System of CARE Approach Emphasized at International Stroke Conference
Sg2 joined more than 4,300 health care professionals at last month’s International Stroke Conference in Los Angeles, CA, where sessions and preconference symposia offered something for everyone. Following game-changing data on mechanical thrombectomy presented at the 2015 meeting, endovascular intervention was again a much-discussed topic, but the focus was spread more broadly across a range of subjects, with highlights including rehabilitation and recovery, treatment for other neurovascular diseases (eg, hemorrhagic stroke, carotid artery stenosis), and new strategies for stroke prevention.
Care Delivery and Stroke Systems of CARE
The past year and a half have seen significant developments in stroke care, particularly as a result of new data and subsequent guideline changes supporting endovascular interventions for acute ischemic stroke. However, ensuring access to this and other advanced treatments remains a challenge, particularly given the need to balance fast access to tissue plasminogen activator (tPA; guidelines recommend that mechanical thrombectomy candidates receive tPA within 4.5 hours of stroke onset) with appropriate triage to the limited number of centers with endovascular expertise.
These logistical access challenges were the focus of a preconference symposium: Stroke in the Real World: Endovascular Therapy and Systems of Care. Sessions on prehospital screening and logistics, as well as debates on stroke triage, transportation and imaging techniques, highlighted the many variables impacting care delivery (eg, geography, number of stroke centers, neurointerventional workforce, emergency medical services [EMS] education levels, triage protocols) when it comes to the stroke System of CARE. Stroke care spreads across the care continuum and requires a coordinated approach across multiple care sites, including community sites and higher-acuity hospitals or stroke centers.
Kaiser Permanente Implements Regional Strategy to Improve Stroke Care
At the conference, Kaiser Permanente of Northern California’s Stroke EXPRESS Program provided a leading-practice example that illustrated how integrating community hospitals into a regional strategy can improve access and timeliness of stroke care. Launched in 2015, the program includes 21 community hospitals across 13 different EMS systems. Kaiser leverages a telemedicine hub to enable a core team of neurologists to rapidly assess patients upon arrival via videoconference and utilizes parallel processes in center that allow for faster diagnosis, tPA delivery as needed, and rapid transfer for patients with large vessel occlusions to an endovascular center. Since program inception, Kaiser has achieved a reduction in door-to-needle times, an increase in cases treated with tPA, and improved rates of tPA received within 30 minutes of arrival.
In addition to shifting paradigms in care delivery, patient selection for advanced stroke treatment (which continues to dominate current research and be a focus in clinical trials) was a key topic of discussion at the conference, indicating that this is an area that will continue to develop and be top of mind in the foreseeable future.
Rehabilitation and Recovery
As the stroke System of CARE evolves, improved access will increase stroke survivorship. Although Sg2 predicts that increasing tPA rates and other factors will shift some volumes from inpatient rehab to lower-acuity outpatient sites, both inpatient and outpatient rehabilitation volumes will grow as patients continue to face significant disability.
However, the optimal timing and mix of rehabilitation to maximize stroke recovery is still unclear, particularly in the critical early window after injury where it is thought that true recovery, rather than learning compensatory skills, largely occurs. Although there are some barriers to research in this area (eg, enrolling patients early enough), some promising approaches were discussed at the conference, including a virtual reality video game intervention out of Johns Hopkins Medicine through which patients can find ways to control a dolphin character through continuous non–task-based movements while their arm is supported in a robotic sling. The game’s control system can be augmented by the provider to ensure that patients are using their full range of motion.
UC Irvine Home-Based Telerehab Pilot Offers Promising Results
A home-based telerehabilitation pilot for arm motor deficits from the University of California, Irvine, was featured and showed promising results. In the intervention, patients 3 to 6 months poststroke were set up with an Internet-connected computer with which they completed structured 1-hour lesson plans, 1 optional hour of free play and 2 videoconferences per week over the course of 28 days. Positive results included good compliance rates and improvements in arm movement (measured by Fugl-Meyer scores).
Results also illustrated an opportunity for holistic care in parallel, as daily education incorporated into the intervention significantly increased stroke knowledge, and videoconference screening detected depression in several patients. If shown to be efficacious in ongoing studies, this type of intervention could provide a model to better engage patients at home and improve connectivity among patients and providers. From an operational perspective, this type of model could also translate to workforce efficiencies, supporting greater access to rehabilitation services.
Preventive Strategies for Recurrent Stroke
Stroke prevention was also a key theme at the conference. Results were presented from the Insulin Resistance Intervention After Stroke (IRIS) Trial, which examined use of the drug pioglitazone to prevent recurrent stroke and heart attack among insulin-resistant, nondiabetic patients who have had a stroke or TIA. Among these patients, treatment reduced the risk of stroke, heart attack and diabetes. Investigators noted that this is the first therapy directed at insulin resistance that has been shown to prevent stroke and heart attack, resulting in a promising new approach to consider for these key patient populations.
In addition to insulin resistance, identification and management of atrial fibrillation (AF) was discussed as another key tool for secondary stroke prevention. Results from the Find-AF randomized trial out of the University of Göttingen in Germany showed that with enhanced and prolonged monitoring of stroke patients via Holter ECG 3 times per day, AF detection was 3-fold the detection level with usual care. Numerically fewer (but not statistically significant) recurrent strokes, TIAs and deaths were seen in the group receiving enhanced monitoring. Though further research is needed, findings of this kind signal the growing need for increased connectivity and well-developed Systems of CARE that will support the follow-up and monitoring to prevent recurrent strokes and limit potentially avoidable admissions. This becomes particularly important as organizations increasingly engage in risk-based payment contracts.
Keys to Success
Recent developments in acute ischemic stroke treatment have increased demand for endovascular services, shifting the supply-demand balance as organizations seek to expand endovascular expertise. However, not all programs will have the volumes (both emergent and elective) to support investment in workforce and other resources that will be required to provide comprehensive care.
Consider the following action steps for optimal stroke care and endovascular services at your organization.
- Develop system-level strategies, but ensure that goals align with local needs across all hospitals and providers.
- Seek comprehensive status only if endovascular volumes and physician expertise are sufficient to support a dedicated 24/7 neurological critical care service.
- Include EMS providers in your stroke team to accelerate response times, improve outcomes and steer referrals when possible. Share quality measures with EMS teams to facilitate their ongoing participation in your stroke care initiatives.
- Participate in a regional telestroke network to increase patient access to tPA and endovascular interventions, while retaining appropriate volumes locally.
- Optimize participation in a telestroke network by:
- Identifying growth and performance metrics to assess your position
- Choosing networks and partners with similar goals, ensuring your organization contributes equally
- Scheduling regular interactions to share network metrics, challenges and best practices
- Employ nurse navigators to improve connectivity along the System of CARE and support patients recovering from stroke.
Sources: International Stroke Conference, Los Angeles, CA, February 16-19, 2016; Telerehabilitation in the Home Versus Therapy In-Clinic for Patients With Stroke. ClinicalTrials.gov. Updated September 29, 2015; Karidis A. Hopkins’ new video game may pave way for stroke therapy. Baltimore Sun. October 15, 2014; Sg2 Analysis, 2016.