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Acute ischemic stroke and transient ischemic attack: A costly business and a strategy to reduce costs (the “Time-Zero” plan)
1Stroke Cerebrovasc Dis 1995;5:1-5 © 1995 National Stroke Association
Acute Ischemic Stroke and Transient Ischemic Attack: A Costly Business and a Strategy to Reduce Costs (The "Time-Zero" Plan) Philip B. Gorelick, M;D., M.P.H., F.A.C.P.
Managed health care systems and other insurers in the United States are scrutinizing cost-containment measures for acute stroke care. Stroke remains a costly inpatient neurologic disease. Diagnostic technology for stroke has become extremely sophisticated, and the clinician must choose from a broad range of expensive tests. Conflict may arise as stroke patients and caregivers expect full range of diagnostic tests, whereas primary care physicians strive for the most efficient diagnostic battery and cost containment. The neurologic specialist may find himself or herself caught in the middle of this conflict, frustrated by the apparent failure of the system to satisfy the expectations of providing the highest quality of patient care within cost-containment needs. The "Time-Zero" proposal is a plan to capture both high-quality stroke care and cost containment because common sense must prevail in these times of medical economic uncertainty. Physicians and stroke diagnostic providers must modify their behavior and maintain a flexible approach regarding availability of diagnostic services, whereas insurers must be willing to maintain quality standards to achieve rapid stroke diagnosis and treatment. There is a common ground where patients, physicians, and insurers can meet to tackle this challenge. The cost -containment "bottom line" will not mysteriously disappear; thus, we must have a rational plan for stroke diagnosis and treatment that lessens patient, physician, and insurer dissatisfaction. Key Words: Cost-Cost reduction-Ischemic stroke-Transient ischemic attack.
a
Stroke is a costly business. It is estimated that over $25 billion is spent each year in the United States (1/ 2). Managed health care systems and other insurers have targeted stroke for cost containment, since it is the major "big-ticket" inpatient neurologic disease. Stroke is the third leading cause of death and a major cause of neurologic morbidity among adults (3). Our diagnostic armamentarium is replete with sophistiFrom the Section of Cerebrovascular Disease and Neuroepidemiology, Department of Neurological Science, Rush Medical Center, Chicago, IL, U.S.A. Address correspondence and reprint requests to Dr. P. B. Gorelick at Department of Neurological Science, 1725 West Harrison, Suite 755, Chicago, IL 60612, U.S.A.
cated technologies to assist in establishing stroke mechanism and proper treatment. However, this powerful technology is costly, and improper use can prolong hospitalization. The available technology, the public's expectations, and the insurer's economic concerns have placed us in the midst of a struggle: the public expects the latest and most sophisticated technology, whereas the insurers and primary care physicians search for cost containment. The neurologic specialist is often caught in the middle of this conflict, attempting to maintain the highest quality of care at a reasonable cost. As a stroke specialist who has faced this challenge on many occasions recently, I will share with you some thoughts about a plan that might reduce hospitalization costs, yet maintain a high stan] STROKE CEREBROVASC DIS, VOL. 5, NO.1, 1995
1
P. B. GORELICK
dard of stroke care. Details of accepted strategies for diagnostic workup and treatment of stroke and transient ischemic attack (TIA), and eligibility for stroke hospitalization, have been discussed by expert panels elsewhere (4-7). This discussion will highlight steps that need to be taken to expedite cerebrovascular workup and treatment to preserve quality of care, yet maintain cost containment.
Assumption Central to this plan to maintain high standards of stroke care, yet contain inpatient hospital cost, is the assumption that delay in diagnosis, treatment, and discharge planning leads to prolonged hospitalization and heightened cost. Smurawska et al. (8) have suggested that reducing the hospital stay is the preferable means of reducing stroke care cost. Furthermore, they concluded that the major determinant of stroke cost during the first admission was social and not medical. The most significant cost reductions were most likely to be achieved by altering discharge policies and improving social conditions for early return to home than by reducing laboratory or medical personnel costs. In a study to identify unnecessary days of hospitalization in a neurology department, Schluep et al. (9) found that discharge delays resulted chiefly from difficulties in obtaining laboratory investigations or from awaiting transfer to either another department or a nursing home. Thus, although diagnostic technology may be relatively expensive, if performed in a timely manner, it does not drive costs upward in a substantial way. However, delay in discharge after stroke diagnosis is established may raise cost significantly. Stroke diagnostic technology is a necessary and indispensable commodity, since its prudent use leads to definition of stroke subtype and specific medical or surgical therapy (10,11).
