A majority of the 50,000 Canadians who suffer a stroke
each year aren't getting the rapid-fire clot busting treatment
that's their best chance of recovery.
"Ten years ago, about all we could
do for a stroke patient was hold their hand," says Dr
Antoine Hakim, CEO and scientific director of the Canadian
Stroke Network. But despite advances in acute treatment
and recovery in the last decade, there are still only
a handful of specialized stroke units in Canada and
these are the places with the best track record for
stroke survival and recovery. The units, which vary
from acute interventional to integrated units where
patients are followed through their rehabilitation,
dramatically improve patient outcomes mainly because
they do offer rapid administration of thrombolytic therapy.
What's more, new research published
in the March issue of Stroke has suggested insufficient
stroke training is leading to sluggish diagnoses and
limits access to care. "The doctor often lacks experience
and confidence," says study author Dr Peter Hand, a
neurologist at Royal Melbourne Hospital in Australia.
Canadian stroke specialists agree there simply aren't
enough qualified specialists to go around.
TIME
IS BRAIN
The thrombolytic drug tissue plasminogen activator (tPA)
has drastically improved outcomes for patients who've
suffered an ischemic stroke, where a clot occludes a
blood vessel that feeds the brain. But time is of the
essence. "After a stroke, brain tissue progressively
dies over time. The greater delay to treatment, the
less likely it is to be successful," explains Dr Hand.
Trouble is, tPA has an extremely
narrow window: ideally, it should be administered within
three hours of symptom onset. The rub is that tPA should
only be given after a CT scan has ruled out hemorrhagic
stroke, where thrombolytic drugs would only make things
worse. Dr Frank Silver, director of the University Health
Network's stroke program in Toronto, says this is the
biggest problem with tPA — figuring out who's appropriate
for the treatment. "If you give it to the wrong person,
it's disastrous," he explains, because it can cause
increased bleeding. But when it's used right, tPA can
greatly reduce the risk of permanent disability.
A
FEW GOOD EXPERTS
As is the case with many other specialities in Canada,
the sad reality is provincial funding cuts have meant
a decline in people with the expertise to treat stroke
(see "Specialists'
thinning ranks", Vol 3, No 5). In 2005, only 27
neurology residency positions were offered in Canadian
medical schools. "Clearly, we have to increase the training
of all physicians, because the average patient isn't
going to be under the care of a stroke neurologist,"
says Dr Silver.
Dr Hakim says it doesn't really
matter what kind of physician sees the patient. "What's
important is that they've received sufficient training."
All the neurology and neurosurgery training programs,
as well as internal, family and emergency medicine,
include training in stroke care, according to Dr Nick
Busing, president of the Association of Medical Schools
of Canada. But each university dictates the amount of
time young doctors actually spend on dedicated stroke
instruction. And whatever that adds up to, experts say
it just isn't enough. "The average cardiologist or internist
can deal with a GI problem, but if it's a neurological
case, they all back off," says Dr Silver. "Med students
receive more training in how to set a broken bone than
in how to manage a stroke patient," adds Dr Hakim.
All of this is borne out by Dr
Hand's study. "The neurological assessment can be daunting
for a non-neurologist," he says. "We were surprised
to find that two clinicians often couldn't even agree
on the day of symptom onset," he says. Given the tiny
window for administering tPA, his data is alarming.
THE
MISSING LINK
That's where the stroke unit comes in. A specialized
stroke centre should have, at minimum, a dedicated emergency
medical team available 24/7 with appropriate expertise
in tPA therapy and diagnostic assessment capabilities
which includes rapid access to a CT scan. Many also
include a prevention clinic and rehabilitation care.
"The organizational stuff is simply related to the fact
that you have a great need for speed," says Dr Michael
D Hill, director of the stroke unit at Foothills Hospital
in Calgary. "If you don't recognize that, you'll never
achieve good outcomes in stroke patients."
Dedicated stroke units lead to
a 14% reduced risk of death at one-year followup and
a 22% reduced risk of death and dependency compared
to traditional services, according to a systematic review
by the Cochrane Consensus published in January.
"Patients who receive organized stroke unit care are
more likely to survive their stroke, return home and
make a good recovery," concluded the authors. Yet according
to data from the Canadian Stroke Network's Registry,
only 18% of stroke patients were admitted to a specialized
stroke unit in 2001 and 2002, and only 31% received
organized stroke care in hospital.
So why are there still so few of
these units in Canada? "Change takes time," says Dr
Silver, "and it's kind of foreign to the average physician
to be a part of a multidisciplinary team." Dr Hill finds
the limited number of specialized centres a bit of a
mystery. "It's most likely a lack of knowledge at the
executive level and a lack of a champion at a local
centre," he speculates.
A
PLAN OF ACTION
Because of the huge regional differences in stroke survival
rates across the country, the Canadian Stroke Network
and the Heart and Stroke Foundation of Canada partnered
up to create the Canadian Stroke Strategy (CSS) in June
2004. The CSS aims to help each province set up a game
plan to close the gap and improve patient care by 2010.
The comprehensive, national stroke
strategy is based on a similar program launched in Ontario
in 2000. "There's a person in each province doing scans
to see where they're at and to help policymakers see
that having a stroke program makes sense because it
provides more cost-effective care," explains Dr Silver.
Ontario's groundbreaking strategy sure got the message
across: the provincial government is now allocating
$30 million a year to the Ontario Stroke System. Alberta
and Nova Scotia aren't far behind, and BC is coming
along as well.
Dr Silver points out that Canada
is actually way ahead of many jurisdictions in the world,
especially the US. "In part it's advocacy, setting up
systems and providing resources," says Dr Hill. "Changing
an existing system is difficult."
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