PhotoIt's a fact of life that where you live often determines the level of health care you receive. If you happen to live in an area of top-notch research hospitals, your care is likely to be better than if you live in a rural area with few hospitals.

But where you are if you were to suffer a stroke may also determine whether or not you get what many physicians believe to be the most effective treatment.

Researchers at the University of Michigan Medical School report only 4.2% of more than 844,000 stroke victims receive a drug type called tPA, which has been shown to be an effective “clotbuster.” If given in the first hours after a stroke, tPA and other treatments can restore blood flow in the brain and prevent the damage that causes stroke-related disability and drives up the long-term cost of caring for stroke survivors.

The Michigan researchers broke down tPA use geographically, and their map graphic shows it isn't concentrated in just one or two areas. In fact, deep divides exist all across the country.

One-fifth of markets don't use it at all

When the researchers looked at how tPA was used for Medicare participants who had strokes in each of the nation's 3,436 different hospital markets between 2007 and 2010, they found tPA was completely missing in a fifth of these regions.

On the other hand, markets such as Stanford, Calif., and Asheville, N.C. use the drug a lot, with as many as 14% of stroke patients getting it.

"These results scream that a major opportunity exists to improve emergency stroke care, if only we can understand how these differences arise and how to eliminate them," said James Burke, the study's senior author. "If we had a perfect system in place nationwide, which delivered treatment at the highest rates seen in this study, thousands of patients could be spared disability."


There were more surprises, especially when regions were grouped from best-performing to worst-performing. In the top fifth, an average of 9% of patients got the clot-busting treatment, while in the bottom fifth, no patients received it.

The researchers say older patients, women, and members of racial and ethnic minority groups were less likely to receive tPA, regardless of where they lived.

"We can clearly do much better, but existing policy solutions are only going to get us so far," said Burke. "In our findings, we do see positive results from primary stroke center designation and ambulance bypass, but we are talking about a complex mix of hospital, EMS, and individual response to stroke. We need to understand better what the areas with the highest rates of use are doing differently."

Gold standard

Tissue plasminogen activator (tPA) is the only FDA approved treatment for ischemic strokes and the American Stroke Association calls it “the gold standard” for treatment. It works by dissolving the clot and improving blood flow to the part of the brain being deprived of blood flow.

Sometimes availability is not the reason a stroke patient doesn't receive the drug. If it can't be administered within 3 or 4 hours of a stroke, it isn't used.

The National Institutes of Health (NIH) lists some health conditions that also preclude its use. The drug is not given to someone who is having a hemorrhagic stroke, meaning there has been bleeding in the brain. The drug could make things worse by causing increased bleeding.

When it comes to tPA use, the overall quality of healthcare in the area does not seem to be a determining factor. According to the researchers' map graphic, the top 20 areas for tPA use are scattered across the country, in urban and rural areas, and in rich and poor ones.

However, the researchers say variation in tPA use did track to lower average levels of education and income, and higher unemployment in hospital service areas. Use of the drug type was slightly higher across all densely populated areas compared with more sparsely populated areas.

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