The "Time-Zero" Plan Step 1: Expedite Stroke Diagnosis The first step of the plan is to expedite stroke diagnosis. This means that bedside evaluation of the stroke patient must be initiated as soon as the patient reaches the Emergency Room (ER) or hospital ward. Once the stroke patient has been examined, a rational and rapid stroke diagnostic workup plan to determine "What is wrong with Mr. Jones?" (12) is formulated 2
J STROKE CEREBROVASC DIS, VOL. 5, NO.1,
1995
(4-7). Stroke Services at larger hospitals and university centers have been placed on 24-h alert 7 days a week to provide rapid response times for acute stroke patients who present to the ER (so-called "Code Stroke," "Dr. Stroke," or "Dr. Clot" ER responses). These rapid response mechanisms have been established to facilitate diagnosis, treatment, and screening of patients for hyperacute stroke treatment protocols (13-15). The model is effective for reducing ER response times and certainly can expedite stroke diagnostic workup and treatment (16,17). Hospitals that do not routinely provide rapid response neurologic ER coverage must become accustomed to training ER physicians to initiate proper stroke diagnostic workup or create a call schedule or rapid response telephone system whereby the ER physician can obtain expert neurologic advice about stroke workup in a timely manner. Unfortunately, primary ER physicians often lack expert knowledge of stroke despite the relatively high frequency of this type of neurologic emergency. As soon as the stroke patient arrives in the ER, the triage nurse should order an electrocardiogram (EKG), routine blood work, and other laboratory studies (47). Cranial computed tomography (CT) is obtained as soon as the triage diagnosis of stroke is confirmed by the ER physician. This approach requires established cooperation between the ER and Radiology Department. For example, the Radiology Department must be willing to expedite the request for CT or magnetic resonance imaging (MRI), since this diagnostic step can be a major rate-limiting factor in the process. Thus, a well thought-out and coordinated hospitalwide diagnostic plan must be put in place. Once the neurologic examination and CT have been completed, the determination of ischemic or hemorrhagic stroke can be made, and proper diagnostic tests can be recommended (4-7) to further define stroke subtype. For ischemic cerebrovascular disease, carotid noninvasive blood flow and transcranial Doppler (when appropriate) can be performed prior to patient transfer to the hospital ward. Again, a hospital-wide plan and cooperation among stroke diagnostic providers are mandatory. Once the patient reaches the hospital ward, cardiac noninvasive diagnostic studies (e.g., echocardiography and holter EKG) can be ordered as deemed appropriate by the admitting physician and with the expectation that these studies will be performed within 24 h of the request. By this point in time, hyperacute stroke therapy should have been administered based on the clinician's impression of stroke mechanism and availability of treatment protocols. Once clinical examination
THE 'TIME-ZERO" PLAN FORACUTE STROKE
and CT have verified the diagnosis of cerebral ischemia, there should be no delay in initiating hyperacute stroke treatment. Furthermore, physiatry/ physical medicine and discharge planning services, as deemed appropriate, should be consulted so as not to delay planning of long-term aspects of stroke care.
Step 2: Communicate with the Patient and Caregiver About the Diagnostic and Therapeutic Plan It is a mistake not to communicate about planned stroke diagnostic tests and treatment with the patient and caregiver. Patients and caregivers must be educated about the diagnostic and therapeutic plan, its rationale, and the risk-benefit ratio. By keeping the lines of communication open, both patient and physician expectations have a better chance of being realized. The physician must determine individual patient expectations, counsel the patient about these expectations, and understand the patient's philosophy and beliefs about diagnostic tests and treatments. Invasive procedures such as conventional cerebral arteriography, if planned, should be discussed early in the course of hospitalization to provide adequate time for the patient to contemplate the risk-benefit ratio of the procedure. Inadequate time for patient contemplation can result in prolonged acute-care hospitalization. Maintenance of good communication with the patient and family member can also lead to a more pleasing patient-physician interaction. In addition, by keeping the patient and family member well-informed, one may be less likely to encounter medical-legal difficulties should there be a poor outcome (18).
Step 3: Consult the Experts Experts in the diagnosis and treatment of stroke should be consulted as soon as possible. All too often, we encounter stroke patients in our consultation practice who are lingering in the acute care hospital because their primary physician has not been able to properly interpret the diagnostic test results to arrive at a diagnosis and treatment plan; the diagnosis is missed due to lack of appropriate examination or study; or too many diagnostic tests are ordered. Studies from stroke units generally show that length of stay may be shorter and outcomes better when patients are under the care of stroke experts (19-21).
Some Dilemmas When Selecting Appropriate Stroke Diagnostic Studies When choosing a diagnostic technology for a patient, we must consider patient, societal, and physician perspectives within the context of safety, efficacy, and economic efficiency (22). Unfortunately, most diagnostic information is imperfect in that there is some uncertainty about the technology, and this is expressed as a probability. We are all familiar with false-negative (patients who have the disease will have a negative test result) and false-positive (patients who do not have the disease will have an abnormal test result) results that exemplify this uncertainty or imperfection in the diagnostic technology. Traditionally, we have employed two measures of test performance as indicators of efficacyto help us decide which of several diagnostic tests is superior (22): (a) sensitivity: (the true positive rate or number of diseased patients with a positive test/number of diseased patients), and (b) specificity (the true negative rate or the number of nondiseased patients with a negative test/number of nondiseased patients). A gold-standard test or procedure is used to define the true state of the patient when the diagnostic technologies are compared. Sensitivity and specificity alone are not necessarily sufficient to decide whether the test should be performed, since questions of accuracy, safety, and cost must be considered. Ideally, our diagnostic technology assessment is carried out through a well-designed and well-executed randomized clinical trial for comparing technologies (22). However, such well-designed study is rarely done because costs may be high; it may be unrealistic to recruit a large number of patients; the technology may become obsolete or irrelevant during the years of study; the results may apply to a narrow spectrum of patients; or the trial may not measure outcomes of clinical interest. Therefore, the clinician who must select the appropriate diagnostic technology for a given patient is not armed with a plethora of data from which to base the decision and must rely on experience and common sense. Thus, it seems that the decision of whether or not to obtain CT and MRIof the head, carotid ultrasonography/transcranial Doppler and magnetic resonance angiography (MRA), or conventional transthoracic echocardiography and transesophageal echo cardiography should be left to the physicians with the most experience in stroke diagnosis and treatment given the relative paucity of well-designed studies of stroke diagnostic technology. These diagnostic technology decisions are not always easily made by a "cookbook" approach or simple flow diagram because individual patient variation exists, and our decisions continue to be peppered ] STROKE CEREBROVASC DIS, VOL. 5, NO.1, 1995
3
P. B. GORELICK
Costof stroke diagnostic studies and hospitalization at a major teaching hospital in Chicago, 1994"
Table 1.
