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Hub leads state in use of stroke drug

Clot-buster data scrutinized amid effort to improve care

By Liz Kowalczyk
Globe Staff / June 7, 2010

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Stroke patients received potentially life-saving treatment more often at hospitals in Boston than in other regions of the state, according to newly released public health data.

State officials said they found wide variation among hospitals in the use of a powerful stroke drug during the years 2006 to 2008, the most recent period for which data are available. The officials have been examining the data as part of an effort to improve care for the more than 10,000 Massachusetts residents each year who suffer strokes.

At 23 hospitals in the Boston area, 72 percent of eligible patients got the drug, called tissue plasminogen activator (tPA), which can halt a stroke and prevent patients from suffering serious lifelong disabilities. In Central Massachusetts, a region that includes Worcester, just 52 percent of stroke sufferers were given the treatment. Statewide, 62 percent of patients got the medication.

On average, teaching hospitals gave the clot-busting drug 69 percent of the time, compared with 59 percent for community hospitals.

But there were exceptions: Some smaller community hospitals performed well at providing patients with this crucial treatment, including Holyoke Medical Center, Newton-Wellesley Hospital, South Shore Hospital in Weymouth, and MetroWest Medical Center in Framingham and Natick, all of which provided the drug to between 90 percent and 100 percent of eligible patients.

At several large teaching hospitals — Brigham and Women’s Hospital, Boston Medical Center, and Massachusetts General Hospital — 100 percent or nearly 100 percent of eligible patients got the drug.

State officials said that when data for 2009 and 2010 are released next year, they expect the gap between hospitals will have narrowed because of improved care.

To be eligible for the drug, patients must arrive at the hospital within two hours of the start of their symptoms and have no medical conditions that would make the medication too risky, such as metastatic cancer.

Many hospitals are struggling with the complexities surrounding tPA, which can have serious side effects including death, and generally must be given to patients within three hours of the start of a stroke, though doctors believe it’s still effective for some patients if given later.

Some small hospitals face a shortage of neurologists to evaluate stroke patients. The availability of neurologists “is the number-one problem,’’ said Laura Coe, a public health official who works with hospitals to improve stroke care. “Many community hospitals don’t have the resources to have 24-hour coverage,’’ she said. “The larger teaching hospitals with more resources can get the CT scan done, the lab tests read, and the neurology consultation done quickly. The community hospital just can’t get it done in time.’’

Public health officials said an even bigger problem is that patients often delay seeking medical care.

Of the roughly 8,000 patients in Massachusetts who suffer ischemic strokes each year — the type of stroke caused by a blood clot and that can be helped by tPA — just 4.5 percent of them made it to a hospital emergency department within three hours. That leaves thousands of stroke victims who don’t have the opportunity to even be evaluated for the drug, because the window had closed by the time they or a family member or friend recognized they were sick.

“The bigger picture is all these other people don’t even know they are having a stroke,’’ Coe said.

In an effort to improve stroke care, the Massachusetts Department of Public Health passed regulations in 2004 requiring hospitals to meet certain requirements to treat stroke patients. Hospitals must be able to provide CT scans 24 hours day, and must have neurologists on call to analyze the scans and decide whether a patient had an ischemic stroke and is eligible for tPA.

Hospitals also must submit detailed data on how fast they treat stroke patients and what percentage receive the tPA drug. In return, ambulances can bring stroke patients to these hospitals, and the hospitals are allowed to market themselves as “primary stroke services.’’

Elizabeth Daake, policy and planning director for the state’s Bureau of Health Care Safety and Quality, said although the state could revoke a hospital’s primary stroke service designation for not providing tPA to patients or other quality problems, that has not been necessary.

“There has been a strong commitment from hospitals to improve in this area,’’ she said. “We do want to see movement in the right direction. If a hospital continued to be on the low end, we would closely examine why.’’

One reason for the difference between community and teaching hospitals may be an advisory several years ago from a national emergency physician organization, which said ER doctors should not give tPA, but instead should wait for a neurologist. The group retracted that statement in early 2009, which makes ER physicians in smaller community hospitals more comfortable administering tPA more quickly, state officials said, and will probably lead to improvements in these hospitals.

At South Shore Hospital in Weymouth, which gave tPA to 21 of 23 eligible patients during the two-year period, the hospital was able to dramatically cut the time it took neurologists to arrive at the hospital. Physicians educated ambulance crews, which now can identify a probable stroke and call a “code stroke’’ on the way to the hospital, automatically paging a neurologist to come in before the patient even arrives at the ER.

“That cuts off minutes and cutting off minutes saves brain tissue,’’ said Dr. John Benanti, chief of emergency medicine.

And some hospitals say they are doing better than the data suggest. Cape Cod Hospital in Hyannis and Baystate Medical Center in Springfield both showed low rates of giving patients tPA — 20 percent and 45 percent respectively — but executives at both hospitals said they provided inaccurate data to the state and that their care is actually much better.

At Cape Cod, for example, doctors neglected to document in 2007 and 2008 why certain patients were not eligible for tPA, making their rates of giving the drug appear much lower than they actually are, said Dr. Michael Markowski, stroke director.

Liz Kowalczyk can be reached at kowalczyk@globe.com.

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