Missed chances: Delays in seeking treatment, gaps in care mean few receive drug treatment for stroke
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Larry Mayros lay helpless in a hospital emergency room, his face going numb and paralysis gripping his left arm and leg.
He was having a stroke.
Robin Rombach, Post-GazetteLarry Mayros, a heavy equipment operator who suffered a stroke in October 2004, was promptly treated with the clot-busting drug known as tPA and walked out the hospital a few days later. Mr. Mayros, of Dunbar, Fayette County, soon returned to work and became a township supervisor in January.
Click photo for larger image.
Neurosurgeons flee high insurance costs Survey on stroke treatment Graphic: A look at acute stroke response Officials split on how to fix stroke care New stroke treatments work miraclesIn his own words
The stroke began with a tingling sensation in his arm. Fortunately he was close to a hospital.
At the hospital he chose to be treated with tPa.
The next morning he was able to get out of bed.
Getting to the hospital quickly was crucial.
It took him a while to realize he was having a stroke.
As upset as he was over having the stroke, he was no less shocked by his quick recovery.
Everything worked out well for me, I'm happy I can sit here and tell you about it.
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A blood clot blocked a vessel feeding his brain, impairing circulation needed to keep his brain cells alive. But doctors told him they might clear the blockage by infusing a drug known as tissue plasminogen activator, or tPA.
His symptoms worsening by the minute, Mr. Mayros, then 57, told them to give it a try.
A few days later, he walked out of the hospital.
"I'd say it's a miracle cure," said Mr. Mayros, of Dunbar Township in Fayette County.
Thanks to the clot-busting drug, he had escaped the clutches of stroke, the nation's third-leading cause of death after heart disease and cancer and a leading cause of serious, long-term disability.
But delays in getting to the hospital and gaps in the system of care mean that stories such as Mr. Mayros' remain the exception. A decade after researchers demonstrated tPA's ability to cut short a stroke, only a fraction of stroke patients receive the drug, both in Western Pennsylvania and nationwide.
Pittsburgh Post-Gazette surveys of area hospitals and ambulance services, conducted jointly with the Hospital Council of Western Pennsylvania and the Emergency Medical Service Institute, showed that only 217 of more than 5,700 stroke patients treated in a year's time received tPA infusions.
The totals indicate that tPA was given to about 3.8 percent of patients in the region whose strokes were caused by clots. Nationally, about 2 percent to 3 percent of stroke patients receive the drug, according to the American Stroke Association, a division of the American Heart Association.
The surveys showed that many of the region's stroke patients failed to get to the hospital soon enough to receive intravenous tPA, which must be administered within three hours of the onset of stroke symptoms.
They also revealed an uneven emergency response to stroke.
Many hospitals reported that they lacked special teams to respond quickly when stroke patients arrive.
Some EMS groups didn't follow state protocols aimed at ensuring that stroke patients receive optimum care.
Yet failing to get patients to hospitals soon enough, or to the right hospitals, means that many patients miss forever their chance to head off paralysis, loss of speech or other disabilities.
For those who miss the opportunity to receive tPA or other acute stroke therapies, "the chance to recover will never come again," said Dr. Lawrence Wechsler, director of the Stroke Institute at the University of Pittsburgh Medical Center.
Proposals to improve stroke treatment nationwide and in Pennsylvania have been discussed for years. Strengthening the system of care, however, has often proved difficult.
Many more stroke victims could avoid permanent disabilities if they called for help sooner and stroke systems of care were improved, Dr. Wechsler said.
"This is the most devastating experience," said Fran Gigliotti, 54, of the stroke she suffered in 2003. Since then, the Brookline resident has been unable to drive or work as a hairdresser and substitute teacher. Despite extensive rehabilitation, her left side remains weak.
Society shares in the toll taken by stroke in lost productivity and higher health care spending. Americans will pay nearly $58 billion this year for stroke-related medical costs and disability, according to the American Stroke Association.
In Pennsylvania and other states, lawsuits have been filed alleging failure to provide tPA or other acute stroke treatment. Local attorneys declined to discuss specifics, saying cases typically have been settled out of court under terms that prohibit disclosure.
Not all hospitals administer tPA, noted medical malpractice attorney John Gismondi, and "the people making the decisions about where patients are going don't necessarily know who does or doesn't."
While nearly all hospitals responding to the survey said they could administer tPA to stroke patients, nearly 30 percent of those hospitals had not done so even once in a year's time.
Experts acknowledge that for all its benefits, tPA is no panacea.
Besides the three-hour limit for receiving the drug intravenously, patients generally don't qualify for the treatment if they have had previous strokes, recent bleeding or surgery, serious head trauma, uncontrolled hypertension or impaired blood clotting.
Even if they do qualify, the drug doesn't work for everyone. And tPA treatment carries a one in 15 risk of bleeding, which can be severe.
Results of a national survey of emergency physicians released last year found that 40 percent were unlikely to use tPA even under ideal conditions, primarily from fear of potentially fatal hemorrhage.
