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Health & Medicine for Senior Citizens

Admission to Designated Stroke Centers Appears to Be Helping Save Lives

Nearly 700 of the 5,000 acute care hospitals in the United States are now Joint Commission-certified stroke centers

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Jan. 25, 2011- Since 2003 many hospitals have been focused on achieving recognition as a certified stroke center, an idea pushed by the Brain Attack Coalition that envisioned a reduction in deaths from this third leading cause of death in the U.S. A new study finds the stoke centers are lowering the stroke death rate, but only modestly.

The study reported in the January 26 issue of the Journal of the American Medical Association found patients who had an ischemic stroke and were admitted to hospitals designated as primary stroke centers had a modestly lower risk of death at 30 days, compared to patients who were admitted to non-designated hospitals.

 

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Stroke is not only a leading cause of death, it is the leading cause of serious long-term disability in the United States. Responding to the need for improvements in acute stroke care, the Brain Attack Coalition (BAC) published recommendations for the establishment of primary stroke centers in 2000, and in 2003 the Joint Commission began certifying stroke centers based on these recommendations, according to background information in the article.

The Joint Commission is an independent, not-for-profit organization that accredits and certifies more than 18,000 health care organizations and programs in the United States. Joint Commission accreditation and certification is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards.

Today, nearly 700 of the 5,000 acute care hospitals in the United States are Joint Commission-certified stroke centers, with some states establishing their own designation programs using the BAC core criteria. "Despite widespread support for the stroke center concept, there is limited empirical evidence demonstrating that admission to a stroke center is associated with lower mortality," the authors write.

Ying Xian, M.D., Ph.D., of the Duke Clinical Research Institute, Durham, N.C., and colleagues conducted a study to evaluate the association between admission to stroke centers for acute ischemic stroke and the rate of death.

Using data from the New York Statewide Planning and Research Cooperative System, the researchers compared mortality for patients admitted with acute ischemic stroke (30,947) between 2005 and 2006 at designated stroke centers and non-designated hospitals.

Patients were followed up for mortality for 1 year after hospitalization through 2007. To assess whether the findings were specific to stroke, the researchers also compared mortality for patients admitted with gastrointestinal hemorrhage (39,409) or heart attack (40,024) at designated stroke centers and non-designated hospitals.

Among the patients with acute ischemic stroke, 49.4 percent (15,297) were admitted to designated stroke centers (104) and 50.6 percent to non-designated hospitals.

The overall 30-day all-cause mortality rate was 10.1 percent for patients admitted to designated stroke centers and 12.5 percent for patients admitted to non-designated hospitals.

Analysis indicated that admission to a designated stroke center hospital was associated with a 2.5 percent absolute reduction in 30-day all-cause mortality.

Use of thrombolytic therapy (dissolving blood clots) was 4.8 percent for patients admitted at designated stroke centers and 1.7 percent for patients admitted at non-designated hospitals (adjusted difference in use, 2.2 percent).

Among patients surviving to hospital discharge, there was no difference in rates of 30-day all-cause readmission and discharge to a skilled nursing facility.

"Differences in mortality also were observed at 1-day, 7-day, and 1-year follow-up. The outcome differences were specific for stroke, as stroke centers and non-designated hospitals had similar 30-day all-cause mortality rates among those with gastrointestinal hemorrhage or acute myocardial infarction," the authors write.

"Even though the differences in outcomes between stroke centers and non-designated hospitals were modest, our study suggests that the implementation and establishment of a BAC-recommended stroke system of care was associated with improvement in some outcomes for patients with acute ischemic stroke."

Editorial: Preventing Death One Stroke at a Time

In an accompanying editorial, Mark J. Alberts, M.D., of the Stroke Program, Northwestern University School of Medicine, Chicago, comments on the future of acute stroke care.

"A multitiered system of stroke care is developing, with the comprehensive stroke center (CSC) at the top of the pyramid, the primary stroke center (PSC) in the middle, and the acute stroke ready hospital (ASRH) at the base.

“Within a geographical region, a small number of CSCs would provide care for patients with the most complicated stroke cases; a larger number of PSCs would provide care for the patients with typical, uncomplicated cases; and the ASRH would provide initial screening and triage and begin acute care for patients in a rural, small urban, or suburban setting.

