Sunday, November 30, 2014

The 'hub and spoke model' of health care: how can we apply to stroke care in India

India is ranked 119 out of 169 countries in Human Development Index (HDI). It spends about 4% of the Gross Domestic Product (GDP) on healthcare, which ranks among the countries with least spending on healthcare. As such, it is essential for the health care organizations in India to manage the expenditure on healthcare in a prudent manner. In continuation to my earlier article on 'telestroke', I will discuss the 'hub-and-spoke' model of stroke care and how it can help us to maximize the benefits of high tech care while minimizing unnecessary costs.

The 'hub-and-spoke' model

Organized inpatient stroke care at designated stroke centers has been shown to reduce mortality and morbidity when compared to treatment at non-specialist centers. With increasing complexity of stroke care, it has become impossible to provide specialist stroke services in every hospital in a specific area. Stroke care involves management by a dedicated stroke team consisting of vascular neurologist, neurosurgeon, neurointerventionist, intensivist, radiologist, anesthesiologist, specialist nurses, rehabilitation facilities and other trained medical personnel. It also requires the availability of cutting-edge technology at their disposal. Given that this requires millions of rupees, it is virtually impossible to have all these facilities in every hospital in a designated area. A simple but effective solution to this problem is to organize the stroke care in the form of a network of hospitals that depend on each other for caring for patients with stroke. In the hub and stroke model, a single hospital with all the specialist physicians and high-tech infrastructure forms the 'hub' and all the other hospitals with lesser complexity of care form the 'spokes'. The 'hub' hospital will be able to maximize the use of its infrastructure and specialized care facilities as patients from all the 'spoke' hospitals that require specialized care are concentrated here. Whereas, the 'spoke' hospitals will be able to maximize the facilities as they have the backup of the 'hub' hospital. In a study from Phoenix, Arizona, a patient with acute ischemic stroke treated at a 'network' hospital incurred $1,436 lower costs than another patient treated at a hospital outside the network.

In addition to the patients receiving the best possible care, the hospitals stand to gain financially as a patient treated at the 'hub' hospital goes back to the 'spoke' hospital for follow up and rehabilitation. That the hospitals are connected makes it easier for researchers to conduct studies for enhancing stroke care. It also makes the implementation of awareness campaigns easier at a larger scale.The 'hub and spoke' model also makes it easy to treat othe disease conditions coronary artery disease, etc.

In another study from the Mayo Clinic involving a network with 1,112 unique acute ischemic stroke patients per year, the study estimated that 45 patients per year would receive intravenous thrombolysis who would not have received it in the absence of a network, and 20 more patients per year would receive endovascular stroke therapies, resulting in 6.11 more discharges to home in a network than in the absence of a network. Researchers estimated cost savings in the network overall at $358,435 per year for the first year, increasing to $393,712 at the end of the fifth year. The hub facility bore the brunt of the costs, which researchers estimated at $405,121 per year, while each spoke saved $109,080 per year. The researchers suggested that with appropriate cost-sharing arrangements, over a five-year period all hospitals in the system could save an average of $44,804 per year. The researchers claimed that their model showed a target transfer rate of approximately 30 percent resulted in cost savings to the hub, the spokes, and the network overall.

Hence, it is high time that the above model of stroke care is planned and implemented in the various states in India. It is through this model that sustainable and cost-effective  stroke care can be offered to the people.


Saturday, November 22, 2014

Can India deliver comprehensive stroke care?

In my previous articles, I talked about the extent to which stroke affects the people in India and how it is important for the country as a whole to take steps towards fighting this epidemic. One of the questions that often comes up during the discussion is how to overcome the high cost of infrastructure, manpower and the lack of awareness among the people. In the coming articles, I discuss the strategies that will help in establishing cost-effective comprehensive healthcare in general and stroke in particular.


Few countries in the world have experienced the explosive growth of internet usage that India is going through. India took more than ten years to grow from 10 million to 100 million internet users, three years to grow from 100 to 200 million; however, only a year to grow from 200 to 300 million users. According to a recent report 'Internet in India 2014', that is jointly published by the Internet and Mobile Association of India (IAMAI) and IMRB International, the number of internet users in India would reach 302 million by December 2014, registering a growth of 32 per cent over last year and surpassing the United States to become the country! It is also interesting to note that whereas the internet usage in urban India has grown by 29% in one year, that in rural India has grown by 39%. The primary use of internet in urban India is for search, online communication and social networking whereas that in rural areas is primarily entertainment followed by communication and social networking.