by our philosophical, ethical, and medical-legal concerns. Until more rigorous technology assessments are hatched, we are left with only fragments of technical knowledge and a more difficult decision-making process for test selection (23).
Concluding Remarks My rationale for presenting the "Time-Zero" proposal for acute ischemic stroke and TIA (see Fig. 1 for summary) is a perceived need to maintain high-quality stroke diagnosis and treatment in an environment of high patient and physician expectation but limited managed health care system economic resources. Central to the plan is the assumption that delay in diagnosis, treatment, and discharge planning leads to prolonged hospitalization and heightened cost. Prior study has suggested that this may be the case (8) and that diagnostic technology should not be considered the major cost barrier. Although diagnostic technology is relatively expensive (see Table 1 for summary), it is an indispensable commodity whose prudent use leads to definition of stroke subtype and specific medical or surgical therapy. Expedient diagnostic workup and treatment as proposed in the "TimeZero" plan requires preplanned cooperation of pa-
STEPS
nIiEIPLACE) I.
( ·0· hou .. (Emergo".,y Room) ,
Triage, EKG. and routine blood labs
2.
Neurologic history and physical exam
3.
CT
4.
Carotid noninvasive blood flow and TeO (as deemed appropriate) on way to hospital ward tnitiate hyperacute stroke pharmacologicintervention (when available)· and communicate with patient and family Order cardiac noninvasive! (as deemed
5.
0·3 hou .. (tronlfor to hoopl~ ward from Emergency Room) 6.
appropriale)
(24-C8 hou .. (Hoapital Ward) ,
7.
Physialry/physlcal medicine
e.
consUltation Consult dischar~ planner
9. 10. I 1.
Complete diagnosUc WOl1<-up Communicale with paUenl and family Decide ~ reoeet CT. MRI of heed. MRA. conventional arteriography. transesophageaJ ecl1ocardiography, special blood studies or other tests
Estimated cost ($) Noninvasive diagnostic tests CT head (no contrast)" MRI head (without gadolinium)" Carotid duplex Transcranial Doppler (TCD) Transthoracic echocardiography Transesophageal echocardiography Magnetic resonance angiography Holter EKG EKG
903.00 1,541.50 711.00 600.00 285.50 285.50 803.00 197.50 125.50
Total
5,452.50
Invasive diagnostic tests Cerebral arteriography (unilateral)'
1,845.00
Total
1,845.00
Hospitalization costs Hospital room (semi-private)" CBC and platelet count Urinalysis Glucose, electrolytes Prothrombin time Partial thromboplastin time.
792.00/day 76.00 30.50 69.00 19.00 31.00
Total Overall totals Noninvasive tests + hospitalization costs Noninvasive tests + invasive tests + hospitalization costs
1,017.50
6,470.00 8,315.00
'Cost estimates represent non-discounted prices and do not include those given to large contractors. bAdd $94 if CT using contrast medium is performed and $461 if MRI with gladolinium is performed. 'Add $1,463.50 if bilateral cerebral arteriography is performed. dAdd $8 for private hospital room.
araneeded
( 4&-72
12. 13.
Comple'e diagnosUc WOl1<-up Make reaJlTent stroke prevention treatment decision (to be adminis· tered eIler hyperacute Itrol
14.
Convnunicatewith patient and family Plan discharge based on treatment decision and need for stroke rehabilitation
hou"IHoapl~ Ward) , 15.
"HyperacYle stroketrealment shoulld be initiated without delay as soon as CT and clinical
examinationhave made the distinction between ischemic and hemorrhagicstroke.
