Addressing inequity in acute stroke care requires attention to each component of regional workflow

A multifaceted approach will enable equitable stroke care for regional communities

About 56 000 strokes occur in Australia annually1 at an estimated economic cost of $5 billion per year.2 Inequity continues to separate regional and metropolitan populations with respect to incidence and management of acute ischaemic stroke. Risk factors for acute ischaemic stroke disproportionately burden regional Australia and this is reflected in the high rate of strokes in regional compared with metropolitan areas (250 v 210 per 100 000 population per year respectively).1 Of the 12 electorates with highest stroke incidence nationally, nine are in regional areas.1

The benefit of time critical management of acute ischaemic stroke is well established. Variances in workflow burden regional communities by delaying these time‐sensitive interventions. The median time from stroke onset to thrombolysis is 2.3 hours (interquartile range [IQR], 1.54–3.24 hours) in metropolitan areas and 3.06 hours (IQR, 2.24–3.38 hours) in regional Australia.3

Endovascular clot retrieval (ECR) has augmented thrombolysis as gold standard of care in emergent large vessel obstruction; however, accessibility to the therapy is limited to comprehensive centres in major cities. The addition of ECR to the treatment algorithm has unavoidably resulted in significant workflow reorganisation. This is especially true in regional and rural health systems, which currently in Australia operate a “hub and spoke” model — where “spoke” health services refer to more comprehensive “hub” services, usually located in metropolitan areas, for definitive treatment.

Regional workflow differences derive from geographical, demographic, workforce and policy variation, in part stemming from state‐by‐state health system governance. Clear, feasible, evidence‐based solutions that address the upstream and downstream contributors to inequality in each component of the patient journey (ie, workflow) are required to curtail the current inequity.

Community awareness

Community recognition of stroke is the first step in the patient journey and is critical to timely intervention. Since 2004, the national FAST (Face, Arm, Speech, Time) campaign has increased public awareness of stroke in Australia. However, when asked to recall two or more common stroke symptoms, rural and regional residents continue to significantly underperform, suggesting the reach and effectiveness of these campaigns in regional areas are insufficient.4

The effect of geographical location on the effectiveness of such campaigns has not yet been delineated, thus hampering the delivery of best evidence interventional campaigns for regional communities. This should prompt the development of a rurally focused, evidence‐based campaign delivered through accessible platforms.

Emergency assessment and transport

Ambulance dispatch and assessment comprise the initial phase of workflow. Potential strokes are classified as high priority by emergency services across Australia, but response times vary depending on location. A trend towards lengthier wait times for priority cases is observed in rural and regional areas. In 2018, 22 of 48 regional Victorian local government areas had category 1 median response times greater than 15 minutes and three were reported as 30–35 minutes, while all metropolitan median times were less than 15 minutes.5

Mobile stroke units (MSU) are specialised ambulances that allow for point‐of‐care stroke treatment and streamlined stroke unit admission. International trials demonstrated clinical benefits and, subsequently, a pilot program is servicing a specific catchment area in metropolitan Melbourne. The use of MSUs in regional populations, however, has not been validated. Distance, prolonged transport time and low patient load could potentially make MSUs ineffective and fiscally unviable in regional areas. Conversely, MSUs could streamline bypass protocols by providing imaging while avoiding the primary stroke centre, the so‐called mothership approach, although this requires modelling. This approach contrasts the “drip and ship” method, which uses the primary stroke centre as an intermediary before transfer to the comprehensive stroke centre for definitive management (Box 1). An expanding body of local research indicates air‐MSUs could be technically feasible and may offer significantly improved access to treatment modalities for rural Australian communities, thus reducing treatment inequity.6

Proximity to a stroke unit correlates with increased likelihood of receiving thrombolysis,7 while longer travel time reduces the probability of ECR.8 Cost–benefit modelling indicates helicopter transfers for thrombolysis are cost‐effective, although there is a paucity of local research with respect to thrombectomy.9 The fixed cost of a helicopter transfer in Victoria is $26 197, but there is an absence of publicly available data pertaining to the number of air transfers for stroke.

