Mark N. Rubin, MD

Skolarus LE, Meurer WJ, Shanmugasundaram K, Adelman EE, Scott PA, and Burke JF. Marked Regional Variation in Acute Stroke Treatment Among Medicare Beneficiaries. Stroke. 2015

The same sprawling wonder of our beautiful country that inspired the lyrics to America, The Beautiful – and the intensely disparate socioeconomic, ethnic and educational variation that comes part and parcel with it – makes estimation of regional stroke treatment practice patterns in the United States quite difficult. Despite that, however, the question must be asked and answered to the best of our ability as acute ischemic stroke remains a very morbid and mortal disease and we must learn from both the highest and lowest performing regions as regards stroke treatment.

Some University of Michigan stroke researchers have provided us with some insight. They undertook a massive search of administrative data from the U.S. Federal government in the form of stroke diagnostic and procedural codes for Medicare beneficiaries over the four year period of 2007-2010. They then screened for any type of thrombolysis – medical and/or endovascular – according to hospital service area, of which there were ~3500 to review, and categorized each by occurrence of stroke diagnosis and frequency of treatment. They attempted to control for regional differences in socioeconomics and education by controlling for many factors including population density, median income, number of primary stroke centers in the region, presence or absence of emergency services bypass protocols, and educational attainment.

Their results are interesting and important. Not surprisingly, there are marked differences between stroke treatment practice patterns across this country. Thrombolysis of any kind was provided to only 3.9% of all patients in the cohort, with a range of 0-9.3%. Perhaps shockingly, 20% of surveyed regions provided no stroke treatment whatsoever during the four year period. True to the idea that we can learn from how practice has grown organically, the authors ran hypothetical algorithms to calculate the potential gain from bringing “low performers” with below-median stroke treatment rates into the median range or above. They estimate that “[a]n optimistic ceiling for acute thrombolysis treatment in the United States can be estimated by increasing all regional treatment rates to that of the highest performing region which would yield an additional 92,847 patients treated with thrombolysis and 8,078 stroke patients without disability.”

This cohort is limited to the Medicare population and the data are inferential from coding and billing which is notoriously flawed, but this still represents a first and important step in better understanding how acute stroke treatment is provided across the country. With hope, these data can be leveraged to enhance acute ischemic stroke treatment and mitigate disability.