Figure 1. schedule. 4
'Time-Zero"proposal: evaluation anddiagnostic test
J STROKE CEREBROVASC DIS, VOL. 5, NO.1, 1995
tients, physicians, and stroke diagnostic providers and could result in maintenance of high-quality standards and options for acute stroke care and reasonable economic cost. Since we have proven stroke therapies and new ones are being developed, we must reckon with the fact that the age of therapeutic nihilism has long passed (24). The economic dock is ticking away, and delays in diagnosis and treatment can be costly from both the
THE 'TIME-ZERO" PLAN FOR ACUTE STROKE
patient and economic standpoint. Based on the estimates of direct costs from a recent Canadian study (8), we may stand to lose $680 Canad ian ($520 us.) each day we delay acute hospital stroke diagnosis and treatment. This could translate into a considerable amount of savings given the estimated 400,000-500,000 stroke patients in the United States each year alone. As cost may vary by nation and region, the Canadian study estimates may be underestimates relative to Ll.S. costs . It is time for us to be more actively moving toward the common ground of quality acute stroke care and economic responsibility. In the future, dedicated outpatient stroke diagnostic facilities with observational units may hold the key to quality care and cost containment for TIA, less severe stroke patients who may not need hospitalization, and those who do not qualify for hyperacute stroke therapy.
Addendum Since the submission of this manuscript, Bowen and Yaste (Neurology 1_994;44:1961-4) have shown significant savings for patients with acute stroke after the introduction of a treatment protocol. These savings were primarily related to decreased length of stay.
first six hours. Emergency evaluation and treatments.
1Stroke Cerebrovasc Dis
Stroke 1994;25:1901-14.
8. Smurawska LT,Alexandrov AV,Bladin CF, Norris JW. Cost of acute stroke care in Toronto, Canada. Stroke 1994;25: 1628-31. . 9. Schluep M,BogousslavskyJ,RegliF,Tendon M,Prod 'hom LS, Kleiber C. Justification of hospital days and epidemiology of discharge delays in a department of neurology. Neuroepidemiology 1994;13:40-9. 10. NASCET Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with highgrade carotid stenosis. N Engl 1 Med 1991;325:44553. 11. Stroke Prevention in Atrial Fibrillation Investigators. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II Study. Lancet 1994;343:687-91. 12. Caplan LR. TIA's: we need to return to the question, "What is wrong with Mr. Jones?" Neurology 1988;7913. 13. Gomez CR Time is brain! 1Stroke Cerebrouasc Dis 1993; 3:1-2. 14. Malik M, GomezCR, Tulyapronchoter R, Malkoff MD, Bandlanudi R, Banet GA. Delay between emergency room arrival and stroke consultation. 1Stroke Cerebrouasc Dis 1993;3:177-80.
15. Biller J, Patrick JT, Shepard A, Adams HP. Delay time between onset of ischemic stroke and hospital arrival.
1Stroke Cerebrovasc Dis Acknowledgment: This work was supported in part by National Institute on Aging grant ROl AG10102-04, the MR Bauer Foundation, and the Herbert and Marjorie Fried Scholarship Fund.
References 1. Fishman RA. Progress and promise 1992: a status report on the NINDS implementation plan for the Decade of the Brain. Ann NeuroI1993;33:320-4. 2. Gorelick PB. Stroke prevention: an opportunity for efficient utilization of health care resources during the coming decade. Stroke 1994;25:220-4. 3. Wolf PA,Belanger A], D'Agostino RB. Management of risk factors. Neurol Gin 1992;10:177-91. 4. Feinberg WM, Albers GW, Barnett HJM, et al. Guidelines for the management of transient ischemic attacks. From the ad hoc committee on Guidelines for the Management of Transient Ischemic Attacks of the Stroke Council of the American Heart Association. Stroke 1994;25: 1320-35. 5. Lanska D] and the Task Force on Hospital Utilization for Stroke of the American Academy of Neurology. Review criteria for hospital utilization for patients with cerebrovascular disease. Neurology 1994;44:1531-2. 6. McDowell FH, Brott TG, Goldstein M, et al. Stroke: the
1993;3:133-44.
7. Adams HP, Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute ischemic stroke.
1993;3:228-30.
16. Brott TG, Haley EC, Levy DE, et al. Urgent therapy for stroke. Part I. Pilot study of tissue plasminogen activator administered within 90 minutes. Stroke 1992;23: 632-40. 17. Alberts MJ, Perry A, Dawson DV, Bertels e. Effects of public and professional education on reducing the delay in presentation and referral of stroke patients. Stroke 1992;23:352-6. 18. Hickson GB, Clayton EW,Githens PB,etal. Factors that prompted families to file medical malpractice claims following prenatal injuries. lAMA 1992;267:1359-63. 19. Indredavik B, Bakke F, Solberg R, Rokseth R, Haaheim L,Holme I. Benefit of a stroke unit: a randomized controlled trial. Stroke 1991;22: 1026-31. 20. Babikian VL,Schwarze JJ. Stroke units. 1Stroke Cerebrovasc Dis 1994;4:183-7.
21. Kalra L The influence of stroke unit rehabilitation on functional recovery from stroke. Stroke 1994;25:8215. 22. Sox HC, Stern S, Owens D, Abrams HL Assessment of diagnostic technology in health care. Rationale, methods, problems and directions. Washington, DC: National Academy Press, 1989:8-72. 23. Donaldson MS, So x He. Setting priorities for health technology assessment, A model process. Washington, DC: National Academy Press, 1992:17-30. 24. Biller J, Love B. Nihilism and stroke therapy. Stroke 1991;22:1105-7.
