More in Mass. get drug for stroke

Massachusetts hospitals have increased significantly the number of stroke patients who get a potentially life-saving drug, two years after the state set quality standards for hospitals providing stroke care.

Still just several hundred patients a year get the treatment; most of the thousands of residents who have strokes annually arrive too late to the emergency room to get the time-sensitive drug, which is ineffective if given more than three hours after stroke symptoms begin.

Preliminary results from the program, the first of its kind in the nation, show that during the first half of 2006, about 125 patients, or 53 percent of those medically eligible for the treatment and who arrived in the emergency room within three hours of the start of their symptoms, got the drug, called tissue plasminogen activator . That compared with 27 patients, or 33 percent, in the first half of 2005. The figures don't include patients who were hospitalized when they had strokes.

However, the data, which the Globe obtained through the state's public records law, show that some patients arriving at the hospital within three hours may be losing the chance to get the drug because of delays once they're there, possibly due to overcrowded emergency rooms.

``There's been a cultural change," said Dr. Lee Schwamm, director of acute stroke services at Massachusetts General Hospital. Treatment with the drug has gone ``from something a few academic medical centers did on a regular basis to something that's become an expectation. The next piece is we've got to ratchet up the number of patients we're treating."

More than 10,000 Massachusetts residents have strokes each year; about 80 percent of the strokes are caused by a blockage, usually a blood clot, in one of the brain's blood vessels. Intravenous tissue plasminogen activator, a clot-dissolving medicine, is used only for this type of stroke, called an ischemic stroke. Doctors rely on imaging, usually a CT scan, of the brain to help determine if a patient is having an ischemic stroke; patients with the other type of stroke, caused by a burst blood vessel, can be harmed if treated with the drug.

The drug is risky -- 4 percent of ischemic stroke patients given the drug die from bleeding into their brain -- and many emergency room doctors are afraid they will cause harm if they give it to the wrong patient, such as someone with a medical condition that puts the patient at particular risk for bleeding.

The reluctance to treat patients is contributing to stroke's devastating effect: Only about 38 percent of stroke patients recover with little or no disability; studies show that among patients given the drug, 50 percent return to normal.

In an effort to improve 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 have neurologists on call to analyze the scans immediately and decide whether a patient had an ischemic stroke and is eligible for the tissue plasminogen activator. Hospitals must submit detailed data on how fast they treat patients and what percentage receive the drug. In return, ambulances can bring stroke patients to these hospitals, and the hospitals are allowed to market themselves as ``primary stroke services."

``Massachusetts has gone a step further" than other states, said Dr. William Likosky, director of the stroke program at Swedish Medical Center in Seattle. ``They said you can't take care of stroke patients unless you prove you can do it, or the ambulance will pass you by. They're the national leader."

But Schwamm said hospitals and public officials need to undertake more ambitious public education campaigns alerting residents to the symptoms of stroke and the importance of rushing to the hospital for treatment. The state Health Department is spending $629,000 in the current fiscal year on stroke education, including radio and television spots in English and Spanish.

The data also show that hospitals in some cases are struggling to determine quickly enough whether patients are eligible for the drug. For example, specialists believe patients should have a CT scan to confirm diagnosis within 25 minutes of their arrival in the emergency department. During the first half of 2006, hospitals met this deadline for about 22 percent of patients. The deadline was met in a similar percentage of cases in the first half of 2005.

The data the Department of Public Health provided the Globe do not identify hospitals by name. The state set up the program in a way that keeps the records of all but the worst-performing hospitals secret.

Primary stroke service hospitals, which now include 68 of the state's 72 acute care hospitals, report performance data to a Cambridge company, Outcome Sciences Inc. Outcome Sciences provides the Health Department with monthly reports, but it does not identify individual hospitals by name -- unless their performance is very poor. That places the names of most hospitals beyond the reach of the public records law because the state does not know them either.

Paul Dreyer, director of the Division of Health Care Quality, said the Health Department plans to visit several hospitals that ``look like they're not giving any tPA" to determine whether the data contain errors or they are not treating patients properly. The results of these visits, along with the names of the hospitals, will be made public when the department's reports are complete. But the department agreed to keep private the performance of all other hospitals as a way to entice institutions to participate in the program, he said.

Amy Lischko, commissioner of the state division of Health Care Finance and Policy, said the state's agreement with Outcome Sciences and with the hospitals was made before most insurers and employers began calling for greater openness of medical cost and quality information, and before Governor Mitt Romney made transparency in healthcare a cornerstone of his administration.

Charles Baker, chief executive of Harvard Pilgrim Health Care and a member of a new state council created to decide what type of cost and quality data should be made public, said he will ask the group to examine the issue and whether there's a way to make the data public.

The federal Medicare insurance program for the elderly plans to make public similar data regarding the time it takes individual hospitals nationally to provide crucial care to heart attack patients.

John Birkmeyer, a University of Michigan Health System surgeon who researches why some hospitals and doctors have better outcomes than others, said public disclosure can push providers to improve faster. Besides, he said, ``informed consent requires a sharing of all available information."