Mana Mana Ma Ma nage nage geme geme ment ment nt of Acu nt of Acu of Acute St of Acute St Stro Stro roke roke ke ke Im Impac Impac Im pact o pact o t of Re t of Re Registr Registr gistratio gistratio tion St tion St Studies Studies udies udies Harold P. Adams, Jr., M.D. Harold P. Adams, Jr., M.D. Department of Neurology Department of Neurology Carver College of Medicine Carver College of Medicine University of Iowa Health Care Stroke Center University of Iowa Health Care Stroke Center Iowa City, Iowa Iowa City, Iowa Isch Is chemic emic St Stro roke ke as a P as a Public ublic He Health alth Isch Is chemic emic St Stro roke ke as a P as a Public ublic He Health alth St Stro roke is an E ke is an Expe xpensive Dise nsive Disease ase Stro St roke is an E ke is an Expe xpensive Dise nsive Disease ase Pr Problem in Problem in Pr oblem in Taiw a oblem in Taiw a Taiw an Taiw an � Direct costs of stroke � � Stroke is a leading cause of death and disability in � Direct costs of stroke Stroke is a leading cause of death and disability in � � Prevention Taiwan Taiwan Prevention � Treatment of risk factors � Treatment of risk factors � Recent report on stroke in Taiwan � Recent report on stroke in Taiwan – – 1998 1998 – – 2007 2007 � Antithrombotic � Antithrombotic medications medications � 258,167 patients with ischemic stroke � 258,167 patients with ischemic stroke � Surgery � Surgery � National Health Insurance Research Database � � Acute treatment � National Health Insurance Research Database Acute treatment � Treatment of acute stroke � 30 � Treatment of acute stroke � 30- -day mortality rate increased following cuts in day mortality rate increased following cuts in � Prevention and treatment of complications � Prevention and treatment of complications reimbursement reimbursement � Rehabilitation and long � Rehabilitation and long- -term care term care � Indirect costs of stroke � Indirect costs of stroke Tung & Chang; Stroke, 2010; 41:504 � � Loss of productivity Tung & Chang; Stroke, 2010; 41:504 Loss of productivity � � Welfare disability Welfare disability Past Pa st Ma Mana nage geme ment nt of Pat of Patients w s w ith Pa Past st Ma Mana nage geme ment nt of Pat of Patients w s w ith Stro St roke in ke in th the United St e United Stat ates es Stro St roke in ke in th the United St e United Stat ates es Ce Cere rebr brovas ovascular cular Disease Disease Disease Ce Cere rebr brovas ovascular cular Disease � 795,000 new strokes annually � 795,000 new strokes annually � 610,000 first strokes � 610,000 first strokes � Sense of hopeless by patients and helpless by health � Sense of hopeless by patients and helpless by health � 185,000 recurrent strokes � 185,000 recurrent strokes care providers care providers � � 1/18 deaths in the United States 1/18 deaths in the United States � Nothing established as effective in improving outcomes � Nothing established as effective in improving outcomes � Mortality from stroke, 1996 � Mortality from stroke, 1996 – – 2006 2006 � No sense of urgency in diagnosis and treatment � No sense of urgency in diagnosis and treatment � � Estimated annual health care costs Estimated annual health care costs - - $80 billion $80 billion � The approach to stroke was summarized by the term of � The approach to stroke was summarized by the term of cerebrovascular cerebrovascular accident accident � Nothing accidental about stroke � Nothing accidental about stroke Lloyd- Lloyd -Jones, Circulation, 2010; 121: e46 Jones, Circulation, 2010; 121: e46- -e215 e215 1
Advan Ad Advan Ad vances in vances in ces in th ces in th the Tr the Tr e Treatm e Treatm eatment o eatment o of of Interv Interv rven rven ention ention tions fo tions fo s for Tr s for Tr r Treatm r Treatm eatment eatment Ce Cere Ce Cere rebr rebr brovas brovas ovascular ovascular cular cular Disease Disease Disease Disease of Ac of Ac Acut Acut ute St ute St e Stroke e Stroke oke oke � Much of the management of stroke has not been tested � Much of the management of stroke has not been tested in clinical trials � � Early 1970 in clinical trials Early 1970’ ’s s – – advent of CT to differentiate ischemic advent of CT to differentiate ischemic � � Recommendations in guidelines based on consensus from hemorrhagic stroke Recommendations in guidelines based on consensus from hemorrhagic stroke � � Area for considerable future research Area for considerable future research � Late 1970 � Late 1970’ ’s s – – utility of aspirin