As rural hospitals close and strokes increase, focus turns to ambulances

As rural communities and aging populations confront an increase in diabetes and cardiovascular disease, a $180 billion threat looms for seniors, families, taxpayers and healthcare systems — stroke.

Despite recent declines in stroke deaths, 4 percent of Americans will still have a stroke in their lifetime, and that incidence rate is expected to increase 20 percent by 2030, according to the American Heart Association. The association also expects stroke-related costs to nearly double in the next 15 years, to more than $180 billion, across everything from hospitalizations to long-term disability care.  

“Strokes will absolutely strain the healthcare system,” said Bruce Ovbiagele, MD, chair of the Department of Neurology at the Medical University of South Carolina. “Ninety percent of stroke patients have residual disability and only 10 percent recover completely after a stroke.”

The prospect of this kind of stroke epidemic presents a major challenge to provider systems at a time when the government is trying to control costs. The pressure is especially acute in rural America, where on average 16 percent of residents are 65 or older, and where hospitals are becoming fewer and farther between.

Forty-eight rural hospitals have closed since 2010, mostly in the American South, what epidemiologists call the Stroke Belt, and more than 280 other rural hospitals are at risk of shutting down, according to the National Rural Health Association.

Today, residents are living in the wake of such a closure in Boothbay, Maine, a small coastal town on a peninsula. In October 2013, Boothbay’s 25-bed St. Andrew’s Hospital — where stroke patients could receive clot-busting medication that helps prevents long-term disability — was converted into a 10-hour-a-day urgent care center by the parent organization, MaineHealth’s Lincoln County HealthCare, in favor of sending all patients 10 to 20 miles away to Memorial Hospital in Damariscotta.

The closure of the hospital, which previously had a medical-surgical unit along with an ER, received a small backlash. Community member formed a “Save St. Andrews” campaign.

“They just want to be able to be taken to St. Andrews in five minutes if something goes wrong,” Jane Good, a beautician who serves the peninsula’s retirees, including seasonal residents, told the Portland Press Herald. “This whole community is so full of fear, fear that somebody they know is going to die because they can’t get to the hospital in time.”

Lincoln County HealthCare, a part of Maine’s largest health system, decided to close the hospital amid declining admissions and financing from Medicare and the state. ER visits fell from 4,690 in 2007 to 3,770 in 2012, and most of the visits were not acute or truly emergent cases. “For many years now, the 24/7 St. Andrews emergency department hasn’t been busy enough to sustain itself from a quality and patient care perspective and secondarily from a financial perspective,” James Donovan, LCHC’s CEO, told the Press Herald.

A major concern for the community members who tried to keep the hospital has been the 20 to 40 to 50 minutes it could take for an ambulance from the Boothbay to reach the Miles Memorial Hospital, with only one major road in an area where summer tourists and winter snow storms create traffic problems. For a stroke patient, those minutes are especially important because “time is brain.” The clot-busting tissue plasminogen activator (TPA) therapy is only effective when given within about three to 4.5 hours of symptom onset, and ideally less than that.

When St. Andrew’s closed, Donovan argued that emergency medical services and ambulances would be able to fill any gaps in patient stabilization, telling the Press Herald that “Ambulances these days are really four-wheeled intensive care units.”

That’s only partly true, said Scott Lash, a realtor and longtime EMS worker who runs the Boothbay Region Ambulance Service, which operates independent of Lincoln County HealthCare. “There are lots more medications that are available for basic life support,” such as nitroglycerin, pain treatment and heart stabilization,  Lash said in an interview. “That’s the limit.”

In this past winter, particularly harsh even for Maine, Lash said the ambulance service has not encountered any of the major problems feared by community members.

“There wasn’t a case of a patient that would have lived had we not had to go to Miles Memorial,” he said. In the summertime, when the population swells and traffic accidents are more likely, “that might be different.”

Despite the closure of St. Andrew’s, Lash has long been looking to newer models of emergency care that, if not creating an ICU on four-wheels, can help bridge gaps in both hospital-based acute care and urgent care. Boothbay’s ambulance service is starting to incorporate telemedicine that can let hospital physicians evaluate patients enroute to the ER, and offer community paramedicine services for EMS providers to check in on at-risk individuals in their homes.

“The coming trend, coming faster than I think people realize, is integrated mobile healthcare,” Lash said. “We’re hoping to be able to expand our scope of practice because we are not at that level of a mobile ICU, but that is the direction we’re going to go.”

One possibility on Lash’s mind is the so-called German model for confronting the stroke burden: a specialized ambulance, equipped with CT scanners and video connection to a neurologist, where a stroke can be diagnosed and treated on the spot with brain-saving tPA or taken more quickly to the hospital for thrombolysis.

Two such fleets of mobile stroke ambulances are being used by the Cleveland Clinic and the University of Texas Health Science Center in Houston, and the results so far are promising.

In a study of the Cleveland Clinic’s patients, those treated in the stroke units had CT scans within 41 minutes, compared to 62 minutes for those taken to an ER, and the time to TPA was 64 minutes in the mobile units and 104 minutes in ER patients.

The rate of tPA administration in those treated by the mobile stroke unit was also higher, at 26 percent, compared to a national average of 3 to 8 percent in patients who must first visit an ER.  

“The main reason for patients not getting treated is that they do not arrive in time for this treatment – 4.5 hours from symptom onset,” said Muhammad Shazam Hussain, MD, head of the Cleveland Clinic Stroke Program. “Estimates are that stroke victims lose two million neurons per minute, so this reduction" could potentially "result in much better outcomes.”

As the clinical evidence to support such ambulance approaches expands, a major challenge for providers who want to use them is financing.

Various Medicare anti-kickback rules prevent hospital systems from funding independent ambulance services. In places like Boothbay, Maine, ambulance service are financed  town tax dollars and some philanthropy, which along with state or federal grants may help pilot new projects that could be scaled.  “There are people in town that support us, and there are foundations that could lay the groundwork for” something like a specialized stroke ambulance, said Lash. “Right now it comes down to the time and muscle to make it happen.”

_{(Photo via 3l3phant, Wikimedia Commons.)}