Clear and effective communication between pre‐hospital and in‐hospital carers is pivotal to ensuring optimal management. Coordinated pre‐hospital notification gives emergency departments and stroke teams time to prepare for incoming admissions, streamlining the process of door‐in, to imaging, to treatment and door‐out if applicable. Pre‐hospital stroke notification has been shown to decrease key time metrics and should thus be standard of care.10,11

Imaging

Imaging provides critical diagnostic information in the early phases of in‐hospital stroke evaluation. Delayed door‐to‐computed tomography (CT) time prolongs reperfusion and increases the risk of expanding irreversible damage to the ischaemic penumbra. One in 14 regional Australian services does not have 24‐hour CT capabilities and only 67% have access to advanced imaging such as magnetic resonance imaging (compared with 96% in metropolitan areas).3 Limited access to imaging in regional areas alters workflow, delays intervention and, thus, negatively affects care and furthers inequity. Immediate CT is the most cost‐effective CT scanning strategy for acute ischaemic stroke;12 however, further rurally focused cost–benefit modelling is required to confirm this in an Australian context. Twenty‐four‐hour CT capabilities are necessary for telestroke networks (discussed below) to function effectively. In the new era of telestroke, all regional hospitals must have capacity to perform CT perfusion, or have protocols for streamlined local bypass.

Door‐to‐needle time

Early thrombolysis significantly improves outcomes at 90 days,13 but only three of five regional patients with stroke are transferred to a hospital capable of providing thrombolysis and just one in ten receive the treatment.3 Of those patients, 23% receive thrombolysis within 60 minutes of arrival — 8% lower than metropolitan services and well below the national benchmark of 61%.3 Moreover, 40% of regional services do not adhere to the national recommendation of coordinated stroke code systems.3 A multimodal approach incorporating training and education may improve door‐to‐needle times in “spoke” hospitals. Door‐to‐needle times may be further optimised by improved access to thrombolysis in regional areas using telestroke networks.

Door‐in to door‐out time

Door‐in to door‐out time is a byproduct of ECR and represents the time from hospital arrival to departure for patients transferred from a primary stroke centre to an ECR centre. This includes the decision to transfer, which has been observed as a substantially time‐consuming metric. The underlying reasons are yet to be meaningfully characterised, although the complexity of tasks during this period may contribute. Tasks include image acquisition and interpretation, treatment decision making, referral, logistical considerations, data transfer and unique patient factors. Low stroke volume, workforce shortages, limited access to diagnostic modalities, protocol inefficiencies and technological barriers are possible causes of delays, although further research is needed. Regional health services must be assisted in developing protocols to streamline intervention and transfer. This may be most appropriate if integrated with evolving telestroke services.

Telestroke

Access to specialists in regional Australia continues to be a significant barrier to thrombolysis and ECR evaluation. Telestroke networks increase the safe and effective delivery of thrombolysis in “hub and spoke” models and allows for real‐time assessment for ECR in remote areas.14 Furthermore, economic feasibility studies demonstrate cost‐effectiveness across most scenarios.15 The first Australian telestroke network (the Victorian Stroke Telemedicine Service) was developed in 2010 and, since then, it has provided collaborative care to more than 5000 patients across Victoria. Reviews of the program have found societal and organisational benefit and, thus, other states have followed with similar emerging programs.16

Telestroke services support regional practitioners in diagnostic and treatment decisions and prevent potentially unsafe interventions and related costs to the health service and the patient. Moreover, there is evidence suggesting upskilling of the Australian rural workforce through use of telehealth networks as educational platforms for practitioners and consumers.17

National telehealth service standardisation is an enduring challenge in Australia, with political, infrastructural and logistical issues being major barriers to unification of services. A nationwide, coordinated telestroke service may benefit consumers and health services in terms of clinical outcomes and cost‐effectiveness, although further cost–benefit analysis is indicated. To ensure future output of telestroke‐trained practitioners, formal education in advanced training programs is required as these services expand.

Conclusion

Equitable care of acute ischaemic stroke in regional Australia remains elusive, and rural sectors continue to underperform in terms of pre‐hospital and in‐hospital workflow metrics. The incorporation of ECR into the treatment algorithm has unavoidably resulted in challenges of workflow reorganisation. An intersectoral, multifaceted approach (Box 2) is recommended to improve and streamline the management of acute ischaemic stroke and bridge the regional divide in stroke care. Given that many Indigenous Australians live in regional areas, and have high rates of acute ischaemic stoke incidence and mortality,18 investigation into the appropriateness of the current workflow model in the Aboriginal and Torres Strait Islander population is mandatory.

Box 1 – Comparison of treatment workflow for acute ischaemic stroke between “drip and ship” and “mothership” approaches

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ECR = endovascular clot retrieval; EMS = emergency medical services; IV‐tPA = intravenous tissue plasminogen activator.