Stroke is a leading cause of death and disability worldwide. Reducing this burden requires high-quality medical care not only to prevent this disease, but also to provide prompt treatment and rehabilitation for patients who suffer strokes. Integrated systems of stroke care are ambitious, large-scale undertakings to coordinate regional stroke care. The aim of such projects is to optimize the continuum of stroke care from prevention through to rehabilitation, and ensure that critical interventions like thrombolysis and stroke unit care are available to all eligible patients. But is such a huge undertaking really worth it?
This was the question that a team of researchers (including myself) investigated in a national study that was just published in Neurology reveals. It turns out that the answer is a resounding YES; in fact, the implementation of such systems in Canada is already saving lives.
It’s important to note here that our “Canadian” healthcare system is actually a collection of similar systems organized and funded by province/territory, which results in regional variability in the kind of services that are available to patients. In 2000, Ontario became the first province to implement an integrated system of stroke care, inspiring the launch of the Canadian Stroke Strategy in 2004. This was a national effort to mobilize stakeholders in every province to invest in an integrated approach. National-level working groups developed tools that could be adapted for use across Canada, including the Canadian Stroke Best Practice Recommendations, training programs for stroke physicians, quality monitoring, and public awareness campaigns about the signs of stroke. The implementation of these systems also included pre-hospital protocols – for transporting patients by ambulance to designated stroke centres – and in-hospital protocols for advanced imaging and tele-stroke services – connecting doctors in more remote centres to stroke specialists by video teleconference to make time-critical patient care decisions. Since the adoption of these systems varied by province, a natural experiment in the delivery of stroke care unfolded in Canada. By around 2008, British Columbia, Alberta, Ontario, Quebec, Nova Scotia, and Prince Edward Island all had integrated stroke systems in place.
Our study examined whether there was a difference in the mortality of stroke patients among these provinces and those that did not yet have such systems in place. Specifically, we looked at whether the stroke patients in provinces with integrated stroke systems were less likely to die in hospital within a month. The results were highly encouraging - there was a sustained, 15% relative reduction in 30-day in-hospital mortality in provinces with stroke systems of care, starting in the 2009/2010 fiscal year and sustained through to the 2013/2014 fiscal year (end of study period). In other words, we found that fewer patients with stroke are dying following the implementation of integrated stroke care systems. The Canadian Stroke Strategy is working.
Commenting on these findings, which essentially validate the Canadian approach to stroke care, Dr. Jeffrey J. Fletcher at the University of Michigan and Dr. Jennifer J. Majersik at the University of Utah noted: “The Canadian experience suggests that the establishment of regional/provincial integrated systems of stroke care has resulted in a demonstrable difference in stroke mortality at a population level. Further reduction in mortality may be expected as stroke systems of care continue to become established across all provinces in Canada and elsewhere internationally.” In contrast, they observed that the current multi-payer system in the United States is highly fragmented, which means that stroke care lacks federal or state-level coordination: “A lack of centralized structure may lead to less efficient stroke systems and create barriers to monitoring and addressing regional issues to ensure the systems act in the best interest of the patient.”
Ultimately, what do these findings mean for the organization of stroke care in Canada and abroad? In much of the world today, stroke care remains highly fragmented, with different hospitals adopting their own approaches to the management of stroke patients. In an integrated approach, all the hospitals in a region become team-players in a coordinated effort to ensure that patients with treatable major strokes get to the most experienced centres as quickly as possible, and that all stroke patients go through a well-defined pathway of care aimed at optimizing their recovery. Our Canadian experience has demonstrated that this approach is already saving lives, and is a rallying call for our entire nation, and other public healthcare systems, to rise up to this challenge.
Dr. Aravind Ganesh (Prairies and St John’s, 2014) is a neurology resident-physician from Calgary, Alberta. He is a co-founder of the Canadian point-of-care mHealth venture, SnapDx and the UK-based personalized wellness and monitoring portal, The Self-Care People. He is also a clinical researcher and public health advocate, currently working with the University of Oxford’s Centre for Prevention of Stroke and Dementia.