Drug prices especially hit hard in rural America

Which is more valuable - the life of someone who lives in Mountain View, Ark., (population 2,860) or someone who lives just one county over?

That's the question from a good NPR piece about how high drug prices hit rural hospitals extra hard, a story beginning with the story of a stroke patient coming in to a small, rural hospital needing an expensive drug:

For example, Langston's 25-bed hospital pays $8,010 for a single dose of Activase — up nearly 200 percent from $2,708 a decade ago. Yet, just 36 miles down the road, a bigger regional hospital gets an 80 percent discount on the same drug. White River Medical Center, a 235-bed facility in Batesville, Ark., buys Activase for about $1,600 per dose.

White River participates in a federal drug discount program Congress approved in the early 1990s. The program offers significant price breaks on thousands of drugs to hospitals that primarily serve low-income patients. One federal report found the average discount ranged from 20 to 50 percent, though as illustrated with Activase, it can be much higher.

Too often, too many people don't get the right treatment

The clot-busting drug tPA has been available now for more than 20 years. But still, too many stroke victims don't get the drug:

Every year, patients were 11 percent more likely to be treated by tPA, even though across the entire period of time only 3.8 percent of total patients got the clot-busting drug, researchers reported.

The team found certain types of patients were less likely to receive tPA:

Adding choices for possible stroke treatments

Last post, I included a link to my own story about the clot-busting drug tissue plasminogen activator, better known as tPA.

Keep in mind, though, that my story is 18 years old. And still, tPA is the only approved drug to treat clot-caused strokes. I ran across an interesting story about the reason why the drug doesn't work every time, and what seems to be coming next:

Twenty years ago stroke doctors celebrated the arrival of a powerful new weapon: the clot-clearing drug tPA. It was hailed as a lifesaver and has proved to be one for hundreds of thousands of patients since. TPA was the first and is still the only medicine approved by the U.S. Food and Drug Administration for treating strokes caused by clots that block blood flow to the brain. But like so many medical marvels, tPA (which stands for tissue plasminogen activator) has turned out to have serious limitations.

What are your odds of the right stroke treatment?

You can read my story here and an update here. But in a nutshell, I wound up in the right place and the right time when my stroke occurred back in 1998, two years after tissue plasminogen activator was approved for stroke patients - a Southern community hospital, of all places.

More than 18 years later, we still have problems getting this medication to stroke patients. Kaiser Health News noted geographic and racial disparities in stroke treatment tracked in a new study:

The findings come from a report published Wednesday in the journal Neurology. Researchers found stroke patients living in the Northeast states had more than twice the odds of receiving tPA — a powerful anti-coagulant that can break up the clot causing the stroke — than those living in the Midwest and the South.

Another tool for important tasks

I have a hammer. I also have an air compressor and a few nail guns.

So, which tool should I use to hang a picture on a wall?

On the other hand, I once had the need to place a piece of cedar siding around 24 feet above the ground. One hand held the siding, but using a hammer is a two-handed operation. Now which tool should I use?

So I see the importance of health professionals with more tools to do the important work of treating stroke patients. Check out the story on the FDA approving a clot-picker use with tPA:

Two Trevo clot retrieval devices were approved Friday by the FDA for use in conjunction with tPA thrombolysis in acute ischemic stroke patients.

Sad but true facts about stroke patients, treatment and response

I was one of the fortunate - most people don't get to a hospital in time to be even considered for the primary treatment for stroke patients.

The treatment, tissue plasminogen activator (tPA) doesn't work all the time, and more treatments are being researched. Still, the drug has reduced the number of people who leave hospitals with little or no disability.

So, why so few people being treated? It's because, it seems, people don't get in a hurry to get to help with a stroke. And that's just not right. Know the symptoms. And get help F.A.S.T. Check out the story on how a medical team studies when an effective but sometimes risky stroke drug should be used:

Will a stroke patient need a mortgage next?

Photo from 401kcalculator.org via Flickr

We've seen lots of stories lately about drug prices. And there are lots of high-price drugs that aren't in the news a lot. Just Google "Jublia price" and you'll get stories like this one.

Now, another drug is making news - and this one is close to home for past and future stroke survivors. It seems that the long-approved clot-buster is a price-buster too:

For those keeping score, here is yet another example of drug price escalation: the cost of alteplase, aka tPA, the clot-busting agent used to treat stroke, increased by 111% from 2005 to 2014 -- but Medicare payment for the drug has increased by 8% during the same period.

A standard alteplase vial contains 100 mg, and in 2014 the cost for that vial was $6,400, said Dawn Kleindorfer, MD, of the University of Cincinnati. Kleindorfer reported the results of her cost-analysis here at the International Stroke Conference. ...

Dead to hope? Jesus offers you his own 'Lazarus effect'

[This was originally posted Dec. 24, 2009; revised in 2014]

Jesus, once more deeply moved, came to the tomb. It was a cave with a stone laid across the entrance. "Take away the stone," he said.