1STROKE
CEREBROVASC DIS, VOL. 5, NO.1, 1995
5
Acute Ischemic Stroke and Transient Ischemic Attack: A Costly Business and a Strategy to Reduce Costs (The "Time-Zero" Plan) Philip B. Gorelick, M;D., M.P.H., F.A.C.P.
Managed health care systems and other insurers in the United States are scrutinizing cost-containment measures for acute stroke care. Stroke remains a costly inpatient neurologic disease. Diagnostic technology for stroke has become extremely sophisticated, and the clinician must choose from a broad range of expensive tests. Conflict may arise as stroke patients and caregivers expect full range of diagnostic tests, whereas primary care physicians strive for the most efficient diagnostic battery and cost containment. The neurologic specialist may find himself or herself caught in the middle of this conflict, frustrated by the apparent failure of the system to satisfy the expectations of providing the highest quality of patient care within cost-containment needs. The "Time-Zero" proposal is a plan to capture both high-quality stroke care and cost containment because common sense must prevail in these times of medical economic uncertainty. Physicians and stroke diagnostic providers must modify their behavior and maintain a flexible approach regarding availability of diagnostic services, whereas insurers must be willing to maintain quality standards to achieve rapid stroke diagnosis and treatment. There is a common ground where patients, physicians, and insurers can meet to tackle this challenge. The cost -containment "bottom line" will not mysteriously disappear; thus, we must have a rational plan for stroke diagnosis and treatment that lessens patient, physician, and insurer dissatisfaction. Key Words: Cost-Cost reduction-Ischemic stroke-Transient ischemic attack.
a
Stroke is a costly business. It is estimated that over $25 billion is spent each year in the United States (1/ 2). Managed health care systems and other insurers have targeted stroke for cost containment, since it is the major "big-ticket" inpatient neurologic disease. Stroke is the third leading cause of death and a major cause of neurologic morbidity among adults (3). Our diagnostic armamentarium is replete with sophistiFrom the Section of Cerebrovascular Disease and Neuroepidemiology, Department of Neurological Science, Rush Medical Center, Chicago, IL, U.S.A. Address correspondence and reprint requests to Dr. P. B. Gorelick at Department of Neurological Science, 1725 West Harrison, Suite 755, Chicago, IL 60612, U.S.A.
cated technologies to assist in establishing stroke mechanism and proper treatment. However, this powerful technology is costly, and improper use can prolong hospitalization. The available technology, the public's expectations, and the insurer's economic concerns have placed us in the midst of a struggle: the public expects the latest and most sophisticated technology, whereas the insurers and primary care physicians search for cost containment. The neurologic specialist is often caught in the middle of this conflict, attempting to maintain the highest quality of care at a reasonable cost. As a stroke specialist who has faced this challenge on many occasions recently, I will share with you some thoughts about a plan that might reduce hospitalization costs, yet maintain a high stan] STROKE CEREBROVASC DIS, VOL. 5, NO.1, 1995
1
P. B. GORELICK
dard of stroke care. Details of accepted strategies for diagnostic workup and treatment of stroke and transient ischemic attack (TIA), and eligibility for stroke hospitalization, have been discussed by expert panels elsewhere (4-7). This discussion will highlight steps that need to be taken to expedite cerebrovascular workup and treatment to preserve quality of care, yet maintain cost containment.
Assumption Central to this plan to maintain high standards of stroke care, yet contain inpatient hospital cost, is the assumption that delay in diagnosis, treatment, and discharge planning leads to prolonged hospitalization and heightened cost. Smurawska et al. (8) have suggested that reducing the hospital stay is the preferable means of reducing stroke care cost. Furthermore, they concluded that the major determinant of stroke cost during the first admission was social and not medical. The most significant cost reductions were most likely to be achieved by altering discharge policies and improving social conditions for early return to home than by reducing laboratory or medical personnel costs. In a study to identify unnecessary days of hospitalization in a neurology department, Schluep et al. (9) found that discharge delays resulted chiefly from difficulties in obtaining laboratory investigations or from awaiting transfer to either another department or a nursing home. Thus, although diagnostic technology may be relatively expensive, if performed in a timely manner, it does not drive costs upward in a substantial way. However, delay in discharge after stroke diagnosis is established may raise cost significantly. Stroke diagnostic technology is a necessary and indispensable commodity, since its prudent use leads to definition of stroke subtype and specific medical or surgical therapy (10,11).
