State's top neurologists suggest higher standards for comprehensive stroke centers

on Monday, 06 January 2014.

This article by Dan Goldberg originally appeared in The Star-Ledger.
Along the New Jersey Turnpike, amid the billboards for cars and coffee, is an ad for JFK Medical Center in Edison, telling motorists it is the No. 1 Stroke Center in New Jersey. The ranking is from Healthgrades, an independent ratings firm. Like Dunkin’ Donuts and Rolex, JFK Hospital wants your business.
JFK, which is affiliated with the Robert Wood Johnson Medical School, is among several hospitals claiming to be No. 1 for stroke care in New Jersey. Its advertisement is one of dozens you can find across the state in an intensifying battle for share in a multibillion-dollar industry.
Neurological advancements in the past decade have allowed doctors to treat the brain more effectively, creating opportunity for hospitals to expand their neurology departments, hire more specialists and treat more patients. The advances have led to the kind of competition once seen in cardiac care.
"It’s kind of sexy and exciting," said John Halperin, chair of neurosciences at Overlook Medical Center in Summit and medical director of neurosciences for Atlantic Health System. "It really is where the cutting edge of medical care is."
Since 2007, 13 New Jersey hospitals have earned the "comprehensive stroke center" label, the top designation from the state Department of Health. Only two are south of Trenton, leading to questions about whether the state has the right balance in regionalizing care. The proliferation of comprehensive centers also has many neurologists calling for higher standards so patients can better identify which hospitals are best qualified to handle the most complex cases.
"The fact that you have a label doesn’t mean you’re in the best place to be," Halperin said.
The designation is more than semantics, said Erol Veznedaroglu, a neurosurgeon who left Thomas Jefferson University Hospital in Philadelphia five years ago to build and run the Capital Institute for Neurosciences in Trenton. When every second delayed could mean brain cells forever destroyed, a hospital claiming to be one of the state’s best owes it to its patients and its community to meet these higher standards.
"People don’t realize what’s lacking until they or their loved one need something," Veznedaroglu said.
Somewhere between 17,000 and 21,000 New Jerseyans suffered some form of stroke in 2012, in line with the past few years. Comprehensive stroke centers are not for the average stroke — 80 percent of which are easily treated with tissue plasminogen activator, or TPA, administered intravenously. That’s a drug that breaks up the clot, allowing blood to flow back to the brain. The treatment can be given at one of New Jersey’s 52 hospitals that are primary stroke centers. Today, 95 percent of New Jerseyans live within 30 minutes of a primary stroke center.
Comprehensive stroke centers are meant for the remaining 20 percent — patients with aneurysms, ruptures of large arteries or other types of bleeding in the brain. These diagnoses require neuro-intensive care units and complicated surgeries, and demand 24-hour staffing of highly skilled neurologists and specialized nurses.
Many of the state’s top neurologists believe this highest designation should be reserved for elite hospitals. Thirteen, they say, is too many.
"I think we all agree that six is the right number," said Martin Gizzi, chairman of the New Jersey Neuroscience Institute at JFK. Gizzi is also the chair of the Stroke Advisory Panel, which recommended the state Health Department adopt stricter standards for a hospital to be designated "comprehensive."
Among the suggested criteria is that the label be reserved for those that treat at least 25 intracranial aneurisms each year. The state Department of Health is considering those recommendations.
Minimum patient volumes are standard in many fields and the theory isn’t complicated, said Dorothea Altschul, clinical director of neurosciences at St. Joseph’s Regional Medical Center. "We become better if we do more of it," she said.
Halperin, chair of neurosciences at Overlook, said there is no way to know the right minimum but more is better.
"If I were going to be treated, I’d want a place that does 100," he said.
If the state accepts the minimum patient recommendation, there wouldn’t be enough people requiring that level of care for all 13 hospitals to keep their designation, Gizzi said.
The changes could cost hospitals millions. Stroke is the fourth-leading cause of death in the United States. The average lifetime cost of stroke is estimated at $140,000, according to the National Stroke Association, which devotes a section of its website to helping hospitals "turn a stroke program into a revenue generating center of excellence!" The key is volume; the expensive equipment that offers three-dimensional scans and improves outcomes pays for itself faster when more patients are treated. Hospitals that take more complex cases also raise their Case Mix Index, which means they receive more Medicare money per patient.
"Having a comprehensive designation, there can be a business advantage to that," said James McKinney, medical director of Robert Wood Johnson’s Comprehensive Stroke Center and assistant professor of Neurology at Robert Wood Johnson Medical School.
As such, no hospital wants to lose its designation. In fact, many tout multiple accreditations to sell themselves to patients, as well as doctors in emergency rooms who often decide where to send patients.
"Hospitals being corporations — some nonprofit, some for profit — recognize this and are concerned that if they don’t hang out a comprehensive flag, they will lose patients," said Ralph Sacco, past president American Heart Association and chairman of neurology at the University of Miami Miller School of Medicine.
A generation ago, there wasn’t much doctors could do for stroke patients. As late as 2000, New Jersey had no "go-to" hospital for strokes. After 2002, TPA became more routine, but any New Jersey patient who needed complex care was flown to New York or Philadelphia.
Kennedy University Hospital in Washington Township in Gloucester County was sending some 500 patients every year to other hospitals in the early to mid-2000s, said Martin Bieber, President & CEO of Kennedy Health System.
Veznedaroglu said most patients he saw in Philadelphia came from New Jersey.
"We would see time-sensitive cases, who were sitting in community hospitals for a few hours while their brains were shutting down," he said. "Obviously not a good model when you consider New Jersey is not the Ozarks. We are talking about a pretty big sophisticated state."
Only two of the 13 comprehensive stroke centers are south of Trenton, leading some to wonder whether New Jersey has done a good job of regionalizing care
Courtesy of State Department of Health
It didn’t take long for hospitals to realize they were losing business. It isn’t just the initial care — it’s all the aftercare and the potential to build those "revenue centers."
Politicians noticed, too. State Sen. Barbara Buono (D-Middlesex) led the charge for legislation requiring the Department of Health designate hospitals as "primary" or "comprehensive" stroke centers. Buono is the Democratic nominee for governor, and in 2002, she married Gizzi, who helped craft the law. His hospital was the second to be accredited as "comprehensive" by the state (behind Overlook), and also has received "comprehensive stroke center" certification from the Joint Commission, a national accrediting body. Capital Health, last week, became the second hospital in New Jersey to earn Joint Commission certification.
The benefit from all the competition is that patients are far less likely to be sent out of state. The downside is hospitals are more prone to send patients to their affiliates even when it is not the closest hospital, several neurologists said.
Ciro Randazzo, medical director of neurosurgery at Atlantic Regional Medical Center, said that practice was "one of the more disturbing things I’ve seen."
Raising standards would at least ensure that wherever a patient ends up, the surgical team will have the necessary training.
"If you are the average Joe, and someone says you are having an aneurysm, you want to know that if you go to a comprehensive stroke center, you will find a team that can take care of you," said Charles Prestigiacomo, professor and chair of neurological surgery at Rutgers New Jersey Medical School and a neurosurgeon at University Hospital. "That’s why the state is discussing whether there is a need for minimum volumes.
"It is not saying we need five or six or 80 comprehensive centers. That would be the wrong message. The message is these are the criteria so that these centers will be better than they are now."
This story has been amended to reflect the following corrections. Martin Bieber is President & CEO of Kennedy Health System, not the CFO. This story also misstated which group has a section of its website devoted to helping hospitals "turn a stroke program into a revenue generating center of excellence!" It is the National Stroke Association, not the American Stroke Association.

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