Revving up rural stroke response
Telehealth, helicopters, and hospitalists all have a part to play in reducing disparities in stroke outcomes, experts say.
Gordian Hubert, MD, believes that stroke patients living in remote areas should have access to the same skills and interventions that experts like him routinely offer at urban centers.
“That the rural population is treated with an equal standard as the city population is so important. … [We should] not leave them out just because they live somewhere where the hospital is not as well developed,” he said.
Researchers appear to agree. Several recent studies have drawn attention to disparities in stroke outcomes between urban and rural Americans. An analysis published in July 2020 by Stroke found that rural patients had significantly higher mortality from stroke: 6.87% versus 5.82% in urban patients. Another, published in May this year, categorized patients by race and location and found that rural White stroke patients were 37% more likely to die than their urban counterparts.
“There is a gap, and the gap is widening,” said Nasim Baghban Ferdows, PhD, an assistant professor of health sciences at Northeastern University in Boston who has studied racial and urban versus rural disparities in older Americans' mortality risk.
A potential way to close that gap is not transferring stroke patients, but instead sending an intervention team out to them, said Dr. Hubert, a neurologist with the TEMPiS telestroke center in Munich, Germany.
“Some of our hospitals are like two and a half hours' driving time away from our center,” he said, noting that at that distance, it wouldn't be feasible to transfer stroke patients in the time window for endovascular thrombectomy. “We said, ‘Well, if we fly our team out there to perform thrombectomy … [the rural hospital] can start immediately preparing [the patient] for the procedure.’”
Thus, in 2018, southeast Bavaria, Germany, got its flying stroke intervention service—a neurointerventional radiologist and an angiography assistant who hop into a helicopter when summoned by any of 15 participating hospitals.
This is one of the more dramatic methods by which experts are currently trying to shrink stroke disparities. They offered their thoughts on why these efforts are necessary, how they're going, and what hospitalists can do to help.
Clear causes
There are several reasons why rural patients have higher mortality from stroke, according to Karen Joynt Maddox, MD, MPH, senior author of both of the recent Stroke studies.
“Stroke reflects a lot of chronic diseases, including diabetes, high blood pressure, and atrial fibrillation, so the incidence of strokes is higher in areas that have less access to good chronic care, where chronic disease is less likely to be controlled, and where there are higher rates of obesity and smoking—all the things that lead into strokes,” she said.
The disparity may also be a side effect of positive changes in stroke care. “Stroke has been a place where we've seen some of the fastest technological advances in terms of time-sensitive care,” said Dr. Joynt Maddox, who is an associate professor and co-director of the Center for Health Economics and Policy at Washington University in St. Louis.
Endovascular thrombectomy “is one of the most effective interventions that we have in medicine,” said Kori S. Zachrison, MD, MSc, co-director of the Center for Neurological Emergencies at Massachusetts General Hospital in Boston. “The problem with rural stroke care access is it requires not only an expert to be able to weigh in, but also being in the place where they have all the tools.”
Rural areas have more limited access to necessary tools all along the stroke treatment pathway, beginning with diagnostics, noted Dr. Joynt Maddox. “More so than heart attacks, it requires technology to even start the care cascade,” she said. “For neurology, you really need to do a CT scan, and that's obviously a much bigger deal than an EKG.”
The limitations of stroke diagnostics in the field pose challenges for rural emergency services. “You could imagine a patient somewhere in Arizona or Nevada who is 70 minutes from the stroke center in Las Vegas in one direction and 30 minutes from a small hospital that can do some things but can't do thrombectomy in a different direction,” said Dr. Zachrison, who is also an associate professor of emergency medicine at Harvard Medical School in Boston. “You can't figure out in the prehospital setting which resources the patient will need.”
Spreading solutions
Even as it increases dilemmas for paramedics, the fact that more small hospitals can now provide emergency stroke interventions—that is, thrombolytics—is an important step forward, experts said.
“There are very innovative ways of delivering stroke care, since technology allows images of the brain to be transmitted electronically, so that even small hospitals or critical access hospitals with a CT scanner should be able to provide IV medication to treat stroke,” said Renee Hsia, MD, a professor and associate chair of health services research in the department of emergency medicine at the University of California, San Francisco.
“You could add telehealth to a small rural emergency department, and you could have a stroke neurologist help the rural emergency physician or physician assistant or family doctor—whoever's taking care of the patient—decide to give thrombolytics and they give it right there,” said Dr. Zachrison. “That's the biggest potential disparity closer.”
The number of U.S. hospitals with stroke certification grew from 961 in 2009 to 1,763 in 2019, according to a study Dr. Hsia and colleagues published in JAMA Neurology in June. However, hospitals in low-income and rural communities were less likely to be certified, the study noted.
