Sending a doctor on call to rural hospitals to treat strokes can save lives, Mizzou study says
Every second counts when you're having a stroke — and University of Missouri Columbia researchers have found that those seconds are better spent with the patient staying at a local hospital while a specifically trained doctor travels to them, particularly in rural areas.
In the nearly 2,000 stroke cases researchers examined in the study, dispatching physicians to patients consistently led to less time between the onset of a stroke and treatment — time that can mean the difference between life and death.
"The current way of delivering care is sub-optimal," said Dr. Adnan Qureshi, lead author of the study and MU School of Medicine professor of clinical neurology. "A lot of (stroke patients) are not getting the treatment they should be, and they're getting it in a manner that is delayed, which is really taking away their chance at a full recovery."
The distance between patients in rural areas and their nearest hospital doesn't change, but the complications associated with moving a high-risk patient disappear when a physician comes to them.
Every four minutes, someone dies from a stroke. Over 795,000 people have a stroke in the U.S. every year.
About 87% of these are ischemic strokes, which stop blood flow to the brain. The most effective way to remove the clots stopping the blood flow is by physically removing them, through a procedure called mechanical thrombectomy.
"Thrombectomy is a very involved process that is very effective, but it can only be done in specialized places," Qureshi said.
Fewer than 8% of emergency rooms across the U.S. are comprehensive stroke centers, and even fewer are thrombectomy-capable.
Study authors thought rather than transferring high-risk patients to larger stroke facilities, might it make more sense for physicians to come to them?
And they weren't the only ones with this question — many smaller studies have been done across the world asking the same thing. However, many of these studies were quite small, and Qureshi said it's harder to draw big conclusions from smaller datasets.
The Mizzou researchers decided to pool all the data they could find comparing physician and patient transfer when it comes to stroke care. They spent months filtering through studies to eventually find the 11 they used in their analysis.
The answer was clear: Physician transfer leads to better outcomes for stroke patients, because it's all about timing.
"The longer one part of the brain doesn't get blood flow, the more likely the brain will undergo irreversible changes," Qureshi said. "You're losing function by the minute, so delivering treatment even five minutes earlier has an impact on a patient's chance of recovery."
The study found that transferring a physician is about 75 minutes faster than transferring a patient to a larger hospital.
"You know, 75 minutes is quite a bit of time in our business," said Dr. Amer Al Shekhlee, a vascular neurologist at SSM Health and adjunct professor at St. Louis University School of Medicine. "Every minute, 2 million brain cells die — so from a science point of view, we can save many millions of brain cells in those 75 minutes."
That's not the only reason it makes more sense to send trained physicians to smaller or more rural hospitals when needed than to try to equip all emergency rooms with their own staff and doctors dedicated to stroke intervention, Qureshi said.
"Let's say all the hospitals decided they wanted to hire their own person, rather than getting someone transferred over," Qureshi said. "One, we don't have enough physicians to start with. And two, those physicians might do four or five procedures in a whole month — that's not enough to keep their proficiency."
Having highly trained physicians and staff work in multiple locations allows them to do more procedures per year, which leads to better outcomes for patients — and again, it's all about timing.
"They get familiar with the procedure, they get familiar with the techniques, and so they are much more time-efficient," he said.
While there aren't any healthcare systems in the U.S. that frequently transfer physicians to smaller hospitals for stroke patients, hospitals in Germany started testing the idea in 2018. Dr. Gordian Huber, a stroke neurologist based in Munich, Germany, led that study and said at the beginning, the protocol was to alternate transferring physicians rather than patients every other week.
After only two years, they were forced to stop their study.
"Our ethical committee said 'You have to stop the study, it's too good. You're too fast, and we know faster is better for the patients — you have to do this every week now,'" Huber said.
Hospitals in southern Germany have integrated physician transfer into their care for stroke patients and have had better patient outcomes for the past six years.
However, there are limits to doing this sort of practice in hospitals stateside, including making sure smaller medical facilities have the right equipment and staff training required to ensure stroke-related procedures go smoothly, said Al Shekhlee.
"If I was told there is a patient 40 miles away from your hospital, and we're going to take you to them, my anxiety would be through the roof," Al Shekhlee said. "Because I don't know the environment, I don't know the people, and I don't know what kind of equipment they have ... will I be comfortable operating on this patient in order to save their life?"
The researchers have begun assembling teams to investigate what it would take for hospitals to implement this practice in the future — including asking if it's financially feasible, which involves getting insurance companies on board, said Dr. Qaisar Shah, an interventional neurologist at Winchester Medical Center in Virginia.
They are also starting clinical trials that will look at how to make physician transfer as practical as possible, while advocating for its implementation.
"There's so much investment in developing new treatments to make stroke a treatable disease, but until we make those treatments available for all people, they're not going to make a huge difference," Qureshi said.
