Stroke Patients Don't Call 911

This is bad. But even with 100% participation, the low success rate of tPA and the lack of further hyperacute treatments still means that reduction in disability due to stroke will be hard to acheive.
http://www.medpagetoday.com/Cardiology/Strokes/31631

Patients may not be getting the message to call 911 at the first signs of stroke, researchers said.

Nationwide, only about half of stroke patients arrived at the emergency department via ambulance and that figure hasn't changed over a 10-year period, Hooman Kamel, MD, of Weill Cornell Medical College in New York City, and colleagues found.

"Our findings suggest that national efforts to address barriers to ambulance use among patients with stroke need to be intensified or adjusted," they reported in a research letter in the March 14 issue of the Journal of the American Medical Association.

Thrombolytic therapy improves outcomes after ischemic stroke, but most patients don't present to the hospital in time, which is typically within 4.5 hours of symptom onset. That's despite numerous educational efforts to encourage people to call 911 at the earliest signs of stroke, especially because being transported via ambulance results in quicker arrival at the emergency department.

Regional studies have shown poor use of ambulance services among stroke patients, but none looked at a nationally representative population, Kamel and colleagues said.

So they assessed data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1997 and 2008 totaling 340 to 408 EDs around the country; the centers were surveyed annually with participation rates of 87% to 98%.

The researchers included patients with ischemic stroke, subarachnoid hemorrhage, intracerebral hemorrhage, and transient ischemic attack.

Overall, 19% of adults nationwide presented to the emergency department via ambulance and that didn't change significantly between 1997 and 2008.

Among 1,605 cases, 51% of patients with stroke arrived at the emergency department via ambulance, and that proportion didn't change significantly during that time period either.

The trend was apparent for all subgroups, except for young patients and those with a payment source other than private insurance, Medicare, or Medicaid, which experienced a downward trend in ambulance use between 1997 and 2008, the researchers reported.

Regression analyses confirmed that overall rates of ambulance use didn't change over time, Kamel and colleagues added, and those results were similar in analyses limited to patients with ischemic stroke, those without any secondary ED diagnoses, or among those admitted to the hospital.

They said several factors may explain the persistent lack of ambulance use among stroke patients, including educational efforts that aren't adequately addressing poor public knowledge about stroke, and additional behavioral barriers that may exist among those without adequate knowledge.

It could also be a symptom of poor response by healthcare providers to patients who are exhibiting signs of stroke, they wrote.

They cautioned that the analysis lacked the power to detect temporal changes within subgroups, and that it couldn't determine what proportion of strokes was coded in error. Still, they concluded that the findings suggest there's plenty of room for improvement in national public efforts to get patients to call 911 at the first signs of stroke.

The end result of this should be a total rethinking of how to prevent neuron death.