Creating Impactful Stroke Systems of Care Policies

by Colby Tiner, MA

Read “Establishing a Baseline: Evidence-Supported State Laws to Advance Stroke Care” in Advancing Legal Epidemiology, March 2020

As a public health policy expert who specializes in issues affecting cardiovascular systems of care, the lion’s share of my work focuses on evaluating current policies targeting population health and how they can be improved. Effective policy implementation and outcome evaluation is critically important and reveals valuable insights that can inform and improve policy development. This is particularly true when it comes to creating impactful stroke systems of care policies because after decades of decline, progress has slowed in preventing stroke deaths.

As Siobhan Gilchrist and colleagues convey with their analysis, over the past decade, stroke systems of care have been targeted for improvements in endovascular therapy, neurocritical care, and stroke center certification. There is also the advent of innovations such as telestroke and mobile stroke units. So why are stroke death rates on the rise again in many locations? Research suggests that a number of factors, including higher rates of obesity and diabetes are increasing both the prevalence and severity of stroke. For those patients having a stroke, getting appropriate, immediate care is the most important step to prevent death and disability. According to Gilchrist and colleagues, a policy-making infrastructure that ensures the pre-hospital (which, in addition to emergency medical service policies, includes community-based stroke awareness programs) and in-hospital segments of stroke systems of care are integrated helps to ensure that stroke patients receive timely, life-saving care.

As a health policy professional, scientific evidence is my I Ching. It is my eternal source of wisdom, the essential component of the “feedback loop” that tells me which policy interventions have the potential to achieve desired results. The “feedback loop” is the continuum that forms the crux of health policy analysis:

Source: Centers for Disease Control and Prevention, Office of the Associate Director for Policy and Strategy

But in a siloed stroke system of care, the impact of evidence-based stroke protocols can be compromised. In a sense, a siloed system of care takes a pizza slicer to the “feedback loop,” and breaks apart an otherwise comprehensive pizza pie. How do we know, for example, the full impact of the Cincinnati Pre-hospital Stroke Scale (used in the pre-hospital setting), if it is not assessed as a component of a broader stroke system of care? This has the potential to compromise stroke care and patient health.

In their paper, Gilchrist and colleagues analyze state laws and regulations that address specific areas of stroke systems of care to determine if state laws are likely to have a positive impact, commensurate with the scientific evidence base of the policy interventions these laws and regulations are seeking to implement. The authors conclude that many states have implemented components of an evidence-based infrastructure for in-hospital stroke care, but that only three states have fully or comprehensively adopted an evidence-based infrastructure that integrates in-hospital stroke with pre-hospital stroke care. The lack of such integration, according to Gilchrist and colleagues, could lead to problems with pre-hospital transport protocols, interfacility transfers, and data sharing between EMS agencies and stroke centers.

Although more states may need to enact laws or regulations that authorize integrated statewide or regional stroke systems of care, the paper notes that more study is needed to assess how such a framework can potentially address the quality of stroke systems of care and what impact it may have on local variations within state or regional systems of care. Research has shown that clinical care accounts for merely 10-20% of modifiable contributors to health outcomes. Additionally, there is a significant degree of heterogeneity of stroke mortality rates within states (including the “stroke belt”), thereby suggesting that local variations in social determinants of health and robustness of stroke prevention efforts may have a substantially greater impact on stroke outcomes.

I look forward to seeing how this work can inform policies that integrate social determinants of health and community-based stroke prevention into stroke systems of care.

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Colby Tiner

Colby Tiner is a policy analyst in the American Heart Association’s Office of Policy Research in Washington, DC, where he heads the Association’s policy portfolios on health technology, cardiovascular systems of care, and surveillance. He also serves as a policy advisor for the Association’s Center for Health Technology and Innovation. 

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