BACKGROUND/RATIONALE:
There are approximately 6,000 Veterans Health Administration (VHA) annual admissions for ischemic stroke nationally. This number of admissions likely underestimates the true stroke burden since the VHA healthcare system enrolls "beneficiaries" even where it has no infrastructure, and acute patients are diverted from some VA medical centers (VAMCs) to other facilities during off-hours. Although tissue plasminogen activator (tPA) remains the only approved disease-modifying therapy for stroke, only 8% of potentially eligible patients currently receive tPA within the VHA system. Quality of care is enhanced when acute-stroke patients are admitted in a timely manner to stroke centers. This study examines the challenges facing acute-stroke care for Veterans requiring specialized and time-critical hospital services. The ultimate goal of the project is to make strategic recommendations to the Veterans Affairs Central Office (VACO) and the 21 VISNs regarding the locations of VHA facilities capable of delivering acute-stroke care, and the use of potential alternate strategies such as tele-stroke care or outsourcing to community stroke centers where VHA acute-stroke care resources are lacking.

OBJECTIVE(S):
This project carried out three specific aims: (1) to define the status for acute-stroke care for all VAMCs based upon the most recent data provided by the VACO Neurology Office, and to determine VHA enrollees' access to specialized acute-stroke care inside and outside the VHA system; (2) to identify VHA enrollees diagnosed with acute stroke, and to ascertain these patients' ground travel access to the closest VHA and non-VHA acute-stroke care facilities; and (3) to estimate the costs of augmenting stroke services at VHA facilities versus outsourcing acute-stroke care to the private sector where both options exist with a 60 minute or less access time, and to estimate the costs of providing access to acute-stroke care in regions lacking VHA resources.

METHODS:
In this retrospective, observational national study, we obtained the VHA and non-VHA acute-stroke care facilities' data from the VACO Neurology Office. The VHA acute-stroke care facilities are classified into three categories: Primary Stroke Center (PSC: full-time stroke care), Limited Hours Stroke Facilities (LHSC: different operation hours), and Supporting Stroke Facility (SSF: limited resources for acute-stroke care). We identified the VHA enrollees hospitalized for an acute stroke during FY2006 through FY2010 in the VHA Medical SAS Patient Treatment File by using the ICD-9 stroke codes of 431 - 437. The patients' residence ZIP codes were extracted from the Medical SAS File and aggregated by VISN. VHA enrollees aged 65 and older in fiscal year (FY) 2010 were identified from VHA online ProClarity data cubes managed by VA Service Support Center (VSSC). Travel times based on eligible enrollees' residence ZIP codes were aggregated by Veterans Integrated Service Network (VISN) and national levels. The acute-stroke care average cost per patient was estimated based upon a three-year (FY2008-2010) average per patient total (direct and indirect) acute-stroke cost obtained from VA ProClarity data cubes.

The Geographic Information System (GIS) analyses included calculating the 15-, 30-, 45-, 60-, and >60-minute ground transportation bands from the enrollees' and stroke patients' residence ZIP codes to the varying closest VHA and non-VHA acute-stroke care facilities at national and VISN levels. All GIS analyses were conducted using the ARC-GIS software version 10 from Esri (Redlands, CA).

FINDINGS/RESULTS:
There are 125 VAMCs providing acute-stroke care (including 33 PSCs; 32 LHSFs, and 60 SSFs) and 1,074 non-VA private stroke care hospitals across the nation. We identified 59,127 unique acute stroke patients between FY2006-2010 and 4,694,511 VHA enrollees in FY2010 who were 65 years old. The three-year per patient total cost for VHA acute-stroke care averaged $15,646.

Our GIS analyses showed that (1) 18,194 (30.8%) acute stroke patients and 802,719 (17.1%) VHA enrollees (over the age of 65) lived within 60-minute driving time from the PSCs; (2) 9,900 (16.7%) acute stroke patients and 474,380 (10.1%) VHA enrollees lived within 60-minute driving time from the LHSCs; and (3) 31,033 (52.5%) acute stroke patients and 3,417,412 (72.8%) VHA enrollees lived beyond the 60-minute driving bands from any type of the VHA PSCs and/or LHSCs.

Furthermore, with the addition of the non-VHA private stroke centers, the overall 60-minute driving time coverage would increase from 47.5% to 61.2% for acute stroke patients and from 27.2% to 41.7% for VHA enrollees over the age of 65.

With the average per patient acute-stroke care total cost of $15,646, we estimated that total annual cost for acute-stroke care within VHA would be $185,020,208, with 30.8% of the cost for PSCs, 16.7% for LHSCs, 13.7% for outsourcing to the private stroke centers, and 38.7% for other facilities beyond the 60-minute driving time from the VHA and non-VHA stroke centers.

IMPACT:
Treatment of acute-stroke patients in stroke centers increases the odds that patients receive tPA, and decreases stroke complications and morbidity. By determining the Veteran population with access to VHA stroke-center level care, identifying gaps, and providing data on how to implement and optimize stroke-center care system-wide in a cost-effective manner, this project's findings will help to improve VHA inpatient stroke care nationally.

The ultimate goal of this project was to make strategic recommendations to the VACO and the 21 VISNs regarding the locations of VHA facilities capable of delivering acute-stroke care, and the use of potential alternate strategies such as tele-stroke care or outsourcing to community stroke centers where VAMCs resources are lacking. Dr. Graham (the initial PI of the project) is the Deputy National Director of Neurology and subcommittee Chair of the VA Stroke Care Task Force (SCTF). He will share and discuss the project's findings (i.e., the national maps and regional maps by VISN, as well as supporting quantitative data) with VACO and VISN leadership to support decision-making during the implementation of the SCTF recommendations on facility requirements.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Phipps MS, Jia H, Chumbler NR, Li X, Castro JG, Myers J, Williams LS, Bravata DM. Rural-urban differences in inpatient quality of care in US Veterans with ischemic stroke. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2013 Jun 6; 30(1):1-6. [view]
2. Cowper Ripley DC, Litt ER, Jia H, Vogel WB, Wang X, Wilson LK. Using GIS to plan specialty health services for Veterans: The example of acute stroke care. Journal of GIS. 2014 Jun 1; 6(3):177-184. [view]

Journal Other

1. Phipps M, Jia H, Litt E, Cowper D, Wang X, Vogel WB, Graham GD. GIS Analysis of Veterans' Access to Acute Stroke Care. [Abstract]. Neurology. 2012 Apr 24; 78(1):P02.187. [view]

Conference Presentations

1. Phipps MS, Jia H, Litt ER, Cowper Ripley DC, Wang X, Vogel WB, Graham GD. GIS Analysis of Access to VA Acute Stroke Care. Poster session presented at: American Academy of Neurology Annual Meeting; 2012 Apr 22; New Orleans, LA. [view]
2. Litt ER, Cowper Ripley DC, Vogel WB, Phipps MS, Wang X, Harnar JA, Graham GD, Jia H. GIS Analysis of Veterans' Access to Acute Stroke Care. Poster session presented at: AcademyHealth Annual Research Meeting; 2013 Jun 24; Baltimore, MD. [view]
3. Litt ER, Jia H, Cowper Ripley DC, Phipps MS, Wang X, Harnar J, Vogel WB, Graham G. Time is a Factor: GIS and Stroke Care in the Veteran Health Administration. Paper presented at: Esri Health GIS Annual Conference; 2012 Aug 20; Scottsdale, AZ. [view]

DRA: Other Conditions
DRE: none
Keywords: none
MeSH Terms: none