Dr. Zachrison and colleagues looked into those hospitals that don't have stroke certification or telestroke themselves or at a facility within 20 miles in a study published in the Journal of the American Heart Association in April.
They found 1,057 such facilities and calculated that introducing telestroke at all of them would result in 164 additional reperfused patients and 90 lives saved in a year. “The numbers were not enormous. The problem is that there are a lot of hospitals, but they all have pretty low stroke volumes,” said Dr. Zachrison. “You are spending a whole lot of money installing telestroke infrastructure at each of those sites.”
Money isn't even the only obstacle for rural hospital administrators considering telehealth, she noted. “Fear of losing their patients: If now they're connecting with the cardiologist at the big-city place, maybe they're just going to start going to the big-city place for all their care, and then we're going to lose our patient base, and then our community loses this hospital.”
This may be an area where hospitalists can help combat the problem. “I've certainly been guilty of this myself,” said Dr. Joynt Maddox. “You get people transferred in from a smaller regional hospital and can be sort of disparaging about, ‘Oh, they had to send you here because they couldn't do it themselves,’ or ‘What are those doctors thinking?’ That's unfair, and it's not actually helpful to anybody.”
Instead, she asks physicians to be collegial and positive when collaborating on patient care with smaller hospitals, whether they're receiving a transfer or providing remote input. “Transferring someone or asking for help is a sign of appropriate care, not some sort of sign of weakness,” Dr. Joynt Maddox said. “And sometimes patients don't want to be transferred. Plenty of rural patients will say, ‘I'll take my chances. I want to be near family.’ … And that's fine, too. We can still find ways to help people get the best care whatever their location.”
Greater collegiality and collaboration among physicians could also help with the cost of telestroke, said Dr. Zachrison, who noted that hospitals generally assess the cost and benefit of a system specific to stroke. “The argument that I make as an emergency physician is why are we just focusing on one condition here? … How about we just put in telehealth infrastructure and make it work for multiple things?” she said.
Specialists have responded to proposals to share their technology with worries about what would happen if someone else is using the telehealth system when they need it for an emergency, so it might work better if the systems are instituted as a shared resource for a hospital community, said Dr. Zachrison. “Figure out how to improve access to specialist care through a system that is condition-agnostic.”
The push for innovative thinking and funding to facilitate collaboration on stroke care could be within hospitalists' domain, the experts said.
“Hospitalists are often in influential administrative leadership positions that can help bring not just the clinical issues to the fore but speak out about the financial drivers underlying the way we deliver and provide care,” said Dr. Hsia. “It is vital that financial incentives be designed in such a way to promote networks of small hospitals that can access the specialists that are more commonly available around the clock in bigger hospitals.”
It may turn out the best way to do that is to put those specialists in helicopters, Dr. Hubert maintains. He led a study, published by JAMA in May, that compared stroke patients treated by the flying intervention service with those transferred for care. Thrombectomy was performed in 83% of the flying team patients compared to 67% of the transfer group, and the median time from decision to pursue thrombectomy to the start of the procedure was 58 minutes versus 148 minutes.
“We showed that we are 90 minutes faster. That's huge for stroke care,” said Dr. Hubert. The study did not show a significant difference in functional outcomes, but that may require a bigger population, he noted. “We know that one and a half hours longer is not good for any of these patients.”
At a conference he attended in California in June, there was much talk of how to get more hospitals thrombectomy-capable, he said. The flying service effectively does that, and with a team that has a high volume of strokes under its belt to boot. Team members bring their own equipment and catheters, requiring the rural hospital to have just an angiography suite and helipad.
Having a helicopter and a set of stroke intervention specialists at the ready does carry a significant cost, Dr. Hubert acknowledged. The German researchers are still assessing that, and cost-effectiveness would likely vary by country.
“We're not at the point where we can say this is the best concept, and everyone needs to do it,” he said. “On the other hand, what is the alternative?”
The status quo, perhaps. “It's probably not ever possible to have quite the same outcomes for time-sensitive conditions in rural areas, with the reality of how long it takes someone to get to medical care or how long it takes medical care to get to them, and I don't know that we'll ever overcome that entirely,” said Dr. Joynt Maddox.
However, she is pleased to see progress in getting rural stroke care in the U.S. closer to as good as it can be. “There's been so much advancement in how we think about systems of care, and how we make these connections, and how we use telehealth,” Dr. Joynt Maddox said. “We need to do more systems thinking in order to be able to get care to the people that need it, but I'm optimistic.”
