The United States stroke system: credentialing and legislative efforts to improve acute stroke care.

In the United States, approximately 700 000 acute stroke emergencies occur each year, and of these about 150 000 result in death, making stroke the third most common cause of death (1). Stroke consistently ranks in the top 10 of hospital admitting diagnoses (2, 3), necessitating awareness, education, and organization of interdisciplinary hospital personnel to ensure timely diagnosis and treatment. With the 1996 approval of intravenous tissue plasminogen activator (tPA) by the US Food and Drug Administration (4), outcomes for acute stroke emergencies were expected to improve, but tPA use in the US has remained low for the past 10 years at treatment rates between 2% and 4% (3,5–7). Factors challenging use of tPA at US hospitals include (1) late patient arrival from symptom onset to hospital, (2) inefficient hospital systems that are incapable of rapidly diagnosing and treating acute stroke patients within 60 min of hospitalization, and (3) lack of interest in acute stroke care among US physicians because of extremely low reimbursement (8). The Brain Attack Coalition (BAC) Guidelines for Primary Stroke Centers (PSCs) (9) provided an organizing framework for stroke centers, complete with timelines and specific processes for provision of acute stroke services. Currently considered the minimum performance standard for hospitals providing acute stroke care, the BAC Guidelines have been adopted by accrediting agencies, insurance companies, and even lawmakers in an attempt to standardize physician practices and hospital services. The BAC’s 2005 release of Guidelines for Comprehensive Stroke Centers (10) will likely provide a similar roadmap in the coming years, although current methods to credential this level of stroke center performance do not exist. In 2003, the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) officially adopted the BAC Guidelines as a framework for their PSC Certification program. The American Stroke Association (ASA) has partnered with the JCAHO in this endeavor, ensuring involvement of expert clinicians in the development of both program standards and performance indicators. At the time of this writing, a total of 202 US stroke centers have been certified by the JCAHO as PSCs (11); the cost of JCAHO certification currently runs just over US$10 000 for the site visit/program assessment (12). Certified hospitals submit self-reported performance data to the JCAHO at specified intervals, using either commercially available process databases or their own custom databases capable of measuring processes, outcomes or research endpoints of interest. It remains unclear how these certified centers’ performance compares with non-JCAHO PSCs. Because the JCAHO serves a quality overseer for a variety of US health care services, certification as a PSC by the JCAHO often translates into improved reimbursement or preferential selection of a hospital by an insurance agency for provision of stroke and other health care services (13). Additionally, hospitals achieving JCAHO certification are encouraged to market their services to the public in an effort to improve awareness of stroke warning signs and the need for early treatment, as well as to encourage a shift in the health care market to those centers that are able to provide standardized stroke care services. Because the US is a federal system, individual states are able to enact legislation, which may vary depending on the needs of citizens and available resources. Currently, several states have adopted laws or are in the process of developing legislation to support improved access and delivery of stroke care services. While these laws differ in their scope and degree of control, content generally includes specific responsibilities for prehospital emergency medical services, hospital services, and community education on primary/secondary prevention and acute treatment. For example, prehospital ambulance personnel requirements often include precise requirements for a number of hours on stroke education, standardization of the practices used to assess, stabilize, and transport stroke patients, as well as requirements for ambulance diversion to hospitals possessing stroke centers that meet specific performance standards. Within hospitals, legislation in some states specifically calls for the development of formal bodies charged with assessing hospital performance and conferring status as a stroke center, while other states will accept attainment of JCAHO PSC Certification for designation as a state stroke center. More recently, a nonlegislative approach to conferring stroke center status has also emerged in a few states, based in prehospital emergency medical services I J S 3 3 B D is p a tc h : 1 0 .3 .0 6 Jo u rn al : IJ S C E : S h al in i