“Emergency medical services personnel would perform initial screening and triage and would transport patients with a clearly defined stroke to the closest stroke center facility. Using telemedicine technologies, hospital personnel could communicate and transfer patients to the facility with the most appropriate level of care. Many states and guidelines now support and even mandate the diversion of patients suspected of having a stroke to the nearest stroke center facility."


Top Ten Advances in Stroke Research in 2010

1. “Time is brain”: Clot-dissolving treatment for acute ischemic stroke found beneficial in the first 4.5 hours after onset, potentially harmful later

A combined patient analysis of eight trials of intravenous tissue plasminogen activator (tPA) for acute ischemic stroke reinforced prior findings of a strong time-to-treatment effect, with greatest benefit in the first few hours after onset, and, for the first time, demonstrated increased mortality from late treatment beyond 4.5 – 6 hours after onset.

· ● Pooled analysis of the ECASS, ATLANTIS, NINDS and EPITHET trials – Lancet, May 15, 2010; www.thelancet.com; Lancet 2010;375(9727):1695-703; Funding: There was no funding source for this study.

2. New mechanism of emboli clearance from the brain vasculature discovered

This study identified an entirely new way by which brain blood vessels are kept open by the body in the face of clots – extravasation. Clots that are not able to be dissolved are sometimes pushed out through blood vessel walls into the surrounding tissue, restoring nourishing flow in blood vessels.

· ● Lam, et al; Nature, May 27, 2010; www.nature.com. Nature 2010;465:478-482; Funding: No funding sources were listed.

3. Carotid endarterectomy and carotid artery stenting directly compared

The large CREST trial compared head-to-head the two major methods to reopen narrowed carotid arteries carrying blood flow to the brain: carotid endarterectomy (open surgical repair) and carotid stenting (endovascular placement of a stent). Overall, both techniques had similar rates of success and complication, but among younger patients, under 70 years of age, stenting appeared advantageous while among older patients endarterectomy appeared advantageous. Those findings were also supported in a preplanned meta-analysis of individual patient data from three randomised controlled trials.

· ● CREST – New England Journal, July 1, 2010; www.nejm.org; N Engl J Med 2010;363(1):11-23; Funding: National Institute of Neurological Disorders and Stroke (NINDS).

· ● Carotid Stenting Trialists' Collaboration – Lancet, Sept. 10, 2010; www.thelancet.com; Lancet 2010;376:1062-73; Funding: Medical Research Council, the Stroke Association, Sanofi-Synthélabo, European Union.

4. Million person milestone, emerging research shows quality initiatives improve outcomes

In an analysis of the first one million stroke patients enrolled in the national Get With the Guidelines® – Stroke quality improvement program at nearly 1400 hospitals across the country, quality of care on 10 performance measures improved substantially from 2003 to 2009. More than 80 percent of patients were receiving defect-free care by 2009, up from less than half in 2003. The Get With The Guidelines database is an invaluable resource in furthering development of tools and outcomes results that are making marked improvement in stroke patient care.

· ● Fonarow, et al – Circulation: Cardiovascular Quality and Outcomes, Feb. 22, 2010; http://circoutcomes.ahajournals.org; Circ Cardiovasc Qual Outcomes 2010; 3;291-302.

· ● Smith, et al - Circulation, Sept. 27, 2010; http://circ.ahajournals.org; Circulation. 2010;122:1496-1504.

· ● Saver, et al – Stroke, June 3, 2010; http://stroke.ahajournals.org; Stroke 2010;41: 1431-1439.

· ● Reeves, et al – Stroke, May 20, 2010; http://stroke.ahajournals.org; Stroke 2010;41(7):1573-8.

Funding: Get With The Guidelines®–Stroke (GWTG-Stroke) is provided by the American Heart Association/American Stroke Association. The program is currently supported in part by a charitable contribution from Bristol-Myers Squib/Sanofi Pharmaceutical Partnership and the American Heart Association Pharmaceutical Roundtable. GWTG-Stroke has been funded in the past through support from Boeringher-Ingelheim and Merck.

