Once in the Emergency Room your taken right back, people crowd around, off come your cloths, someone puts an IV in your arm and you’re rushed off for a Head CT. When you return you get an EKG, more blood tests and a lot of questions. A cheery young lady comes in and says she is the Stroke Coordinator. She talks with you and gives you some handouts and asks more questions. Then someone brings a big machine into the room and does an ultrasound of your heart and neck. Your symptoms seem to have subsided but you are admitted to the Hospital just as a precaution. The ER Doctor is still not sure if you had a TIA or some other problem. Since your better you don’t need the miracle clot buster drug. Good thing.
The response to a potential stroke patient is modeled much like the response to a trauma patient entering a Trauma Center. These patients go to the top of the priority list and command the resources of the facility. The goal initially is to identify rapidly if the potential stroke patient is a candidate for TPA. A wide net is cast where most every patient with any acute neurological presentation gets entered into the Stroke Protocol. Some communities have implemented EMS destination protocols so potential Stroke patients are routed to a Stroke Center. San Francisco did this and the response of the hospitals was the all became or have applied to be Stroke Centers.
So is all this good medicine or marketing to increase patient volume and charge for a lot of expensive procedures? The good medicine argument is subject to much debate just as TPA’s use for ischemic strokes is controversial. Grunt Doc in recent posts here and here sheds light on the controversy, mainly in response to a recent Wall Street Journal Article that promotes TPA. The main Emergency Medicine organizations have taken positions that TPA not be considered standard of care for Ischemic Stroke but be an option in certain cases. AAEM’s position statement can be viewed here The movement towards Stroke Centers seems to have steamrolled over the concerns of Emergency Physicians and is moving ahead at a brisk pace. A list of current Stroke Centers can be viewed here. The ED I work at is a Stroke Center. Some of the ED MD’s are very reluctant to give TPA but know its not a good career move for them or their ED group to not give it on a qualified candidate. So they do it. ED Physicians are in a no-win situation. They are likely to get sued for giving or not giving TPA if the outcome is not good.
The marketing aspect of Stroke Centers is closely tied to the marketing of TPA. The creation of, or at least the illusion of, TPA as the Standard of Care for Ischemic Stroke seems to be the strategy with an aggressive media campaign as well as involvement with the American Heart Association in setting standards. Genentech who makes TPA has promoted the establishment of Stroke Centers and has made it one of their marketing goals.
The “Stroke Center” paradigm provides a way to segment hospitals by their treatment patterns and shed light on how to overcome barriers to treating with TPA. Source:Genentech Stroke Assessment Market Research, 02/2003 – 07/2003
Genentech also offers educational grants to assist Stroke Centers in defraying the cost of educating their staff in stroke care. The American Heart Association, long criticized for recommending TPA’s use due to conflicts of interest of its Leadership, some with financial ties to Genentech and weak supporting data for TPA use in stroke, also is very involved in the Stroke Center concept and assists hospitals in getting Stroke programs started.
Genentech knows that promoting Stroke Centers will increase the use of TPA. One study showed an dramatic increase in TPA use at Stroke Centers versus non centers but no decrease in mortality or length of hospital stay associated with TPA. The real data out there does seem to support a modest decrease in long term disability when TPA is used according to strict criteria although some studies have actually shown an increase in mortality with TPA use. My suggestion would be to place this illustration on the TPA consent form which basically says, you may have less disability but your likelihood of a fatal hemorrhage is increased, and if your symptoms are not due to a stroke but some other neurological disorder you assume all the risk and none of the benefit, you make the call.
The Hospital I work holds Stroke Fairs catering to senior citizens. They have speakers go to community events and organizations. More than once I have seen or read material distributed or articles in the local newspaper or directly heard reference to getting to the hospital early to get the “miracle clot busting drug”. Is this information helpful? accurate? The education on lifestyle changes and symptom recognition is very helpful but I have big concerns about the promotion of TPA and minimization of risks. Again, perhaps the above chart which was produced by AAEM should accompany the handouts.
So are Stroke Centers good medicine or marketing? My opinion, some good medicine (the education and rehab portion) and a lot of marketing and optimistic claims. The whole thing kinds of smells bad to me. As a Nurse when tasked to give TPA for stroke I make sure that the patient and family are fully informed, repeated several times, that while the treatment may eventually reduce disability it also might kill you. As far as the Stroke Center cheer leading, I just hold my nose.
So are Stroke Centers good medicine or marketing? My opinion, some good medicine (the education and rehab portion) and a lot of marketing and optimistic claims. The whole thing kinds of smells bad to me. As a Nurse when tasked to give TPA for stroke I make sure that the patient and family are fully informed, repeated several times, that while the treatment may eventually reduce disability it also might kill you. As far as the Stroke Center cheer leading, I just hold my nose.
