Sunday, May 18, 2008

Stroke Care Discussed on the Hill

A total of 750,000 strokes occur in North America each year and the projected cost of stroke care in 2008 is expected to be $65 billion. To help the nation deal with this enormous health issue, experts in the field gathered in Washington D.C. on May 15th to speak at a special session of the Capitol Hill Steering Committee on Telehealth and Healthcare Informatics. The American Heart Association and the American Telemedicine Association collaborated on the session.

The speakers were in agreement that there is a tremendous opportunity to reduce disabilities from stroke by simply treating patients within the three hour window after the stroke has occurred. However, only 2 to 5 percent of eligible stroke patients are currently able to receive these treatments.

Neal Neuberger, President Health Tech Strategies and Chair, ATA Public Policy Committee pointed out that a number of Telestroke Networks have been established throughout the country. One network, the Virginia Acute Stroke Telehealth (VAST) Network was recently launched to develop HIT solutions for each of the five areas within the “Stroke Continuum of Care”.

Karen S. Rheuban MD, President-elect ATA, and Medical Director, Office of Telemedicine, Professor of Pediatrics and Senior Associate Dean for CME and External Affairs, University of Virginia, emphasized that telehealth plays an important role in helping during the critical time immediately after a stroke by improving access to care and the quality of the treatment.

Sue Nelson, Vice President of Federal Advocacy, American Heart Association/American Stroke Association, said “stroke is the nation’s number three killer, on the average one person in the U.S. has a stroke every 40 seconds, with death and disability from strokes expected to double by 2032.

Nelson wants to see the “STOP Stroke Act” that was passed by the House also be passed by the Senate. The Act would authorize a grant program to help states ensure that patients have access to quality stroke prevention, treatment, and rehabilitation services. The act would also raise public awareness concerning stroke warning signs and would continue the Coverdell Stroke Registry and Clearinghouse to collect data.

Trisha Carney came from her home in New York State to put a face on patients that have had strokes. Most people think that stroke victims are elderly but this is not always the case. Trisha is a 38 mother and never pictured having a stroke at her age. It’s been a very difficult experience and every day can be a challenge but she is moving forward and working towards gaining her life back.

Darwin R. Labarthe, MD, MPH, PhD, Director, Division for Heart Disease and Stroke Prevention, CDC, explained that the “2008 Atlas of Stroke Hospitalizations among Medicare Beneficiaries” recently published, is the fifth in a series of CDC atlases related to cardiovascular disease. The atlas was developed in collaboration with CMS and includes county-level maps of stroke hospitalizations by stroke-subtype, race/ethnicity, discharge status, and co-morbidity within the Medicare population.

Dr. Labarthe pointed out that an important strength of the Atlas is the examination of geographic disparities in stroke hospitalizations for blacks, Hispanics, and whites in the U.S. Previous reports have focused predominantly on blacks and whites.

Paul M. Katz.MD, Medical Director, Renown Health System Institute for Neurosciences Comprehensive Stroke Center, Reno, Nevada discussed stroke care in rural areas. Dr. Katz reports that there are challenges in delivering acute stroke care in the large rural areas in the state, since there is limited stroke awareness, few specialists in the field, narrow therapeutic time windows, there are traditional patterns of practice in the communities, competitive hospital systems, and costs are high for treatment.

A study done by Renown looked at stoke care to determine if the care were organized and standardized, would the use of thrombolytic therapy improve care in the greater Reno metropolitan area and the 27 rural hospitals serviced by Renown.

They found the solution for improving care was to organize a 24 hour regional stroke team with a stroke neurologist, along with a neuroradiologist, neurosurgeon, nurse, pharmacist, and emergency department personnel. Also, standard pre-hospital and hospital protocols were put into place in all communities, and each rural hospital and EMS provider was personally visited and received information on the protocols.

Teleradiology is currently being used for CT interpretations, and Dr. Katz reports that ultimately telemedicine will really be able to effectively optimize the evaluation of patients. Presently, an internet-based system is now being piloted at Renown Regional Medical Center and in three rural hospitals.

Dr. Katz stressed that the success of a regional comprehensive stroke center involving many rural hospitals depends upon having standardized protocols for the pre-hospital and hospital settings, and a careful assessment by the regional stroke team on the capabilities and limitations in each rural area.

Adnan H. Siddiqui, MD, PhD, Assistant Professor of Neurosurgery, University at Buffalo, State University of New York, agrees with the other speakers that caring for stroke patients is greatly impacted by the fact that there are not enough neurologists, neurosurgeons, and stroke specialists. Added to the problems, there is low use of IV-tPA at 0.6%, hospitals have no leverage over specialists to take emergency department calls, and emergency department physicians are not comfortable using tPA.

Dr. Siddiqui explained how the medical community realizing that there is an enormous problem in the state, established a rural telemedicine initiative for stroke treatment. They set up the REACH stroke system originally developed at the Medical College of Georgia. This system is a 100% web-based service that provides decision support solutions for remote diagnosis and evaluates acute diseases such as stroke. The system permits real-time interactive consultations service to take place from different sites with twelve hospitals in the network.

Dr Siddiqui is pressing for regional development of Comprehensive Stroke Centers that are modeled after Regional Level 1 trauma centers. The requirements for the centers are to have a stroke team available 24/7, an imaging center, rapid response capabilities, endovascular team available 24/7, and a neuro ICU.

Continuing Honorary Steering Committee Co-Chairs are Senators Kent Conrad (D-ND), Mike Crapo (R-ID), Sheldon Whitehouse (D-RI) and Representatives Eric Cantor (R- VA), Rick Boucher (D-VA), Bart Gordon (D-TN), Allyson Y. Schwartz (D-PA), David Wu (D-OR) and Phil English R-PA). The Steering Committee coordinates many activities with the House 21st Century Health Care Caucus, co-chaired by Representatives Patrick Kennedy (D-RI) and Tim Murphy (R-PA).

The next session will be held on May 21st. The topic is “Moving Toward an E-Enabled Healthcare Environment: Telehealth, EMR, PHR, eRX, and Related Technology Tools from 30,000 Feet.” The session will be held at noon in Room 2325 Rayburn House Office Building (House Science and Technology Committee Hearing Room). For more information, contact Neal Neuberger, President, Health Tech Strategies LLC, at (703) 790-4933 or email