New stroke care strategies for prevention, acute treatment and post-stroke care could lower U.S. health-care costs by as much as $1.6 billion per year.
Every two seconds, on average, someone on the planet suffers a stroke. For these people, life or death hinges on a precise choreography of health-care workers and machines, all working to restore blood flow to injured brains.
Now, a new stroke care delivery model, developed by researchers at the Stanford Clinical Excellence Research Center, offers evidence-based strategies that enable clinics and hospitals to improve stroke patient outcomes while at the same time lowering costs related to their care.
The main components of the new stroke care delivery model include the following:
Better stroke prevention by coaching at-risk patients to take preventive medications and to make lifestyle changes.
Reduction of unnecessary hospital admissions of low-risk, transient ischemic attack patients by setting up TIA outpatient clinics for urgent evaluation.
Reduction of prolonged hospital stays for mild ischemic stroke patients through a more efficient, 24-hour protocol for in-hospital stroke care.
Redesign of emergency care to more rapidly administer the clot-busting tissue-plasminogen activator, or tPA, to all eligible ischemic stroke patients.
Reduction of hospital readmissions by improving the transition of stroke patients to post-hospital care in the community.
The research team estimates that implementing all its recommendations would significantly improve patient care and reduce U.S. health-care costs by up to $1.6 billion per year. The care model and its potential cost savings were described in the Oct. 22 issue of Stroke.
“Our nation needs to find ways to safely treat more patients for less money,” said Arnold Milstein, MD, the center’s director, who helps shape national health policies. “Our center’s innovative care models provide clinicians and administrators with a road map to improving patient outcomes while simultaneously responding to this national imperative.”
Launched three years ago, the Clinical Excellence Research Center assembles small teams of physicians, business scholars, engineers, and management and social scientists to redesign care delivery for some of the most expensive disease conditions in the United States.
In 2012, three fellows — Lucy Kalanithi, MD; Waimei Tai, MD; and Jared Conley, PhD, MPH — targeted strokes, the nation’s leading cause of disability, with an annual national price tag of $20.6 billion in direct health-care spending. (Another team worked on strategies for transitioning chronically ill young adults from pediatric to adult care.)
“We recruit creative young scholars into our center, introduce them to some of the most progressive thinkers both inside and outside of health care, then challenge them to find better ways to address our biggest and most costly health-care challenges,” said Milstein.
In the first six months of their fellowship, Kalanithi, Tai and Conley analyzed major stroke treatment guidelines, care delivery methods and cost-effectiveness studies. They then visited or interviewed more than 20 top-performing stroke care and prevention centers in the United States, Finland, Canada, Australia and Spain. In developing their new care model, which brings together best practices that both improve care and reduce costs, they also borrowed quality-improvement ideas from companies outside of health care. For example, they visited Intel’s laser lithography group to learn how this company reduces mistakes in human management of their microchip fabrication processes.
'An evidence-based toolkit'
The second half of the year was spent getting feedback on their ideas with stroke-care experts, hospital administrators and health-care insurers, using this input to steadily refine their care delivery model. They also began recruiting hospital partners to test the model.
“We had an exciting journey engaging with diverse thought leaders, and homing in on a set of innovative clinical management strategies that we believe will help further transform stroke care,” said Conley, the CERC team’s expert on health-care organization and system redesign.
“Our stroke care model is essentially an evidence-based tool kit that institutions can implement in whole or part as they participate in the scientific process to test it,” added Kalanithi, now a clinical instructor of medicine at Stanford and a faculty member at CERC.
This year, four institutions are testing the new stroke care model: Stanford Health Care, Allina Health in Minnesota, Geisinger Health in Pennsylvania, and Virginia Mason Health System in Washington.
“Our ultimate goal is to accelerate the dissemination of these models across the nation, so these initial partnerships are essential in ironing out the bugs and smoothing obstacles to their widespread adoption,” said Tai, now a clinical assistant professor of neurology at Stanford.
On Sept. 1, 2013, Stanford Heath Care launched the first phase of its transition to CERC’s recommended stroke emergency care redesign. The primary quality goal for this phase is to improve the delivery times of tPA to eligible stroke patients. This plan module was inspired by innovations at Helsinki University Central Hospital in Finland and Washington University Physicians in St. Louis.
The first step in determining a stroke patient’s course of treatment is to find out if blood-flow disruption is being caused by a clot or a broken blood vessel in the brain. Typically this can be diagnosed through a CT scan of the head. For patients with clots, tPA is quickly administered through an IV to dissolve the clot and restore blood flow. Delivery of tPA to patients with broken vessels can worsen the bleeding and be fatal, so care must be taken to make the right diagnosis as soon as a patient arrives.
