It is vital that treatment for stroke is given as quickly as possible in order to minimize the amount of long-term damage that occurs. Unfortunately, a new study has suggested that one third of Americans would be unable to access a primary stroke center within 1 hour should they need to.
The study, published online in Neurology, was a population-level virtual trial simulating how long it would take for patients to access stroke care following changes to systems of treatment.
"Research has shown that specialized stroke care has the potential to reduce death and disability," says study author Dr. Michael T. Mullen. "Stroke is a time-critical disease. Each second after a stroke begins, brain cells die, so it is critically important that specialized stroke care be rapidly accessible to the population."
According to the authors, stroke is one of the leading causes of death and disability in the US, occurring when the flow of blood to a portion of the brain is blocked or an artery in the brain ruptures or leaks.
In 2012, the beginnings of a three-tiered regionalized system of care were implemented. This involved the designation of certain hospitals as primary stroke centers (PSCs) and comprehensive stroke centers (CSCs), with CSCs providing the highest level of care.
Dr. Mullen and his colleagues decided to create virtual models in order to estimate what percentage of the population would have access to a comprehensive stroke center after selectively converting a number of primary stroke centers to facilities providing a higher level of care.
"In this report, we demonstrate how mathematical optimization modeling can inform the strategic development of the US network of stroke centers by simulating the conversion of PSCs into CSCs," the authors write. "This allows for virtual trials of competing system configurations in order to design a system that maximizes population access to care."
Reduced access to specialized stroke care could worsen pre-existing disparities in health
Data from 2010 was utilized, at which point there were 811 PSCs and no CSCs in the US. The researchers converted up to 20 PSCs in each state into CSCs and calculated how long it would take local populations to access these treatment facilities by ambulance or plane in optimum conditions.
After converting the PSCs to CSCs, the researchers found that only 63% would live within a 1-hour drive of a CSC, with an additional 23% within a 1-hour flight of one.
"Even under optimal conditions, many people may not have rapid access to comprehensive stroke centers, and without oversight and population level planning, actual systems of care are likely to be substantially worse than these optimized models," says Dr. Mullen.
Levels of access to care also varied in different geographical areas. Worryingly, access to care was lowest in an area often referred to as the "Stroke Belt" - 11 states where stroke death rates are more than 10% higher than the national average, predominantly situated in the southeast of the US.
"Reduced access to specialized stroke care in these areas has the potential to worsen these disparities," says Dr. Mullen. "This emphasizes the need for oversight of developing systems of care."
The authors suggest the actual number of CSCs that will be established is likely to be much smaller than 20 per state, and that increasing the number of CSCs is not an ideal way to improve access for patients due to the high costs involved.
A number of limitations are acknowledged, such as using trauma data to calculate the amount of time taken to reach a hospital, and calculating population access to hospitals using where people live, rather than where strokes occur. However, the authors argue that the majority of strokes (over 70%) occur at home.
In a linked editorial, Dr. Adam G. Kelly and Dr. John Attia suggest that CSC status is likely to be determined more by financial motives, however, rather than a population health basis.
They write that timely accessibility of PSC services, either on-site or via telemedicine, should be the first priority in the organization of regional stroke care. Following this, "CSCs should be added in a coordinated, stepwise manner with regional needs - not hospital bottom lines - as the major determinant for new CSCs."