The "Time-Zero" Plan Step 1: Expedite Stroke Diagnosis The first step of the plan is to expedite stroke diagnosis. This means that bedside evaluation of the stroke patient must be initiated as soon as the patient reaches the Emergency Room (ER) or hospital ward. Once the stroke patient has been examined, a rational and rapid stroke diagnostic workup plan to determine "What is wrong with Mr. Jones?" (12) is formulated 2
J STROKE CEREBROVASC DIS, VOL. 5, NO.1,
1995
(4-7). Stroke Services at larger hospitals and university centers have been placed on 24-h alert 7 days a week to provide rapid response times for acute stroke patients who present to the ER (so-called "Code Stroke," "Dr. Stroke," or "Dr. Clot" ER responses). These rapid response mechanisms have been established to facilitate diagnosis, treatment, and screening of patients for hyperacute stroke treatment protocols (13-15). The model is effective for reducing ER response times and certainly can expedite stroke diagnostic workup and treatment (16,17). Hospitals that do not routinely provide rapid response neurologic ER coverage must become accustomed to training ER physicians to initiate proper stroke diagnostic workup or create a call schedule or rapid response telephone system whereby the ER physician can obtain expert neurologic advice about stroke workup in a timely manner. Unfortunately, primary ER physicians often lack expert knowledge of stroke despite the relatively high frequency of this type of neurologic emergency. As soon as the stroke patient arrives in the ER, the triage nurse should order an electrocardiogram (EKG), routine blood work, and other laboratory studies (47). Cranial computed tomography (CT) is obtained as soon as the triage diagnosis of stroke is confirmed by the ER physician. This approach requires established cooperation between the ER and Radiology Department. For example, the Radiology Department must be willing to expedite the request for CT or magnetic resonance imaging (MRI), since this diagnostic step can be a major rate-limiting factor in the process. Thus, a well thought-out and coordinated hospitalwide diagnostic plan must be put in place. Once the neurologic examination and CT have been completed, the determination of ischemic or hemorrhagic stroke can be made, and proper diagnostic tests can be recommended (4-7) to further define stroke subtype. For ischemic cerebrovascular disease, carotid noninvasive blood flow and transcranial Doppler (when appropriate) can be performed prior to patient transfer to the hospital ward. Again, a hospital-wide plan and cooperation among stroke diagnostic providers are mandatory. Once the patient reaches the hospital ward, cardiac noninvasive diagnostic studies (e.g., echocardiography and holter EKG) can be ordered as deemed appropriate by the admitting physician and with the expectation that these studies will be performed within 24 h of the request. By this point in time, hyperacute stroke therapy should have been administered based on the clinician's impression of stroke mechanism and availability of treatment protocols. Once clinical examination
THE 'TIME-ZERO" PLAN FORACUTE STROKE
and CT have verified the diagnosis of cerebral ischemia, there should be no delay in initiating hyperacute stroke treatment. Furthermore, physiatry/ physical medicine and discharge planning services, as deemed appropriate, should be consulted so as not to delay planning of long-term aspects of stroke care.
Step 2: Communicate with the Patient and Caregiver About the Diagnostic and Therapeutic Plan It is a mistake not to communicate about planned stroke diagnostic tests and treatment with the patient and caregiver. Patients and caregivers must be educated about the diagnostic and therapeutic plan, its rationale, and the risk-benefit ratio. By keeping the lines of communication open, both patient and physician expectations have a better chance of being realized. The physician must determine individual patient expectations, counsel the patient about these expectations, and understand the patient's philosophy and beliefs about diagnostic tests and treatments. Invasive procedures such as conventional cerebral arteriography, if planned, should be discussed early in the course of hospitalization to provide adequate time for the patient to contemplate the risk-benefit ratio of the procedure. Inadequate time for patient contemplation can result in prolonged acute-care hospitalization. Maintenance of good communication with the patient and family member can also lead to a more pleasing patient-physician interaction. In addition, by keeping the patient and family member well-informed, one may be less likely to encounter medical-legal difficulties should there be a poor outcome (18).
Step 3: Consult the Experts Experts in the diagnosis and treatment of stroke should be consulted as soon as possible. All too often, we encounter stroke patients in our consultation practice who are lingering in the acute care hospital because their primary physician has not been able to properly interpret the diagnostic test results to arrive at a diagnosis and treatment plan; the diagnosis is missed due to lack of appropriate examination or study; or too many diagnostic tests are ordered. Studies from stroke units generally show that length of stay may be shorter and outcomes better when patients are under the care of stroke experts (19-21).
Some Dilemmas When Selecting Appropriate Stroke Diagnostic Studies When choosing a diagnostic technology for a patient, we must consider patient, societal, and physician perspectives within the context of safety, efficacy, and economic efficiency (22). Unfortunately, most diagnostic information is imperfect in that there is some uncertainty about the technology, and this is expressed as a probability. We are all familiar with false-negative (patients who have the disease will have a negative test result) and false-positive (patients who do not have the disease will have an abnormal test result) results that exemplify this uncertainty or imperfection in the diagnostic technology. Traditionally, we have employed two measures of test performance as indicators of efficacyto help us decide which of several diagnostic tests is superior (22): (a) sensitivity: (the true positive rate or number of diseased patients with a positive test/number of diseased patients), and (b) specificity (the true negative rate or the number of nondiseased patients with a negative test/number of nondiseased patients). A gold-standard test or procedure is used to define the true state of the patient when the diagnostic technologies are compared. Sensitivity and specificity alone are not necessarily sufficient to decide whether the test should be performed, since questions of accuracy, safety, and cost must be considered. Ideally, our diagnostic technology assessment is carried out through a well-designed and well-executed randomized clinical trial for comparing technologies (22). However, such well-designed study is rarely done because costs may be high; it may be unrealistic to recruit a large number of patients; the technology may become obsolete or irrelevant during the years of study; the results may apply to a narrow spectrum of patients; or the trial may not measure outcomes of clinical interest. Therefore, the clinician who must select the appropriate diagnostic technology for a given patient is not armed with a plethora of data from which to base the decision and must rely on experience and common sense. Thus, it seems that the decision of whether or not to obtain CT and MRIof the head, carotid ultrasonography/transcranial Doppler and magnetic resonance angiography (MRA), or conventional transthoracic echocardiography and transesophageal echo cardiography should be left to the physicians with the most experience in stroke diagnosis and treatment given the relative paucity of well-designed studies of stroke diagnostic technology. These diagnostic technology decisions are not always easily made by a "cookbook" approach or simple flow diagram because individual patient variation exists, and our decisions continue to be peppered ] STROKE CEREBROVASC DIS, VOL. 5, NO.1, 1995
3
P. B. GORELICK
Costof stroke diagnostic studies and hospitalization at a major teaching hospital in Chicago, 1994"
Table 1.