"But, Lord," said Martha, the sister of the dead man, "by this time there is a bad odor, for he has been there four days."

Then Jesus said, "Did I not tell you that if you believed, you would see the glory of God?"

So they took away the stone. Then Jesus looked up and said, "Father, I thank you that you have heard me. I knew that you always hear me, but I said this for the benefit of the people standing here, that they may believe that you sent me."

When he had said this, Jesus called in a loud voice, "Lazarus, come out!" The dead man came out, his hands and feet wrapped with strips of linen, and a cloth around his face.

Jesus said to them, "Take off the grave clothes and let him go."

-John 11:38-44

A few years ago (2008), I heard a presentation by one of the doctors responsible for making tPA (tissue plasminogen activator) available to stroke patients.

In my own 1998 experience, I could not speak, I could not move my right arm or leg - but after the clot-busting tPA, I regained those abilities. It was a dramatic experience. The doctor called it "the Lazarus effect."

One more way to potentially speed treatment

Speed, as you know, is key in treating stroke patients.

Recent news about telemedicine shortening door-to-needle time:

A mobile stroke treatment unit (MSTU) operated by Cleveland Clinic which uses telemedicine to connect emergency team members to a hospital-based vascular neurologist, reduced time to tPA treatment by more than 25 minutes in an analysis of the first 100 patients transported. ...

Hospitals hiring weight-guessers? Or is there a better solution?

Image from Wellness Corporate Solutions via Flickr

Ever seen someone offering to guess your weight at a carnival? It's been a while for me.

Maybe we need to hire some of those folks for hospital work - when knowing someone's weight means administering the correct amount of a drug that could bring you back from a stroke, or put you in danger - at least partly depending on how the accuracy of your weight in its calculation.

Recently, some research shows that weight guesses for stroke treatment are often wrong:

"Relying on our ability to 'guess' the weight of a patient in the acute setting is no longer acceptable and potentially dangerous," Pankaj Sharma, MD, PhD, from the Institute for Cardiovascular Research at the University of London, told Reuters Health.

The recommended dose of alteplase (recombinant tissue-type plasminogen activator [r-tPA]) is 0.9 mg/kg, up to a maximum dose of 90 mg. In the interest of time, clinicians often estimate patients' weights to determine the r-tPA dose. ...

We're supposed to go F.A.S.T. - but are those preaching it do the same?

Second round in this week's theme: Taking stroke patients seriously.

We're all told to get possible stroke patients to medical help fast - there's even a program with the acronym F.A.S.T. We're all told brain = time.

But, according to a recent study, it seems that many hospitals overestimate their adherence to stroke guidelines:

Researchers surveyed staff in 141 hospitals across the United States who treated more than 48,000 stroke patients in 2009 and 2010, and compared their responses with patient data. The results revealed significant differences between staff perception and reality.

Was your stroke an emergency? Not all that long ago...

Photo by Chris Violette via Flickr

We've gone a long way.

Twenty years ago, a stroke wasn't considered an emergency. No treatment to reverse or limit a stroke's brain damage.

In 1996, the clot-busting drug tissue plasminogen activator was approved to treat strokes. That also caused a great deal of rethinking how health care providers responded to strokes. What was not an emergency suddenly became one. That meant a lot of rethinking of roles and actions of health professionals when a stroke happens.

An interesting take on that history and more ideas evolving, focusing on when stroke care is a statewide effort:

Where are you? And why should that matter for stroke treatment?

Place can have a lot to do with your health. That's been demonstrated, and experts have talked about diet, access to providers, lifestyles and more.

But a recent study has its own author puzzled about baffling disparities in stroke treatment across the United States:

In the bottom one-fifth of the hospital markets patients received no tPA. In the top one-fifth of markets 9% of patients received clot-busting drugs. In Asheville, NC and Stanford, CA as many as 14% of patients received IV tPA or an intra-arterial treatment using tPA or another drugs.

There were only minor improvements in treatment levels for patients in regions with certified primary stroke centers, or where emergency medical services drove patients further to get stroke treatment. Older patients, minorities, and women were less likely to get tPA regardless of where they lived, the study showed.

What's the next phase of stroke treatment?

Designed by Freepik

I was fortunate enough to be in the right place, right time in 1998 - just two years after approval of clot-buster tissue plasminogen activator, also known as tPA or alteplase.

However, it's true that little has changed since then. Researchers have looked at different windows of time for the drug, which can quickly dissolve a clot to prevent further stroke damage, but new, safer and more effective drugs have not come to pass.

I have little right to complain about tPA, but I'm just one guy who benefited. It has its dangers, too. And while there are some good signs related to using devices to remove clots, much more research and work are needed to improve treatment and stroke outcomes.

