Editor: Robert M. Friedlander, MD, MA Associate Editor: Murat Gunel, MD
From the Chair Warren R. Selman, MD
Stroke Care at a Crossroads Are Primary Care Centers the Right Way to Go?
I went down to the crossroads, tried to flag a ride. I went down to the crossroads, tried to flag a ride. Nobody seemed to know me; everybody passed me by. Robert Johnson
Stroke care is at a crossroads. Efforts are now underway to certify primary centers of care for stroke patients. The growth of the AANS/CNS Cerebrovascular Section, which was established in 1975, serves as evidence that specialization is an accepted part of organized neurological surgery. By definition, the goal of specialization is to permit the development of special expertise and ultimately improve outcome. It is intuitive that specialized expertise is beneficial in providing optimal care for patients with cerebrovascular disorders. Demonstrating proof of this intuition, however, is not as straightforward. Volume and outcome in the management of cerebral aneurysms is a subject that has come to the forefront in two recent articles in the Journal of Neurosurgery.4,5 These articles and the thoughtful editorials provided by Roberto Heros, MD, deserve and warrant careful examination by all members of our section.8,9
A Correlation Between Volume and Mortality? The question as to why hospital death rates vary is not new. In fact, it was raised by Florence Nightingale in 1863, and again by Codman in 1914.3,11 Just over 20 years ago, Luft and colleagues demonstrated that hospitals with higher volumes of specific surgical procedures experienced significantly lower inpatient mortality rates than did their lower volume counterparts.10 It is important to remember that there are many fundamental factors that may underlie and trigger differences in outcome. These include patient selection, preoperative, anesthetic and postoperative intensive care, and surgical judgment, skill, and technique. Although identifying the relative contribution of these factors is a substantial undertaking, we must be committed to this process in an effort to help identify those best practices that can be incorporated by all surgeons and hospitals.
This is especially important since it is clear that volume is not an immutable determinant of the rate of adverse outcomes. This was demonstrated for cardiac bypass surgery in New York state, where the risk-adjusted mortality of high-volume surgeons decreased, but the risk-adjusted mortality of low-volume surgeons decreased to an even greater extent.7 In this experience, the gap in risk-adjusted mortality between high-volume and low-volume surgeons narrowed, and the mortality for both groups decreased substantially. Similarly, improving the outcomes for all practitioners providing care to patients with cerebral aneurysms is clearly the goal for which we should strive.
Epstein notes that the imperfect correlation between volume and mortality stands as a reminder that volume alone is not an indicator of quality of care. He goes on to further comment that the volume-outcome hypothesis has created a policymaker's dilemma.6 This dilemma posed for the management of cerebral aneurysms and subarachnoid hemorrhage is complicated by the nature of the data from which the studies have been conducted. The excellent studies by Cross and colleagues as well as Cowan and colleagues have limitations—the retrospective uncontrolled nature of these studies and the lack of specific data on the initial neurological condition of the patients treated-that must be considered before adopting recommendations for transferring patients to high-volume centers.8,9
Given the limitations imposed upon these studies by the databases utilized, it is the conclusion of the American Association of Neurological Surgeons (AANS) that, at this time, a mandate for regionalization of neurosurgical care would be premature.1 The recommendation of Cowan and colleagues that practitioners should refer patients to centers in which superior outcomes are consistently demonstrated deserves thoughtful consideration. Although, for all the reasons cited, this recommendation cannot be viewed as a mandate, but rather should serve as a timely and appropriate reminder of the need for neurosurgeons to take the lead in the development of tools that would permit identification of specific processes of care that improve outcomes.
New Stroke Certification In this regard, I want to call your attention to my discussion in the Fall 2003 issue of Cerebrovascular News of the American Stroke Association which, in conjunction with the Joint Commission on Accreditation of Healthcare Organizations, will begin offering Disease Specific Stroke Care Certification. This certification is based upon the Brain Attack Coalition's Recommendations for the Establishment of Primary Stroke Centers.2 Neurological surgery played a major role in the development of the recommendations for primary stroke centers, and the availability of neurosurgical services is a key component. I would urge the members of the Cerebrovascular Section to participate and actively support the American Stroke Association in this important effort to improve the care of stroke patients.
In recognition of the belief that committed multidisciplinary teams offer distinct advantages through their ability to provide all the therapeutic options to bear on the management of patients with cerebrovascular disorders, the Brain Attack Coalition is currently in the process of developing recommendations for comprehensive stroke centers. As with the primary centers, the AANS, Congress of Neurological Surgeons and Cerebrovascular Section have been instrumental in the development of these recommendations. It is anticipated that a comprehensive stroke center will possess all the comparable characteristics of a primary stroke center, and much of what will distinguish a comprehensive stroke center is specific, documented expertise and infrastructure in several key areas including diagnostic radiology, endovascular therapy, intensive care, and neurological surgery.
CV-ASITN Annual Meeting Opportunities Providing the opportunity to observe and discuss the latest innovations in the basic scientific and clinical foundation for the management of patients with cerebrovascular disease has always been the priority of the Cerebrovascular Section's Annual Meeting. The upcoming Seventh Joint Meeting of the AANS/CNS Cerebrovascular Section and the American Society of Interventional and Therapeutic Neuroradiology will be held at the Sheraton San Diego Hotel, Feb. 1-4. The scientific program will feature practical courses, special symposia and seminars that specifically address the details and processes of care. The scientific program was designed to highlight up-to-the-minute information on clinical trials, discuss current topics of interest such as volume and outcome, and focus on "real world" experience in the management of cerebrovascular disorders. I encourage you all to attend and participate, and I look forward to seeing you in San Diego.
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