by our philosophical, ethical, and medical-legal concerns. Until more rigorous technology assessments are hatched, we are left with only fragments of technical knowledge and a more difficult decision-making process for test selection (23).
Concluding Remarks My rationale for presenting the "Time-Zero" proposal for acute ischemic stroke and TIA (see Fig. 1 for summary) is a perceived need to maintain high-quality stroke diagnosis and treatment in an environment of high patient and physician expectation but limited managed health care system economic resources. Central to the plan is the assumption that delay in diagnosis, treatment, and discharge planning leads to prolonged hospitalization and heightened cost. Prior study has suggested that this may be the case (8) and that diagnostic technology should not be considered the major cost barrier. Although diagnostic technology is relatively expensive (see Table 1 for summary), it is an indispensable commodity whose prudent use leads to definition of stroke subtype and specific medical or surgical therapy. Expedient diagnostic workup and treatment as proposed in the "TimeZero" plan requires preplanned cooperation of pa-
STEPS
nIiEIPLACE) I.
( ·0· hou .. (Emergo".,y Room) ,
Triage, EKG. and routine blood labs
2.
Neurologic history and physical exam
3.
CT
4.
Carotid noninvasive blood flow and TeO (as deemed appropriate) on way to hospital ward tnitiate hyperacute stroke pharmacologicintervention (when available)· and communicate with patient and family Order cardiac noninvasive! (as deemed
5.
0·3 hou .. (tronlfor to hoopl~ ward from Emergency Room) 6.
appropriale)
(24-C8 hou .. (Hoapital Ward) ,
7.
Physialry/physlcal medicine
e.
consUltation Consult dischar~ planner
9. 10. I 1.
Complete diagnosUc WOl1<-up Communicale with paUenl and family Decide ~ reoeet CT. MRI of heed. MRA. conventional arteriography. transesophageaJ ecl1ocardiography, special blood studies or other tests
Estimated cost ($) Noninvasive diagnostic tests CT head (no contrast)" MRI head (without gadolinium)" Carotid duplex Transcranial Doppler (TCD) Transthoracic echocardiography Transesophageal echocardiography Magnetic resonance angiography Holter EKG EKG
903.00 1,541.50 711.00 600.00 285.50 285.50 803.00 197.50 125.50
Total
5,452.50
Invasive diagnostic tests Cerebral arteriography (unilateral)'
1,845.00
Total
1,845.00
Hospitalization costs Hospital room (semi-private)" CBC and platelet count Urinalysis Glucose, electrolytes Prothrombin time Partial thromboplastin time.
792.00/day 76.00 30.50 69.00 19.00 31.00
Total Overall totals Noninvasive tests + hospitalization costs Noninvasive tests + invasive tests + hospitalization costs
1,017.50
6,470.00 8,315.00
'Cost estimates represent non-discounted prices and do not include those given to large contractors. bAdd $94 if CT using contrast medium is performed and $461 if MRI with gladolinium is performed. 'Add $1,463.50 if bilateral cerebral arteriography is performed. dAdd $8 for private hospital room.
araneeded
( 4&-72
12. 13.
Comple'e diagnosUc WOl1<-up Make reaJlTent stroke prevention treatment decision (to be adminis· tered eIler hyperacute Itrol
14.
Convnunicatewith patient and family Plan discharge based on treatment decision and need for stroke rehabilitation
hou"IHoapl~ Ward) , 15.
"HyperacYle stroketrealment shoulld be initiated without delay as soon as CT and clinical
examinationhave made the distinction between ischemic and hemorrhagicstroke.
Figure 1. schedule. 4
'Time-Zero"proposal: evaluation anddiagnostic test
J STROKE CEREBROVASC DIS, VOL. 5, NO.1, 1995
tients, physicians, and stroke diagnostic providers and could result in maintenance of high-quality standards and options for acute stroke care and reasonable economic cost. Since we have proven stroke therapies and new ones are being developed, we must reckon with the fact that the age of therapeutic nihilism has long passed (24). The economic dock is ticking away, and delays in diagnosis and treatment can be costly from both the
THE 'TIME-ZERO" PLAN FOR ACUTE STROKE
patient and economic standpoint. Based on the estimates of direct costs from a recent Canadian study (8), we may stand to lose $680 Canad ian ($520 us.) each day we delay acute hospital stroke diagnosis and treatment. This could translate into a considerable amount of savings given the estimated 400,000-500,000 stroke patients in the United States each year alone. As cost may vary by nation and region, the Canadian study estimates may be underestimates relative to Ll.S. costs . It is time for us to be more actively moving toward the common ground of quality acute stroke care and economic responsibility. In the future, dedicated outpatient stroke diagnostic facilities with observational units may hold the key to quality care and cost containment for TIA, less severe stroke patients who may not need hospitalization, and those who do not qualify for hyperacute stroke therapy.