It will be, but foolish to not reap the benefits of telecommunication in healthcare and, India stands at a distinct advantage among the developing countries in this regard. Using telecommunications to connect stroke experts to the physicians and patients in rural areas dramatically improves the quality of care. With telestroke, patients in rural hospitals can have round-the-clock access to stroke specialists in specialized stroke centers. With telestroke, stroke specialists can clinically examine the patients in a remote hospital hundreds of kilometers away, view the CT and MRI scans and assist the physicians directly taking care of the patient in decision making. If the patient requires to be transferred to the specialized center, the transfer process can be expedited, thus cutting down the time to recanalization.

In Bavaria, Germany, telestroke units were introduced in 12 regional hospitals lacking neurology and neurosurgery departments. These 12 regional hospitals were linked to two stroke centers with 24 x 7 availability of vascular neurologists and neurosurgeons. Between 2003 and 2012, the percentage of patients with stroke treated at these hospitals increased from 19% to 78%. It also helped to provide immediate neurosurgical consultation in patients with hemorrhagic stroke. With the help of good internet and telecommunications, many district level and rural hospitals can be linked to the specialist stroke centers and patients cared for immediately at presentation. This will dramatically reduce the delay between the onset of symptoms and treatment. If tPA is to be administered, the medication can be administered and then the patient transported to a higher center. Another interesting finding from the German telestroke study was that the percentage of patients that actually were transferred to the specialized stroke center decreased over the ten years. The reason was that more and more patients were being treated at the peripheral hospitals and only those that genuinely required advanced care were treated at the referral center.

Low-cost strategies such as the use of video conferencing, smart phone apps that relay information to healthcare workers and assist the emergency medical services personnel to treat patients while being transferred to the hospital are very helpful and hospital systems should incorporate them while developing protocols for stroke care. Effective and innovative use of telecommunication systems is paramount to effective management of stroke in India.

Friday, November 14, 2014

Organization of Pre-hospital stroke services in India

Stroke and Cerebrovascular disease is the third leading cause of death in India. As such, timely recognition and management of acute ischemic stroke is paramount to reducing mortality and morbidity. Organization of stroke services has been one of the key elements in the management of stroke in many developed countries and has led to a reduction in DALYs (Disability Adjusted Life Years) and YLL (Years of Life Lost due to premature death). The various key components of the ‘acute stroke chain’ include recognition of stroke symptoms, prompt communication with the stroke center which then dispatches the team for pre-hospital stroke care, availability of imaging, stroke neurologist and endovascular neurosurgeon at the hospital and the infrastructure for appropriate treatment. Malfunctioning or inefficiency of any component of the acute stroke chain may lead to adverse outcome and, ultimately, increased morbidity and mortality.

Pre-hospital management of acute stroke forms an important component of the acute stroke chain. The team should be available 24 x 7 and be able to reach out to the patient as soon as possible, document the history and diagnose stroke reliably, evaluate and manage airway, breathing, circulation and blood pressure, perform and document stroke assessment using the NIHSS (National Institute of Health Stroke Scale) and alert the hospital. Efficient Pre-hospital service significantly reduces the time to treat a patient of stroke and ultimately translates into better outcomes. Documenting the history and evaluating the patient with regards to the severity of stroke significantly reduces the time to formulate the appropriate treatment and helps the team at the stroke center to be prepared for the patient. It is very concerning that despite the availability of stroke neurologists and endovascular neurosurgeons and the infrastructure in some of the hospitals in India, many patients with stroke fail to reach the hospital in time so as to be eligible for acute stroke therapy. Any patient with acute stroke should be treated in the same manner as a patient with trauma and should receive the same level of priority. 

The concept of telestroke is another important aspect in the acute stroke chain. The capability of Pre-hospital stroke team to effectively communicate with the acute stroke center significantly reduces delays in imaging and treatment. Documenting the history, medications and NIHSS eliminates the delay in imaging and decision making. With its widespread availability, smart phone technology has a great potential for application in that the on-field team can communicate with the stroke team at the hospital and send essential data. The availability of telestroke services at the referring hospitals is also important to diagnose, evaluate and initiate the treatment of acute stroke. Despite the availability of teleradiology at many centers in India, telestroke is still in its infancy and its potential for use needs to be harnessed.

It is expected that, with increasing awareness among the patients and general practitioners and availability of stroke specialists and trained paramedical professionals, acute stroke services in India will improve in the coming years. Unless a team approach is adopted and a systematic protocol based therapy is instituted, it is not long that stroke and cerebrovascular disease will become the most common cause of death in India.

Sunday, November 9, 2014

StrokeINDIA: Stroke Scenario in India

StrokeINDIA: Stroke Scenario in India: Cerebrovascular disease and Stroke (Brain Attack) is the third leading cause of death in India, according to a joint report released i...

StrokeINDIA: Stroke Scenario in India

StrokeINDIA: Stroke Scenario in India: Cerebrovascular disease and Stroke (Brain Attack) is the third leading cause of death in India, according to a joint report released i...

