ORLANDO, Feb. 5 -- While medical professionals may understand how and why a stroke happens, researchers say the wide variation in treatment of stroke patients shows that much professional education is needed to ensure they receive the most up-to-date care.
The findings, part of a benchmarking project of academic medical centers undertaken by researchers at Yale University, were presented here today at the American Heart Association's 23rd International Joint Conference on Stroke and Cerebral Circulation.
"Variation in practice is seen for many diseases, and the differences can be dramatic," says Lawrence M. Brass, M.D., professor of neurology at Yale University. "Once they have been highlighted, variation of practice tends to decrease -- especially when guidelines are adopted. We are trying to devise constructive ways to improve and standardize medical care."
By exploring how various practices are associated with desired clinical, administrative and fiscal outcomes, researchers hope to create improved management strategies which can be tested in clinical practice.
"We are showing that even among academic medical centers, there is a huge amount of variation," says Brass. "This is not a punitive issue. We need to recognize that there are areas for improvement and work on fixing them."
The researchers, working with the University Healthsystem Consortium (UHC), collected data for 30 consecutive patients with stroke caused by obstructed blood flow to the brain at each of 36 participating academic institutions from Jan. 1 through March 31, 1996. They found wide variations in the frequency in which common stroke diagnostic tests and medical therapies are used.
For example, testing to evaluate carotid bifurcation -- an examination to detect a narrowing of the arteries that carry blood and nutrients to the brain -- was done in 30 to 90 percent of patients at the institutions. This is an important test that the American Heart Association recommends to identify patients who could benefit from vascular surgery. Such surgery is known as carotid endarterectomy. Brass says carotid endarterectomy can reduce the risk of recurrent stroke by two-thirds in certain patients.
According to the researchers, one in four patients were not discharged on any therapy, indicating a significant under-use of therapies such as aspirin, which the American Heart Association recommends to prevent recurrent stroke or heart attack. "In addition, other therapies are used too often," Brass says.
One example of such a therapy is drugs to lower blood pressure -- high blood pressure is a risk factor for stroke. "Lowering blood pressure too much can worsen a stroke. This may be occurring more commonly than recommended by American Heart Association guidelines for acute stroke treatment.
"The wide variations should serve as an 'eye-opener' for those who think that all patients must have cardiac imaging," adds Brass, chief of the neurology service at the Veterans Administration hospital in Connecticut. "Often there are provincial views that mandate that the way people practice in one area is the only way to do things."
The research found that the mean length of stay for acute stroke patients was 7.5 days and in-patient mortality was 7.1 percent. While mortality did not differ significantly for men and women (8.1 percent and 6 percent mortality respectively), there were differences by ethnicity as evidenced by a mortality rate of 8.1 percent of Caucasians and 4.6 percent for African-Americans.
Brass says this research should lay the groundwork for creating improved programs in the future. He adds that his group plans on continued work with the UHC centers to examine stroke care issues in greater detail.
"Patients should be an active partner in the health-care system both in talking and asking questions and expecting that the American medical system actively explores ways to raise the standard of care," says Brass.
Co-researchers are Judith H. Lichtman, Ph.D., and Harlan Krumholz, M.D., at Yale University and the Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE); and Julie Cerese, R.N., M.S.N., program director, clinical process improvement at UHC.
Media advisory: Dr. Brass can be reached at (203) 785-3351. (Please do not publish telephone number.)