have their own stroke center criteria, and some regions require EMS programs to take patients to the nearest stroke center instead of the closest hospital.
Stroke centers are also required to do community education to boost awareness of symptoms.
Unlike heart attacks, "stroke is almost never painful," so people often don't seek help, said Dr. Joseph Broderick, a University of Cincinnati neurologist. Signs like dizziness or numbness in an arm may be chalked up to things like sleeping in a funny position.
The stroke association task force issued a detailed plan last week for how hospitals and communities can improve stroke care.
An independent panel also recently re-analyzed information from the landmark 1995 study to more firmly establish the risk of side effects that so troubled emergency room doctors. Its conclusion: the drug's risks were smaller and its benefits even greater than the study originally found.
Stroke experts believe TPA use will rise as doctors become confident in their ability to pick the right patients to get it. But the only way to develop such judgment, they say, is to start using the drug.