Addendum Since the submission of this manuscript, Bowen and Yaste (Neurology 1_994;44:1961-4) have shown significant savings for patients with acute stroke after the introduction of a treatment protocol. These savings were primarily related to decreased length of stay.
first six hours. Emergency evaluation and treatments.
1Stroke Cerebrovasc Dis
Stroke 1994;25:1901-14.
8. Smurawska LT,Alexandrov AV,Bladin CF, Norris JW. Cost of acute stroke care in Toronto, Canada. Stroke 1994;25: 1628-31. . 9. Schluep M,BogousslavskyJ,RegliF,Tendon M,Prod 'hom LS, Kleiber C. Justification of hospital days and epidemiology of discharge delays in a department of neurology. Neuroepidemiology 1994;13:40-9. 10. NASCET Collaborators. Beneficial effect of carotid endarterectomy in symptomatic patients with highgrade carotid stenosis. N Engl 1 Med 1991;325:44553. 11. Stroke Prevention in Atrial Fibrillation Investigators. Warfarin versus aspirin for prevention of thromboembolism in atrial fibrillation: Stroke Prevention in Atrial Fibrillation II Study. Lancet 1994;343:687-91. 12. Caplan LR. TIA's: we need to return to the question, "What is wrong with Mr. Jones?" Neurology 1988;7913. 13. Gomez CR Time is brain! 1Stroke Cerebrouasc Dis 1993; 3:1-2. 14. Malik M, GomezCR, Tulyapronchoter R, Malkoff MD, Bandlanudi R, Banet GA. Delay between emergency room arrival and stroke consultation. 1Stroke Cerebrouasc Dis 1993;3:177-80.
15. Biller J, Patrick JT, Shepard A, Adams HP. Delay time between onset of ischemic stroke and hospital arrival.
1Stroke Cerebrovasc Dis Acknowledgment: This work was supported in part by National Institute on Aging grant ROl AG10102-04, the MR Bauer Foundation, and the Herbert and Marjorie Fried Scholarship Fund.
References 1. Fishman RA. Progress and promise 1992: a status report on the NINDS implementation plan for the Decade of the Brain. Ann NeuroI1993;33:320-4. 2. Gorelick PB. Stroke prevention: an opportunity for efficient utilization of health care resources during the coming decade. Stroke 1994;25:220-4. 3. Wolf PA,Belanger A], D'Agostino RB. Management of risk factors. Neurol Gin 1992;10:177-91. 4. Feinberg WM, Albers GW, Barnett HJM, et al. Guidelines for the management of transient ischemic attacks. From the ad hoc committee on Guidelines for the Management of Transient Ischemic Attacks of the Stroke Council of the American Heart Association. Stroke 1994;25: 1320-35. 5. Lanska D] and the Task Force on Hospital Utilization for Stroke of the American Academy of Neurology. Review criteria for hospital utilization for patients with cerebrovascular disease. Neurology 1994;44:1531-2. 6. McDowell FH, Brott TG, Goldstein M, et al. Stroke: the
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16. Brott TG, Haley EC, Levy DE, et al. Urgent therapy for stroke. Part I. Pilot study of tissue plasminogen activator administered within 90 minutes. Stroke 1992;23: 632-40. 17. Alberts MJ, Perry A, Dawson DV, Bertels e. Effects of public and professional education on reducing the delay in presentation and referral of stroke patients. Stroke 1992;23:352-6. 18. Hickson GB, Clayton EW,Githens PB,etal. Factors that prompted families to file medical malpractice claims following prenatal injuries. lAMA 1992;267:1359-63. 19. Indredavik B, Bakke F, Solberg R, Rokseth R, Haaheim L,Holme I. Benefit of a stroke unit: a randomized controlled trial. Stroke 1991;22: 1026-31. 20. Babikian VL,Schwarze JJ. Stroke units. 1Stroke Cerebrovasc Dis 1994;4:183-7.
21. Kalra L The influence of stroke unit rehabilitation on functional recovery from stroke. Stroke 1994;25:8215. 22. Sox HC, Stern S, Owens D, Abrams HL Assessment of diagnostic technology in health care. Rationale, methods, problems and directions. Washington, DC: National Academy Press, 1989:8-72. 23. Donaldson MS, So x He. Setting priorities for health technology assessment, A model process. Washington, DC: National Academy Press, 1992:17-30. 24. Biller J, Love B. Nihilism and stroke therapy. Stroke 1991;22:1105-7.
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CEREBROVASC DIS, VOL. 5, NO.1, 1995
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