Yet stroke experts said that perhaps 30 percent or more patients with ischemic strokes, the type in which a blockage cuts off blood flow to the brain, could be treated with tPA if systems of care were improved and patients arrived at the hospital more quickly.
In Western Pennsylvania, however, many people get to the hospital four or more hours after stroke symptoms begin, according to the surveys. Still others don't receive tPA because doctors can't tell when symptoms started.
"There's not that much awareness out there about the signs and symptoms of stroke, and people don't understand the seriousness of the situation," said Dr. Tudor Jovin, co-director of UPMC's Center for Endovascular Therapy.
Click photo for larger image.Dr. Lawrence Wechsler provides some background:
A stroke is an injury to the brain
The majority of recovery from stroke occurs early, but it can extend over years
Warning signs of stroke shouldn't be ignored. Getting treatment immediately is very important
Advice for people seeing someone else who may be having a stroke
The risk factors for stroke are similar to the risk factors for heart attack
By the time their symptoms worsen and they get to the hospital, patients often are beyond the time windows for administering tPA or other acute treatments, Dr. Jovin said.
National surveys in 2000 and 2003 by the American Heart Association found little progress in public knowledge of stroke symptoms, despite efforts to boost awareness.
Mr. Mayros acknowledged that under other circumstances, he might have ignored the nausea and the tingling in his hand and arm that heralded his stroke in October 2004.
But the symptoms occurred while he was with his daughter, Lorri DeMarco.
After they had taken her daughter to a doctor's appointment, Ms. DeMarco, noticing that he appeared ill, took him to Frick Hospital, a five-minute drive away. Doctors quickly diagnosed the problem, administered tPA and had him airlifted to UPMC Presbyterian.
"Everything fell into place for me that day," Mr. Mayros said.
Rebecca Kesser was not so fortunate.
When she woke up with nausea one morning in June 2004, the Turtle Creek resident, then 44, decided to stay home from work.
By the time her roommate returned home that afternoon, Ms. Kesser was lying on the couch, unable to get up. She was taken to UPMC McKeesport, where doctors determined she had suffered a stroke. Part of her skull had to be removed as her brain swelled. Today, she walks with a cane and requires other assistance.
In Western Pennsylvania, even those who seek help promptly may not be taken to a hospital best able to treat acute stroke, according to the surveys.
State Department of Health protocols direct ambulance agencies to notify their medical supervisors and the receiving hospital if stroke patients can be transported within three hours of symptom onset. Supervising physicians, the protocols note, could redirect patients to hospitals most prepared to treat acute stroke.
While nearly all agencies surveyed claimed to follow the protocols, 11 of 49 respondents said they did not notify their medical command physicians and the receiving hospital about patients who could be treated within the three-hour period.
"As a command physician, that was disturbing," said Dr. Ronald Roth, medical director for the Pittsburgh Bureau of Emergency Medical Services.
Andrew Gilger, EMS planning and clinical systems manager for the state health department, said ambulance agencies may need more education about the protocols, which took effect in September 2004.
But even when EMS crews notified medical command, that was no guarantee that patients would be sent to hospitals with expertise in acute stroke care.
Of the 36 survey respondents who said they contacted medical command and the receiving hospital, 18 said medical command often routes acute stroke patients to primary stroke centers. But 17 said this happens occasionally, rarely or never.
Asked whether they typically took patients to stroke centers, 27 EMS agencies said yes. But 15 said no, and 5 said they didn't know. Among those 20 agencies, 17 said they took patients instead to the nearest hospital or a hospital preferred by the patient or patient's family.
"Often, family members or the patient's primary care physician will request transport to a non-stroke center hospital," Rick Duffy, executive director of Foxwall EMS, said in completing his agency's survey.
Many ambulance crews were unaware if hospitals in their areas met national guidelines for stroke care, according to the surveys.
Only one area hospital, UPMC Presbyterian, is certified by the Joint Commission on Accreditation of Healthcare Organizations as a primary stroke center, the only national certification for acute stroke care.
About half the hospitals surveyed said they met similar recommendations for primary stroke centers issued by the Brain Attack Coalition, a group of medical professionals, advocates and others dedicated to reducing the harmful effects of stroke.
Only one-third of hospital campuses reported having a stroke team, led by a health care professional trained in stroke care, that could evaluate patients within 15 minutes of arrival around-the-clock.
Overall, the survey results suggest that the region needs to improve its response to acute stroke, said Fred Peterson, director of constituent services for the Hospital Council.
The council is using a grant from the Highmark Foundation to improve stroke treatment and public awareness of stroke in rural Western Pennsylvania counties.
Improving stroke care is not easy, Mr. Peterson noted. "When it's this whole interplay of physicians, hospitals, nurses, pre-hospital care, patients and families -- a lot of work, a lot of changes have to occur."
First Published March 26, 2006 12:00 am
