Primary Stroke Centers May Boost Use of TPA : Improved patient care and wider use of tissue plasminogen activator are likely, experts say.

Acute stroke care in the United States is undergoing a dramatic transformation. The era of primary stroke centers has arrived.

In February 2004, the Joint Commission on Accreditation of Healthcare Organizations began accrediting primary stroke centers. By the end of last year, JCAHO had certified 61 stroke centers and was in the process of reviewing another 68 applications.

Within the next few years, it's likely that about 500 hospitals across the country will be certified as primary stroke centers, predicted Mark J. Alberts, M.D., director of the stroke program at Northwestern University in Chicago, and a developer of the primary stroke center concept.

The process of creating stroke centers is having two effects: identifying the hospitals that are best equipped to diagnose and treat patients with suspected stroke and forcing medical staffs to agree on an in-house protocol that dictates how acute stroke patients will be managed and which types of physicians are responsible.

The net result should be improved patient care and, probably, wider use of tissue plasminogen activator (TPA), experts predict.

Two additional changes now underway will likely further expand the role of neurologists in acute stroke care: establishment of vascular neurology as a recognized subspecialty, and setting a Medicare billing code for treating patients with acute stroke.

The 1996 approval of TPA for treating selected patients with acute stroke meant that stroke was no longer managed exclusively as a chronic disability. The availability of a treatment that was effective only if it was delivered within a few hours of stroke onset put a new premium on the rapid and accurate diagnosis of ischemic stroke, and on the need to rule out hemorrhagic stroke.

Public education campaigns were created so that, ideally, a patient with new-onset symptoms of acute stroke would go to an emergency department, get a brain CT scan, and then an emergency medicine physician would consult with a neurologist and radiologist to decide whether the patient should get TPA.

Unfortunately, it hasn't always worked this way in the ensuing 8 years.

“For a neurologist in an office, it's very disruptive to leave to see a stroke patient [in an emergency department]—it's not very lucrative, and there is medicolegal risk,” said Howard S. Kirshner, M.D., vice-chairman of neurology and director of the stroke center at Vanderbilt University in Nashville, Tenn.

“Emergency department physicians often like neurologic backup because a patient is atypical or they are uncomfortable with the diagnosis, but for neurologists there have been many disincentives,” said Arthur M. Pancioli, M.D., vice chairman of the department of emergency medicine at the University of Cincinnati.

“Most neurologists are not set up to take emergency calls, and there's a huge economic disincentive because there is no billing code for neurologists to use. They not only have to leave their patients, but they lose money in the process.”

The result has been that many acute stroke patients in the United States have not been getting optimal treatment. “Most often, they're not getting TPA when they should,” although sometimes they get TPA when they shouldn't, said William G. Barsan, M.D., chairman of the department of emergency medicine at the University of Michigan in Ann Arbor.

“About 3%–4% of acute stroke patients in the United States are getting TPA, even though at least 10% would probably qualify,” Dr. Kirshner said. “The biggest factor is that patients don't come for treatment quickly enough.”

But another stumbling block has been that many hospitals have lacked an in-house protocol that either laid out a way for emergency medicine physicians to routinely get a quick neurologic consult, or provided a go-ahead from the hospital's neurologic staff for emergency physicians to give TPA treatment on their own in cases that meet the protocol criteria.

“You don't need a neurologist for every case. You just need a protocol,” Dr. Kirshner said. “There needs to be a protocol that neurologists are involved in designing.”

When protocols are in place, neurologists are comfortable with treating stroke patients during the chronic, rehabilitative phase even it they were not directly involved in acute treatment.

“What's often lacking is the willingness of a neurologist to take over care of the patient,” Dr. Barsan said. “You don't want an emergency medicine physician to treat a patient with TPA and then have the neurologist say, 'I wouldn't have done that.' You need for neurologists to come on board, agree to an acute-treatment protocol, and agree that emergency physicians will give TPA and then the neurologists will take over.”

Another new development that will further standardize acute stroke care and the key role of neurologists is the establishment of vascular neurology as a recognized subspecialty. In May About 200 neurologists have registered to take the test, said Edgar J. Kenton III, M.D., a neurologist at Jefferson Medical College in Philadelphia and former president of the Neurology Board. With this new subspecialty becoming a reality, fellowship programs are now also starting around the country, he said.