Recently we wrote about lopsided news coverage of tissue plasminogen activator (tPA), a drug used in emergency rooms to open blocked vessels in patients suspected of having a stroke.
While experts vigorously debate whether tPA helps patients, there’s a movement underway to speed the administration of this clot-buster by deploying specially equipped ambulances called mobile stroke units (MSUs).
Mobile stroke units such as this one at Indiana University Health have been the subject of superficial news coverage.
These vehicles–which have mini-CT scanners on board to rule out brain hemorrhages that would preclude the use of tPA–have been drawing boosterish coverage from local news outlets.
Several stories we’ve seen have not reported their substantial costs or the fact that there is no evidence they benefit patients.
Some used dramatic anecdotes that conveyed the idea that MSUs actually save lives:
“Lifesaving” claims were repeated in a recent Washington Post op-ed headlined “Too many people die from strokes because treatment is delayed; There are treatments that could be saving patients from death and brain damage.’ The opinion piece, authored by Yale neurology professor Kevin Sheth, MD, advocates for the deployment of more MSUs, calling them an “affordable” way to deliver “proven life-changing therapy.” But the piece doesn’t offer up any data or disclose that Sheth receives research funding from Stryker Corporation, which develops MSUs.
While tPA has been used to treat strokes for more than two decades, there’s no evidence that the drug saves lives, as we have written.
Further, MSUs have yet to be proven effective at improving outcomes for patients. One completed study on MSUs showed they reduced the time between an emergency call and a treatment decision but found no statistically significant difference in the percentage of patients who exhibited no disability 90 days after a stroke.
Clinical Neurology News reported last year that mobile stroke units “remain investigational, with no clear proof of their incremental clinical value or cost effectiveness.”
It wrote that “findings from preliminary analyses suggest better functional outcomes for patients treated this way. However, leaders in the nascent field readily admit that the data needed to clearly prove the benefit patients receive from operating MSUs are still a few years off.”
According to clinicaltrials.gov, a trial measuring clinical outcomes, cost-effectiveness, and the effect of using telemedicine with MSUs is scheduled to be completed in 2021.
Despite the uncertainty about a benefit, MSUs have been popping up around the country. About 13 MSUs have been deployed in the U.S, according to medical news web site Healio.com,
Clinical Neurology News reported MSUs are “expensive to start up, with a price tag of roughly $1 million to get a MSU on the road for the first time, and also expensive to operate, with one estimate for the annual cost of keeping an MSU on the street at about $500,000 per year for staffing, supplies, and other expenses.”
The cost of buying the vehicles is often shouldered by a local foundation, according to various news reports.
Meanwhile, some news releases about these units have danced around the fact that their impact is unclear. For example, last year we reviewed a vague news release from the American Heart Association about an unpublished study that suggested mobile units “may reduce stroke disability” but said “future clinical trials with a greater number of patients are needed.”
News releases we reviewed from four health systems all indicated MSUs can save lives.
For example, Indiana University Health recently announced it’s “launching the state’s first mobile stroke treatment unit — that will race to the scene of a patient having a stroke, provide a CT scan and, if needed, give life saving, clot-busting medicine on the spot.”
Further along it acknowledges that in fact research is still underway:
IU Health’s unit is part of a national study of six mobile stroke units. “You’ve got to have pioneers across the country who are willing to take the risk,” says (neurologist Jason Mackey, MD). “I’m happy to say IU is one of those. The idea behind the study is to show this helps people and it makes financial sense. Everything we are seeing so far shows it’s going to be robustly cost effective.”
UCLA Health quoted its board chairman, Henry Gluck, saying an MSU “can save lives today, while improving care in the future.”
Its news release also had a supervisor of Los Angles County — which contributed $1.5 million toward operating the unit — asserting that the vehicle will benefit her constituents:
“Minutes matter when it comes to treating strokes,” said Supervisor Janice Hahn, who wrote the motion for funding. “With a mobile stroke unit operating in L.A. County, doctors will be able to diagnose and treat stroke patients faster than ever before — making it more likely that they not only survive, but go on to live longer, healthier lives.”
To their credit, some news organizations — including the New York CBS affiliate mentioned above — did mention MSUs are still under study.
Indiana Public Media reported IU Health’s vehicle “is part of a clinical study to measure improvements in stroke outcomes and evaluate the potential for future additional vehicles.”
Indianapolis’ WIBC quoted an IU official saying, somewhat confusingly, that the hospital is “using a study to prove that the stroke ambulance is necessary and economical.” But the overall message of that story — as with some others — was upbeat:
While local coverage has been awash in optimism, plenty of questions about MSUs have been raised in professional publications.
Concerns about patient and community benefits appeared in the Journal of Emergency Medical Services, where Bryan Bledsoe, D.O., a professor of emergency medicine at the University of Las Vegas, argued MSUs are a product of hospital competition rather than community need.
“Nothing says ‘high-tech’ like a mobile stroke ambulance or a medical helicopter. They know that once patients have gotten into their hospital system they will stay in the system,” Bledsoe said.
He and others noted many patients with stroke-like symptoms have other conditions — such as temporary blockages called transient ischemic attacks — that resolve without treatment.
Citing studies in cities where many more runs were canceled en route rather than resulting in treatment of patients, two academic physicians writing in the journal Neurology concluded it could be a “tall order” for MSUs to achieve a return on investment for individual health systems and communities.
The risk that some patients who aren’t actually having a stroke might be needlessly treated with tPA — which sometimes leads to dangerous bleeding in the brain — was among many concerns raised by Andrew W. Asimos, MD, medical director of the stroke network at Carolinas HealthCare System in Charlotte, North Carolina, and professor in the department of emergency medicine at Carolinas Medical Center in Charlotte, Healio.com reported.
“EMS is underfunded, but we have money to pay for these expensive things that we really don’t have compelling data to show that they resulted in improved outcomes,” said Asimos, whose own health system has opted against deploying one.
But for a funnier take on the risks that local communities incur when they heedlessly invest in medical technology, check out this video. We’ve plugged it before, but it’s worth repeated viewing.