ONE IN FOUR IN US LIVES IN AREAS WITH NO PRIMARY STROKE CENTER

Neurology Today
3 June 2010; Volume 10(11); pp 1,11

LAINO, CHARLENE

An analysis of data on 719 hospitals with primary stroke centers certified through the Joint Commission or states in 2007 found a disproportionate number of centers in high-density areas, leaving large areas of the country underserved.

TORONTO—Over one-fourth (28 percent) of the US population lives in areas with no primary stroke centers, and 32 percent are people 65 and older, a new study shows.

Reporting the data at the AAN annual meeting here, Adnan I. Qureshi, MD, professor and associate head of the department of neurology at the University of Minnesota in Minneapolis and executive director of the Minnesota Stroke Initiative, said: The absence of centralized planning has resulted in aggregation of certified primary stroke centers in a disproportionate manner to the population of United States.

A comprehensive certification plan that assesses certification in relation to population needs is required for ensuring homogeneity in delivery of high quality of stroke care in United States.

Dr. Qureshi noted that the Joint Commission's Primary Stroke Center certification program was developed to improve stroke care in United States, and several states including Florida, Massachusetts, and New Jersey have initiated state-specific certification programs for stroke centers.

The Joint Commission's Primary Stroke Center certification program is based on an assessment of standardized set of 10 performance measures for stroke patient care within the hospital, he said. But since the stroke certification is not based on a population-needs assessment, there is a risk that hospital competition will leave regions without certified stroke centers, Dr. Qureshi said.

To figure out who is and who is not being served by primary stroke centers in the US, the researchers identified all 719 hospitals with primary stroke centers certified through the Joint Commission or states in 2007, matched them to geographic locations based on their zip code, and developed county square-mile population density maps based on 2007 census estimates. Finally, the researchers analyzed populations served by primary stroke centers in various strata based on population.

The population served per stroke center decreases in geographic units with high population density — that is, the number of stroke centers increases as population density increases.

Figure. INVESTIGATORS REPORTED that the number of primary stroke centers increases as the population density increases.

[ Click here to enlarge ]

“There are too many primary stroke centers in geographic units with high population density,” Dr. Qureshi said.

In response to a question from the audience, Dr. Qureshi acknowledged that it might be useful to determine the number of people that live within a reasonable, perhaps 75-mile distance from a primary stroke center rather than define areas using zip codes and county square-mile population density maps.

Also, “with telemedicine, perhaps patients don't have to be in an area actually served by a primary stroke center to get excellent care,” he said in response to another question.

Commenting on the findings, Larry B. Goldstein, MD, director of the Duke Stroke Center at Duke University Medical Center in Durham, NC, said that his team has performed mapping studies in the state of North Carolina, with similar results.

One of the issues is that stroke centers are driven by market forces, he said.

“When one hospital becomes a primary stroke center, it influences others in the area to also become stroke centers,” Dr. Goldstein said. He agreed that telemedicine plays a big role in treating patients in underserved areas.

“In North Carolina, 40 percent of people live in a county with a primary stroke center, but another 40 percent live in counties that are linked in by outside sources —telemedicine or other transfer systems,” Dr. Goldstein said.

So what's the solution for reaching the remaining underserved areas? For starters, states should use available resources to target hospitals in underserved areas, Dr. Goldstein suggested. “If states have monies allocated to develop stroke centers, you could give grants to hospitals to underwrite their development, giving preference to hospitals in underserved areas,” he said. Also, more telemedicine and transfer networks need to be developed to link in underserved areas, he added. •