Stroke is the third leading cause of death and leading single cause of disability in the United States. The estimated direct and indirect costs of stroke for 2008 are about $65 billion. It is known from prior research that early recogniton and treatment reduces the morbidity and costs associated with stroke. Thrombolysis with intravenous tissue plasminogen activator (IV t-PA) remains the only proven treatment for acute ischemic stroke who present within three hours of symptom onset with no established contraindication. However, it is also known that the rate of t-PA use in ischemic stroke patients is only 2-3%. Large scale studies have shown that poor rates of thrombolysis are due to lack of patient recognition of stroke symptoms, delay in accessing Emergency Medical Services (EMS) and in-hospital delays like lack of expedited triage.Therefore, it is well known scientifically that a multi-disciplinary approach is necessary to improve the rate of t-PA use in eligible acute stroke patients. In addition to improving knowledge on early stroke recognition in the community, the Brain Attack Coalition (BAG) determined that two levels of stroke care i.e primary and comprehensive stroke centers be created to improve emergency and other types of clinical care for stroke. With establishment of certified primary stroke centers and evidence for improved quality of care at primary stroke centers, county authorities and EMS agencies created policies to bypass the nearest emergency department and transport stroke patients to primary stroke centers. Although multiple counties are adopting the change, the impact of the policy change on regional patient outcomes has not yet been established through scientific evidence. In addition, studies on accuracy of stroke recognition by prehospital providers have shown that there is considerable scope for improvement in stroke recognition. To address these issues, I propose to conduct a study with the primary goal of studying comparative patient outcomes in regionalized and non-regionalized stroke systems. The secondary goals will be to assess the cost-effectiveness of regionalized care and accuracy of prehospital stroke recognition before and after regionalization of systems.

Public Health Relevance

The study results will help to determine 1) regional differences in the rate of intravenous t-PA use and mortality among acute ischemic stroke patients 2) the impact of increasing volume in primary stroke centers and longer transport times within a regionalized system on patient outcomes.By providing evidence for patient outcomes in a regionalized stroke system.our research will provide scientific knowledge to promote health policy changes of great public health importance at a national level.

Agency
National Institute of Health (NIH)
Institute
Agency for Healthcare Research and Quality (AHRQ)
Type
Clinical Investigator Award (CIA) (K08)
Project #
5K08HS017965-04
Application #
8242622
Study Section
HSR Health Care Research Training SS (HCRT)
Program Officer
Anderson, Kay
Project Start
2009-04-01
Project End
2014-03-31
Budget Start
2012-04-01
Budget End
2013-03-31
Support Year
4
Fiscal Year
2012
Total Cost
Indirect Cost
Name
University of California San Francisco
Department
Internal Medicine/Medicine
Type
Schools of Medicine
DUNS #
094878337
City
San Francisco
State
CA
Country
United States
Zip Code
94143
Hodell, Evan; Hughes, Shana D; Corry, Megan et al. (2016) Paramedic Perspectives on Barriers to Prehospital Acute Stroke Recognition. Prehosp Emerg Care 20:415-24
Tataris, Katie L; Mercer, Mary P; Govindarajan, Prasanthi (2015) Prehospital aspirin administration for acute coronary syndrome (ACS) in the USA: an EMS quality assessment using the NEMSIS 2011 database. Emerg Med J :
Govindarajan, Prasanthi; Friedman, Benjamin T; Delgadillo, James Q et al. (2015) Race and sex disparities in prehospital recognition of acute stroke. Acad Emerg Med 22:264-72
Stephens, Caroline E; Sackett, Nathan; Govindarajan, Prasanthi et al. (2014) Emergency department visits and hospitalizations by tube-fed nursing home residents with varying degrees of cognitive impairment: a national study. BMC Geriatr 14:35
Govindarajan, Prasanthi; Dickert, Neal W; Meeker, Michele et al. (2013) Emergency research: using exception from informed consent, evaluation of community consultations. Acad Emerg Med 20:98-103
Govindarajan, Prasanthi; Lin, Lisa; Landman, Adam et al. (2012) Practice variability among the EMS systems participating in Cardiac Arrest Registry to Enhance Survival (CARES). Resuscitation 83:76-80
Govindarajan, Prasanthi; Desouza, Natalie T; Pierog, Jessica et al. (2012) Feasibility study to assess the use of the Cincinnati stroke scale by emergency medical dispatchers: a pilot study. Emerg Med J 29:848-50
Govindarajan, Prasanthi; Larkin, Gregory Luke; Rhodes, Karin V et al. (2010) Patient-centered integrated networks of emergency care: consensus-based recommendations and future research priorities. Acad Emerg Med 17:1322-9