StrokeINDIA: Stroke in India

StrokeINDIA: Stroke in India: A campaign aimed at raising stroke awareness in India

Stroke Scenario in India

Cerebrovascular disease and Stroke (Brain Attack) is the third leading cause of death in India, according to a joint report released in January 2013 by the Government of India and the Centres for Disease Control, Atlanta, US. More Indians die of cerebrovascular disease than due to tuberculosis, malaria, HIV/AIDS or road traffic accidents. Whereas there are national programmes for control of tuberculosis, HIV and malaria, there is no such programme for prevention and management of stroke and cerebrovascular disease in India.

The annual incidence of stroke in the country has increased from 13 per 100,000 in 1969 to 145 per 100,000 in 2006. The costs of acute care and managing these patients in long term are astounding. In another study, the overall DALYs (Disability Adjusted Life Years) lost due to stroke were 795.57 per 100,000 person years. This means that if 100,000 people were to live for one year, about 800 people will be disabled due to stroke and will not be able to go to work. Further, studies have shown that stroke and intracranial atherosclerotic disease is more common in people of Asian descent and occurs at a younger age.

Despite the explosive epidemic, there is little awareness among the people in India. Up to 80 per cent of strokes may be prevented by appropriate risk factor management. Stroke occurs when a blood clot blocks a blood vessel or artery, or when a blood vessel breaks, interrupting blood flow to an area of the brain. When a stroke occurs, it kills brain cells in the area surrounding where the clot or breakage occurs. A brain attack should warrant the same degree of emergency care as a heart attack. Immediate response is crucial because every minute matters – from the time symptoms first become noticeable to the time treatment is received, more brain cells die. In other words TIME IS BRAIN. Treatment of acute stroke should be made available in specialized stroke centres, as some options are most effective if administered within the first three hours after experiencing symptoms. Recognition of stroke and timely referral by a general practitioner to a stroke centre is crucial. Hence, it is also important to create awareness among general practitioners and physicians in other specialties.
Creating awareness about stroke and cerebrovascular disease involves assessment of the existing knowledge of people, assessment of the barriers to effective communication and the available resources, planning strategies to impart knowledge while overcoming the barriers, implementing the programme and periodic assessment of the effectiveness of the programme. In addition, collaboration between the physicians of various specialties such as neurology, neurosurgery, cardiology, diabetologists, general practitioners and physical therapists is essential for adequate control of the risk factors. Social media can also play an important role in spreading awareness among people and the physicians.

It is very important to organize specialized multidisciplinary stroke service in India. Typically, a hub and spoke model has been shown to provide the best service to a defined population and at the same time be cost-effective. Studies show that acute treatment is significantly less expensive than the costs of extensive rehabilitation and long-term care.

Unless a strong programme for control and management of cerebrovascular disease and stroke is brought in action, it is not long that it will be the cause of the highest number of deaths and disability. It is high time that the people and the physicians take necessary steps to curb the epidemic of stroke in the country.

Stroke in India

I have been wanting to start a stroke awareness campaign for the people in India for over a year now. I approached many magazines that claim they publish current medical news in India. I was turned down by most of them, although a couple of magazines published my articles. Finally, I decided to start my own blog so that I can write about the current scenario of stroke in India and what could we do collectively to counter the epidemic of stroke in India.

I am a neurosurgeon. I went to medical school at the prestigious JIPMER, Pondicherry and then for neurosurgery residency to NIMHANS, Bangalore. I then went on to do a year of cadaver and clinical research at the LSUHSC at Shreveport, Louisiana followed by a year of Endovascular neurosurgery fellowship at LSUHSC before coming to the University of Miami for the last year of endovascular fellowship. It has been a a long and arduous journey to say the least. 

During my fellowship, I had the opportunity to study the stroke management system in place in the United States and compare with that in India. I was appalled to know that strokes (ischemic and hemorrhagic) are more common in India than in the United States. Not only that there are no systems in place to treat stroke in India, the awareness among the people in India including the medical fraternity is lacking. Most people who call themselves educated, have heard about stroke only if one of their family members or friends suffered from it. The common notion of stroke in India is that it is a devastating condition that leads to paralysis of an arm or leg and that makes the person bed ridden. Many superstitions have been floated in the Indian culture that blame the person's sins either in the present life or the previous one, those committed by ancestors, involvement of supernatural beings, the specific configuration of stars and the person's fate as the cause of stroke. This list is by no means comprehensive as there is no end to imagination. I do not agree with any of these theories because their scientific basis is not proven yet.

In my coming posts, I will discuss the current scenario for stroke in India and the various components of a stroke program and how we, as the people of India can fight against one of the top three causes of death in India.

No program is successful without a team effort and I urge everyone interested in joining me in this campaign against stroke

Sudheer Ambekar