5. International study identifies the ten major risk factors for stroke

In the worldwide INTERSTROKE study, 10 simple risk factors were found to be associated with 90 percent of the risk of stroke. Targeted interventions that reduce blood pressure and smoking, and promote physical activity and a healthy diet, could substantially reduce the worldwide burden of stroke.

· ● INTERSTROKE Investigators – Lancet, June 18, 2010; www.thelancet.org; Lancet 2010;376,112-123; Funding: Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Canadian Stroke Network, Pfizer Cardiovascular Award, Merck, AstraZeneca, Boehringer Ingelheim.

6. Ultrasound detection of silent emboli identifies patients at high risk of stroke

This international, multicenter, prospective study confirms that detection of silent, microclots traveling to the brain on transcranial Doppler ultrasound identifies a subgroup of patients with asymptomatic narrowing of the carotid artery who are at high risk for stroke and might benefit from surgery or stenting.

· ● ACES – Lancet Neurology, July 2010; www.thelancet.com; Lancet Neurol;9(7):663-71; Funding: British Heart Foundation.

7. Robot-assisted therapy beneficial for long-term arm impairment after stroke

This randomized trial suggested that robot-assisted therapy can improve the rehabilitation of arm function after stroke compared with ordinary care, though no more than intensive therapist care.

· ● Lo, et al – New England Journal of Medicine, May 16, 2010; www.nejm.org; N Engl J Med. 2010;362(19):1772-83; Funding: Veterans Affairs Cooperative Studies Program and Rehabilitation Research and Development Service.

8. Genetic findings important in understanding, treating aneurysms

Two new studies looked at the genetics and treatment of aneurysms, balloon-like dilations of arterial walls that can be fatal if they rupture or tear. Saccular intracranial aneurysms are located in the intracranial arterial wall; their hemorrhage commonly results in severe neurologic impairment and death.

This multicenter genome-wide association study in Europe and Japan identified three new and confirmed two previously-suspected chromosome sites as harboring genes predisposing to the formation of intracranial aneurysms. Vascular Ehlers-Danlos syndrome is a rare, genetic, severe disease that causes arterial dissections and ruptures that can lead to early death. This randomized trial found that treatment with a beta-blocker medication to lower mechanical stress on arterial walls prevents dissection and hemorrrhages in Ehlers-Danlos patients.

· ● Yasuno, et al – Nature Genetics, May 2010; www.nature.com; Nat Genet;2010;42(5):420-5; Funding: Yale Center for Human Genetics and Genomics,Yale Program on Neurogenetics, US National Institute of Health, Howard Hughes Medical Institute.

· ● Ong, et al – Lancet, Sept. 7, 2010; www.thelancet.com; Lancet. 2010;376;1476 – 1484. Funding: French Ministry of Health, Programme Hospitalier de Recherche Clinique 2001.

9. Lowering blood pressure early reduces brain hemorrhage growth

One out of six strokes is due to bleeding into the brain, intracerebral hemorrhage, a major cause of death and disability. Two pilot trials found that aggressively lowering blood pressure, starting within six hours of stroke onset, is feasible and can reduce hemorrhage expansion. Larger trials have been launched to determine if this improves patient final outcome.

· ● ATACH Investigators – Critical Care Medicine, Feb. 2010; www.ccmjournal.org; Crit Care Med. 2010;38(2):637-48; Funding: ?

· ● INTERACT – Stroke, Dec. 31, 2009; Stroke. 2010;41(2):307-12; Funding: National Health and Medical Research Council (NHMRC) of Australia.

· ● INTERACT – Hypertension, Sept. 7, 2010; Hypertension; 2010;56:852-858; Funding: National Health and Medical Research Council of Australia.

10. Physical activity, even moderate in degree, reduces stroke risk

A large study found leisure-time physical activity, even in modest degree, is associated with lower stroke risk in women. In particular, walking was generally associated with lower risks of total, ischemic, and hemorrhagic stroke.

 ● Sattelmair, et al – Stroke, April 6, 2010; http://stroke.ahajournals.org; Stroke 2010;41(6):1243-50; Funding: National Institutes of Health.

 

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