You can read a recent article summarizing the need for the next phase in stroke treatment:

From biblical times to modern hospitals, timing can make all the difference

From Flickr by Sean MacEntee

Starting out in left field here. One of my favorite books in the Bible is Acts. Why? Because a lot of important events are happening quickly, and timing is critical. The order of events is part of a grand plan there.

I like timing things in life, too. I'm not as good as God with timing, but when my sequence of actions works, it gives me a great deal of satisfaction.

So, I'm interested in this recent story about how workflow processes can be a success, showing how clot busters can be delivered in an hour, even with an MRI:

Two centers -- one academic, one community -- that use MRI as part of an NIH study dropped their median DTN [Jeff's note: DTN stands for door-to-needle, or the time between the patient enters the hospital to the time of stroke treatment] time from 93 to 55 minutes after focusing their workflow processes, Amie Hsia, MD, of MedStar Washington Hospital Stroke Center, and colleagues reported online in Neurology.

Best stroke outcome still comes down to speed, it seems

When the drug tissue plasminogen activator (tPA) came along, we've heard time and again that speed is vital for improved outcomes for stroke patients.

Now, with other tools becoming available, it seems that the rule of speed still applies. The most recent example comes from an article about three keys to blazing fast thrombectomy:

Reduced disability with mechanical clot removal for large-vessel ischemic strokes -- as consistently seen across recent trials -- gave a clear mandate for use but also re-emphasized the need for speed.

"It's all about timing," said Patrick Lyden, MD, director of the stroke program at Cedars-Sinai in Los Angeles.

Read the whole story about the three keys. And remember - if you or someone you care about exhibit stroke signs, get to care. Fast.

Researchers are still puzzling through clot-buster's best timing and use

So, should we use tissue plasminogen activator more, or less?

Depends on where you read it.

The general rule is that the clot-busting drug (click here to read more about tPA) should be given within 3 and 4.5 hours, depending on who you ask.

One recent article leans toward the three hours:

"From analyzing all the available data, tPA [tissue plasminogen activator] after 3 hours for stroke patients may not be of any benefit but has a definite risk of fatal bleeding," Dr Alper told Medscape Medical News.

He pointed out that most guidelines on tPA in stroke recommend its use up to 4.5 hours after symptom onset, including those by the American Heart Association/American Stroke Association (AHA/ASA), which give tPA a Class 1 recommendation in this time window, but he says the data do not justify such recommendations.

"Other societies give weaker recommendations but the latest guidelines of the Canadian Association of Emergency Physicians give a weak recommendation against use of tPA after 3 hours. They are recognizing the uncertainty of the benefit and the greater consistency in harm," he added.

"Unless and until there are data showing unequivocal benefits to outweigh known harms, we believe that there should not be any strong recommendation or encouragement for the use of alteplase beyond 3 hours after stroke," Dr Alper and colleagues conclude in the BMJ paper.

But, on a different tack from a different story and a different study, you can find the suggestion for widening the use of tPA - not by time, but by type of patient. The article suggests that tPA could be used more widely for stroke patients:

'Lazarus effect' - then and now

[This was originally posted Dec. 24, 2009; revised in 2014]

Jesus, once more deeply moved, came to the tomb. It was a cave with a stone laid across the entrance. "Take away the stone," he said.

"But, Lord," said Martha, the sister of the dead man, "by this time there is a bad odor, for he has been there four days."

Then Jesus said, "Did I not tell you that if you believed, you would see the glory of God?"

So they took away the stone. Then Jesus looked up and said, "Father, I thank you that you have heard me. I knew that you always hear me, but I said this for the benefit of the people standing here, that they may believe that you sent me."

When he had said this, Jesus called in a loud voice, "Lazarus, come out!" The dead man came out, his hands and feet wrapped with strips of linen, and a cloth around his face.

Jesus said to them, "Take off the grave clothes and let him go."

-John 11:38-44

A few years ago (2008), I heard a presentation by one of the doctors responsible for making tPA (tissue plasminogen activator) available to stroke patients.

In my own 1998 experience, I could not speak, I could not move my right arm or leg - but after the clot-busting tPA, I regained those abilities. It was a dramatic experience. The doctor called it "the Lazarus effect."

Another study shows possible stroke treatment outcomes

As the year gets close to an end, we've lately seen two pieces of news that might - might - lead to better outcomes for stroke patients in hospitals.

A few days ago, there was research showing that a clot removal technique might be the next step in certain stroke treatment. Click here to read about it.

One of the concerns about tissue plasminogen activator clotbuster - tPA - is a risk of bleeding. Now, though, research indicates the possibility that another drug might counters tPA risks:

Positive news for new stroke treatment - clot removal

There's promising news that there's more than one way to battle a clot-related stroke. Maybe, in some circumstances, better than current medical treatment.

Read here about a study showing how clot removal proves mettle in large-vessel strokes: