Plan to improve stroke care tracks treatment of patients

WASHINGTON -- Only about two of every 100 stroke victims are treated with the clot-busting drug TPA that might not only save their lives but keep them from being disabled.

Many simply don't get to the hospital fast enough, because TPA must be given within three hours of the first symptoms. Hospitals also bear some responsibility: One recent study found fewer than a quarter of eligible patients who had arrived in time got this crucial treatment.

A major new program, ordered by Congress, aims to improve stroke care. It would establish a monitoring system to track exactly how hospitals treat stroke patients, to uncover the missteps and to fix them.

Dozens of hospitals in eight states are pilot-testing the Paul Coverdell National Stroke Registry, named for a Georgia senator who died of a stroke two years ago.

Huge gap in knowledge

The program won't track just who gets TPA but every aspect of stroke care, from paramedics' speed answering the 911 call and how well emergency rooms give the brain scan, to rehabilitation and prevention of a second stroke. Indeed, improper preventive care is another major problem: Less than half of patients at high risk of a stroke because of irregular heartbeat get the protective blood-thinning drug warfarin.

"There is a huge gap between what we know and what we do" to fight strokes, says Dr. Lee H. Schwamm of Massachusetts General Hospital, who is preparing to analyze the first results from Massachusetts' pilot registry.

"Unless you understand what's happening and where the fail-points are, you don't know how to make the system better."

More than 700,000 Americans will suffer strokes this year. It is the nation's No. 3 killer.

Some strokes are caused by bleeding in the brain; that's what killed Coverdell. But the vast majority are ischemic strokes, where arteries feeding the brain are blocked -- the type TPA can help, yet only about 2 percent of ischemic stroke sufferers get the medicine.

The registry will monitor care for both types. The Centers for Disease Control and Prevention has financed pilot registries in California, Georgia, Illinois, Massachusetts, Michigan, North Carolina, Ohio and Oregon.

Studies already have shown that care varies widely, from state to state and among urban, rural and teaching hospitals.

'Therapeutic nihilism'

Why is stroke care so hard? Consider just one aspect, TPA.

Each possible stroke sufferer must get a CT scan to be sure a clot exists, because TPA could worsen the bleeding if a patient were to have had a hemorrhagic stroke. Not every hospital has a technologist to run its CT scanner round-the-clock, nor in-house stroke specialists to examine the scan and the patient, relying instead on nearby neurologists to come when called.

Then there's "therapeutic nihilism," complains Schwamm. Some doctors still "don't really believe there's much to do about stroke. ... It is stunning."