Rapid access to care after an acute stroke is one of the most important aspects to improve the outcomes of this devastating disease. Primary and comprehensive stroke centers have a shared objective, to give IV-TPA as soon as possible if the situation warrants it. Comprehensive stroke centers are usually involved in carrying on clinical trials and have access to a multidisciplinary team that includes neurointensivist, neurosurgeons, and neuroradiologist, among others. We usually think of cases from a comprehensive stroke center, usually, tertiary care centers, to have a referral bias due to the complexity of their disease.
Jose Gutierrez, MD, MPH
In this issues of stroke, Albright et al. present data from the Houston metropolitan area that shows a shifting referring bias. While early in 2005 the majority of their stroke patients were brought directly to their hospital, 6 years after almost half of their patients were transfers from outside hospitals. This increased rates of transfers did not affect the overall rates of IV-TPA. The majority of the transfers were either intracerebral hemorrhages or minor strokes while the proportion of large artery occlusion strokes fell.The overall impact of the observed change was lower odds of enrollment in time-sensitive acute stroke clinical trials. The authors attributed this change to the increase in the number of primary care centers in the area.
Although it is encouraging that the rates of IV TPA were not affected, it is worrisome that the enrollment in clinical trials has dropped. After all, without clinical trials like the NINDS, IV-TPA would not be in our landscape. Favoring recruitment of eligible patients in stroke trails seems a priority in planning the delivery of acute stroke care. But, some question arise: What would the role of primary care centers if all stroke were to be transferred to a comprehensive stroke center? Could we imagine a triage scheme that allows EMS to bypass primary care centers to comprehensive stroke centers for patients with more severe strokes without compromising the time to administer IV-TPA? What would be the financial incentives for smaller hospital to gear up and set up stroke care if more stroke cases are to be transferred to larger, comprehensive stroke center? The realities of stroke care vary widely in the US, so a one fit for all seem elusive, but the results from the UT Houston group open the conversation.