Duy Le, MD

Opeolu A, Albright K, Carr B, Wolff C, Mullen MT, Abruzzo T, et al. Geographic Access to Acute Stroke Care in the United States. Stroke. 2014.

Opeolu et al evaluate how accessible acute stroke care treatment is to the US population. In order to tackle this task, they evaluated the MEDPAR database from 2011 using ICD-9 codes seeking out patients who recieved IV-tPA and or intra-arterial therapy (IA-therapy). Time duration from the field to ED arrival was calculated by employing the ArcMap 10.1, a proven EMS ground model used to estimate call to ED arrival time. For helicopters, the Atlas and Database of Air Medical Services (ADAMS) model was used. 370,351 patients were diagnosed with a primary diagnosis of acute ischemic strokes (AIS). 4% of patients received IV-tPA and 0.5% received IA therapy. Of the 4,583 acute care hospitals in the MEDPAR database, 2,895 (63%) did not give any doses of IV-tPA while 4,252 (93%) did not perform any thrombectomy procedures for stroke. 327 (7%) of hospitals gave at least one dose of IV-tPA and performed at least one thrombectomy for stroke. 455 hospitals (9.9%) gave IV-tPA more than ten times during the year. 

Results showed that 81% of the US population had 60 minute access to IV-tPA capable hospitals; 66% had access to primary stroke centers and 56% had access to endovascular capable hospitals. By air, 97% had 60-minute access to IV capable hospitals, 91% had access to primary stroke centers and 85% had access to endovascular capable hospitals.

Between 2008, the same group reported that 55% of the US population had ground access and 79% had air access to primary stroke centers within 60 minutes. Those numbers have increased as noted in the results above. This is likely owing to the increased number of primary stroke centers. No data remains available yet regarding comprehensive stroke center certification.

While it is a practical way to evaluate the data, use of the Medicare database may not be truly reflective of the US population as a whole. Patients omitted include carriers of private insurance, those younger than 65 years of age and those without insurance. Additionally, much of the time to hospital is inferred through models and calculations; and not actual monitored times. However, due to practicality, these methods were employed; and this data does provide us with a national perspective on acute stroke care and show us that there has been an improvement with regards to increasing access since 2008. The increase in access can be loosely tied to an increase in number of primary stroke centers. However, a question that remains at large is whether or not comprehensive stroke center certification will have an effect on patient care outcomes and improving access to acute stroke interventions.