Doctors Push for More Scans in Stroke Cases

We thought this article was extremely compelling and touched all bases. We left it intact:

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The first three or four hours after a stroke are the most crucial.

For most stroke patients, receiving a clot-dissolving drug shortly after arriving at a hospital can reduce the effects of stroke and limit permanent disabilities. But for some patients, with a certain type of stroke, such a drug can actually increase bleeding in the brain and boost the risk of death. Stroke experts say the best way to tell which patients should get the drug is by having a CT scan of their heads read within 45 minutes of their landing in the emergency room.

But a rule that would call for a scan within 45 minutes was rejected last fall by a quasi-governmental group that sets medical guidelines used by Medicare to evaluate and reimburse U.S. hospitals. The group, known as the National Quality Forum, said the vague wording of the rule raised too many questions.

The forum’s decision on stroke treatment underlines how difficult it can be for medical-industry officials to agree on guidelines for best-treatment practices at a time when the Obama administration is pushing the medical profession to set such standards to help cut health-care costs. Even when the benefits of certain treatments are widely accepted, such as swift CT scans for stroke patients, hospitals and doctors might push back against setting treatment standards for a number of reasons, including cost.

Stroke neurologists say the forum’s rejection of the 45-minute CT-scan rule threatens to compromise stroke care nationwide, possibly resulting in more deaths and disabilities among stroke patients. Hospitals that receive Medicare funding will have to begin publicly reporting as early as next year how well they comply with other stroke-treatment guidelines, but need make no mention of whether they perform CT scans.

“If you don’t image the person in a timely fashion, the whole treatment process is dead in the water. Every minute lost can translate into devastating consequences,” says David S. Liebeskind, associate neurology director at the University of California Los Angeles Stroke Center.

The American Academy of Neurology, which strongly objected to the forum’s decision, is expected to discuss the matter at its national meeting in Seattle this month.

The National Quality Forum now says it is willing to reconsider the stroke-treatment guideline.

Stroke doctors like to say that “time is brain,” meaning the faster a stroke is treated, the more likely treatment will lead to complete recovery or at most mild disability. In the most common type of stroke, in which a clot blocks blood flow to the brain, studies show that quick administration of the drug tPA, or tissue plasminogen activator, can improve outcomes. The stroke association’s guidelines currently say tPA should be administered within three hours of a patient’s suffering what’s known as an ischemic stroke to be effective. The group may extend this time to as much as 4½ hours following additional recent research

Choosing a Treatment

But because tPA can cause bleeding, it’s precisely the wrong treatment for strokes caused by a brain hemorrhage. Treatment for hemorrhagic-stroke patients aims to relieve pressure on the brain, including with surgery or medication. The CT image is pivotal in determining which course of treatment is called for.

Many hospitals that don’t specialize in stroke care don’t perform timely CT scans for a variety of reasons, including the costs of having an imaging technician, and a doctor to read the scan, available at all hours. About 750,000 strokes hit Americans each year, and an estimated 83% of these are ischemic. Stroke doctors say only a small number of patients receive a clot-dissolving drug, either because they don’t arrive at the hospital in time or because it isn’t part of a hospital’s treatment routine.

“No one is denying that a person with a stroke should have a CT scan very quickly,” says David C. Levin, chairman emeritus of radiology at Philadelphia’s Thomas Jefferson University and co-chairman of the committee appointed by the National Quality Forum that rejected the 45-minute rule. But, he says, the committee had trouble with the rule as it was proposed because it was written imprecisely.

For one thing, some non-stroke patients arrive at the hospital with symptoms that resemble stroke, including abrupt numbness and weakness. “The committee asked for a better definition of the word ‘stroke.’ You’ve got to be extremely precise,” Dr. Levin says. Committee members also concluded that the term “arrival” was unclear: Did it mean arrival at the hospital door, or the moment when a nurse’s triage of the patient began?

Janet M. Corrigan, the National Quality Forum’s president, says the rule needed to be more finely honed, but that “it has the potential to be a worthy measure.”

The concept of fast CT images is well established among stroke specialists. In a major article published in the Journal of the American Medical Association in 2000, a group of leading stroke neurologists recommended that hospitals be able to do a CT or MRI scan “within 25 minutes of the order being written” and that specialists should be “available to read these scans within 20 minutes.” The American Stroke Association’s guidelines include the 45-minute standard.

But the association’s guidelines are voluntary, and, like standards of treatment for other conditions, often aren’t followed by doctors and hospitals that don’t specialize in stroke treatment. Stroke neurologists had hoped that adoption of the 45-minute rule by the National Quality Forum would help prod many community hospitals to upgrade their stroke treatment.

Writing Guidelines

The National Quality Forum, set up in 1999, creates committees of doctors and other medical experts. Each of these writes multiple guidelines, or “quality measures,” used by the Centers for Medicare & Medicaid Services to evaluate hospitals. The measures are then sent to the forum’s board for ratification. CMS, as it’s called, is the federal agency that administers the twin government insurance programs.

Stroke doctors complain that the committee didn’t include stroke neurologists among voting members. Five of the 15 members were imaging specialists or researchers, and four were radiologists, who read CT scans but don’t treat stroke victims. The committee also included emergency doctors. Stephen M. Sergay, president of the American Academy of Neurology, wrote to Ms. Corrigan last summer saying the committee “lacks the appropriate qualified personnel to evaluate such a critical issue.”

The forum did pass 16 quality measures related to strokes. Some were related to rehabilitation, such as how hospitals work with patients to improve speech and language comprehension. One guideline called for giving clot-dissolving drugs to eligible patients within three hours of a stroke. But stroke neurologists argue that such a standard means little if there is no requirement that a CT scan be read first.

By: Thomas M. Burton
Source: Wall Street Journal

22. April 2009 by Ruth Folger Weiss
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