to prevent ischemic utility of aspirin to prevent ischemic � A larger number of interventions have been tested in � A larger number of interventions have been tested in stroke stroke the setting with stroke with largely negative results the setting with stroke with largely negative results � � Mid 1980 Mid 1980’ ’s s – – nimodipine nimodipine effective in treatment of SAH effective in treatment of SAH � Neuroprotective � Neuroprotective therapies in treatment of ischemic stroke therapies in treatment of ischemic stroke � Late 1980 � Late 1980’ ’s s – – use of MRI to improve diagnosis of acute use of MRI to improve diagnosis of acute � Anticoagulants in treatment of ischemic stroke � Anticoagulants in treatment of ischemic stroke stroke stroke � � Surgical evacuation of large deep hemisphere Surgical evacuation of large deep hemisphere hematoma hematoma � � 1995 1995 – – utility of intravenous utility of intravenous rtPA rtPA for treatment of stroke for treatment of stroke � � Recombinant Factor Recombinant Factor VIIa VIIa in treatment of hemorrhage in treatment of hemorrhage � 2000 � 2000’ ’s s – – intra intra- -arterial techniques to treat acute stroke arterial techniques to treat acute stroke Re Regula gulatory Ap y Appr prove oved I Interv rven ention tions Utilization of Util ization of rt rt rtPA PA fo fo for Tr r Trea eatmen tment o t of Re Regula gulatory Ap y Appr prove oved I Interv rven ention tions Utilization of Util ization of rtPA PA for Tr r Trea eatmen tment o t of Trea Tr Trea Tr eatmen eatmen tment o tment o t of Ac t of Ac Acut Acut ute St ute St e Stroke e Stroke oke oke Stro Stro St St roke in roke in ke in th ke in th the United St the United St e United Stat e United Stat ates ates es es � Review of Medicare claims in the US 2005 � � � Regulatory approvals vary among countries and lists of Review of Medicare claims in the US 2005- -2007 2007 Regulatory approvals vary among countries and lists of � � 4750 Hospitals approved medications may differ considerably approved medications may differ considerably 4750 Hospitals � 495186 Patients with acute ischemic stroke � 495186 Patients with acute ischemic stroke � Local interpretation of data and different requirements � Local interpretation of data and different requirements � Treatment with � Treatment with rtPA rtPA � Still, some interventions have received approval for � Still, some interventions have received approval for � 64% of hospitals had not treated a single case � 64% of hospitals had not treated a single case treatment of acute stroke treatment of acute stroke � 0.9% of hospitals had treated 10 or more cases in 2 years � 0.9% of hospitals had treated 10 or more cases in 2 years � Nimodipine � Nimodipine for preventing ischemia after for preventing ischemia after aneurysmal aneurysmal � Least likely in small, rural, underserved areas � Least likely in small, rural, underserved areas subarachnoid hemorrhage hemorrhage subarachnoid � Despite having a therapy of proven efficacy, it is being � Despite having a therapy of proven efficacy, it is being � Intravenous � Intravenous thrombolysis thrombolysis with with rtPA rtPA for acute ischemic stroke for acute ischemic stroke underutilized and there is considerable room for underutilized and there is considerable room for � Mechanical interventions to extract clots � Mechanical interventions to extract clots improvement improvement Kleindorfer et al, Stroke, 2009; 40: 3580 Kleindorfer et al, Stroke, 2009; 40: 3580 Guidelines in Manageme Guidelines in M agement t of Str of Stroke Guidelines in Manageme Guidelines in M agement t of Str of Stroke � Written by professional panels of experts � Written by professional panels of experts � Physicians of multiple specialties � Physicians of multiple specialties � Other health care providers � Other health care providers � Adapted to local country or region of the world � Adapted to local country or region of the world � � Sponsored by professional, public interests, or governmental Sponsored by professional, public interests, or governmental bodies bodies � Guidelines may have different formats � Guidelines may have different formats � American Heart Association � American Heart Association – – several complementary several complementary statements statements � European Stroke Association � European Stroke Association – – single major statement single major statement 2
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