If Olympic gold medals were given out for rapid tPA delivery, it would go to the Helsinki team. It maintains the best door-to-needle tPA delivery times in the world, with a median time of less than 20 minutes. (The U.S. median is 67 minutes, according to a study in the April 23 issue of the Journal of the American Medical Association.)
The important lesson learned from the Finns — who spent more than 10 years refining their stroke-care processes — is that the key to rapid stroke treatment is to do as much as possible before the patient arrives.
“Every 15 minutes that we cut from the initiation of treatment, an average patient will gain one month of disability-free life,” said Atte Meretoja, MD, one of the architects of the Helsinki stroke care model. In 2012, he implemented the model at the Royal Melbourne Hospital in Australia, bringing median door-to-needle times down to 25 minutes in a project that took only four months.
The Helsinki stroke team goes into motion as soon as an ambulance team calls in a probable stroke. Paperwork, test setups and drug orders are initiated before the patient arrives. To achieve this, it is crucial that the ambulance relay patient details to the stroke team. From the emergency bay, patients are wheeled directly on ambulance gurneys to an adjacent imaging room, bypassing the emergency department. (This recommendation is currently not part of the American Heart Association/American Stroke Association Stroke guidelines.) A physician and infusionist stand by the CT scanner, ready to infuse tPA immediately, if appropriate for that patient.
“This is like a clinical ballet, where people have to work together seamlessly in a busy emergency situation,” said Stephanie Casal, RN, Stanford Health Care’s stroke team coordinator.
This is like a clinical ballet, where people have to work together seamlessly in a busy emergency situation.
The challenge to making sweeping changes to a traditional hospital’s stroke procedures is this: The very thing that makes a hospital a safe place — reliance on well-established protocols — is the same thing that makes it hard for these institutions to embrace change. Incorporating CERC’s recommended changes, which involve disrupting the established routines of dozens of emergency medical personnel working in life-or-death situations, has to be done in a careful, methodical way.
Tai, the neurologist, is managing Stanford Health Care’s transition to the new model. An essential tool in this process is the mock stroke code drill, which Tao and Casal call “dynamic problem solving.” During drills, the team looks for areas where things get bogged down. Problem areas are noted and workarounds are tested.
For example, the Stanford stroke team shaved a few minutes off the hospital admissions process by having the paperwork people meet patients in the ambulance bay. A few more minutes were saved by putting a sample-collection station in the imaging room.
Casal, the keeper of the stroke team’s performance metrics and a disciple of Toyota’s lean production methods, is pleased with the progress thus far. Following implementation of the new CERC care design, 94 percent of suspected stroke patients arriving via ambulance have brain imaging initiated well within national targets, and median door-to-needle time for tPA administration has already dropped by 30 percent.
“The Joint Commission just re-accredited our Comprehensive Stroke Center, and they were very impressed with our continuous improvement processes, including the impact that applying the Helsinki model to Stanford has had on our performance,” Tai said.
Innovation in health-care delivery
Though the 2012 CERC stroke fellows initially signed up for a year, all opted for a second year. As year three begins, they are helping the four pilot sites that are adopting various components of the care model.
Today, the fellows feel that their CERC experience has been transformative for them personally and for the health-care industry at large.
CERC gave me a way to fix these problems at a national level.
“Like many working physicians, every day I would see needed health-care improvements, both large and small, that weren’t happening,” said Tai. “CERC gave me a way to fix these problems at a national level.”
A number of other CERC care delivery models are entering pilot-testing at 10 sites around the nation. The CERC team is working to recruit more sites to test ways of improving the affordability of high-quality chronic kidney disease care, colon cancer prevention, poor-prognosis cancer care, the transition of chronically ill children to the adult health-care system, and nonemergency surgical care outside of hospitals.
“CERC is an innovation accelerator that increases the flow of new care delivery methods that yield better health with much less national health spending,” said Milstein. “CERC accelerates the flow via three activities: inventing much more cost-effective care methods for the illnesses that account for the bulk of suffering and spending in the U.S., testing the methods in diverse sites with the support of progressive health insurers and finding industry partners to spread them nationally.”
More information about CERC is available at http://cerc.stanford.edu/. Fellows participating in the stroke study were supported in part by the Sue and Dick Levy Fund, a donor-advised fund of the Silicon Valley Community Foundation; and Spectrum, the Stanford Center for Clinical and Translational Research and Education.