• stroke

In 1895 a promising young surgeon graduated from Harvard Medical School. An iconoclast with strong opinions, he would end up “one of the most important surgeons of the twentieth century.1” His name was Ernest A Codman. Dr Codman had a career to which almost any physician, at the dawn of the 20th century or otherwise, would aspire. He trained at a famous medical school; became a faculty member at a premier medical institution (Massachusetts General Hospital); and participated in founding the American College of Surgeons (ACS). However, academic pedigree did not matter to him. In fact, he eventually left Massachusetts General Hospital in disgust at its leadership’s lack of commitment to honestly and transparently evaluating patient outcomes.2

Dr Codman spent his life advocating something called the ‘End Results System’ (ERS). At its core, the ERS proposed an honest reckoning of every patient’s outcome, with frank recording of complications, commitment to long-term follow-up, and, perhaps most importantly, clear and transparent communication of those data to the public. How else was the public to choose where to get its care, unless each and every hospital published a clear account of complications and long-term outcomes? After leaving the Massachusetts General Hospital, Dr Codman founded the End Results Hospital and published the hospital’s data annually, using his own money. He felt that hospitals’ obligations were “for the interest of no one—except for the patients and for the community.2”

Dr Codman was not afraid of controversy. He is reported as having said that most clinical research reported only very good results and were therefore mere advertisements.² His influence, while controversial, and costly to his personal reputation and finances, was immense.1 His efforts led to the ACS declaring the ERS as one of its objectives.3 Not long thereafter, in 1924, the ACS, an independent academically oriented college, began publishing ‘The Minimum Standard’, a guidance document for hospitals.4 The establishment of minimum standards eventually led the ACS, in partnership with the American College of Physicians, the American Hospital Association, the American Medical Association, and Canadian Medical Association, to form the Joint Commission on Accreditation of Hospitals as an independent, not-for-profit organization whose primary purpose is to provide voluntary accreditation.3 These organizations had no legal mandate, but rather an ethical obligation to ensure meaningful standards and improve patient care5; they eventually became the organization recognized today as The Joint Commission.

The fight to ensure meaningful quality standards, and thereby improve patient outcomes, continues to this day. For the readership of JNIS this is most evident in the ongoing efforts to create a tiered certification system for stroke centers: primary stroke centers (PSCs), thrombectomy capable stroke centers (TSCs), and comprehensive stroke centers (CSCs). The concept behind setting standards, in general, are well-validated and, as we see from Dr Codman’s story, a long time in the making. No one set of standards will ever make everyone happy, and there are many ways in which a particular set of standards may fall short of certain strongly held ideals. I myself have penned arguments that more substantive public reporting of stroke data should be considered,6 and that physician expertise is critically important.7 Standards are a messy business. They require smart, passionate, and dedicated individuals to find a way to compromise, despite some strongly varied beliefs about what is best for patients—a classic ‘how the sausage gets made’ experience. However, there is a new threat to Ernest Codman’s vision; a rotten apple that is, unknowingly, and probably unintentionally, spoiling the sausage.

Over the past decades there has been a proliferation of certifying or accrediting organizations. In the state of New York there are four different Department of Health (DoH) approved certifying organizations (COs). All of them provide certifications for PSCs, TSCs, and CSCs. At first glance, this seems innocuous and possibly even beneficial. With multiple vendors, competition should drive down cost, improve the quality of service, and generally advance the quality of patient care. However, on a closer look, it becomes evident that the standards these vendors require from hospitals widely vary. Two different hospitals identified as CSCs may meet substantially different metrics to obtain their respective certifications. Physicians, patients, and the general public have no knowledge of these differences and no ability to discern one from the other. Ernest Codman would not be happy.

Although most COs are non-profit organizations, they still must maintain a certain critical mass of hospitals to be economically viable. This may create an invisible (and sometimes not so invisible) pressure on them to lower their standards to maintain, or gain, competitive advantage. For-profit COs, which also exist, would have an even stronger pressure to increase their number of customers and therefore potentially lower their standards to increase the number of hospitals they certify.

Now this conclusion is not provable in a broad sense and therefore represents opinion, but I am personally aware of certain centers across the country that have chosen to switch COs specifically because they could get the same certification with less stringent, and therefore less costly, standards. Having multiple COs need not be all bad. They should compete on the cost and quality of the services they provide. However, they should not compete, even if unrecognized, on the stringency of their certification standards.

There are ways to correct this threat to the quality of care for patients with a stroke. New York has enacted a very elegant, and efficient, solution to this dilemma. The New York State DoH convened relevant stakeholders (physicians, hospital representation, patient advocacy groups, DoH representatives, etc) and determined state-based DoH standards for what should be required of a PSC, TSC, and CSC. Hospitals then engage any of the four approved COs to perform the site visit and review the process, but if the hospital desires DoH stroke center acknowledgment and a listing on the DoH website (which many emergency department networks rely on for triage guidance), then that CO must certify to the state standards for PSC, TSC, and CSC, not to the COs’ standards (which might be lower). This allows the COs to compete in availability, quality of review, and cost; but it ensures a uniform set of standards for the public. This solution costs the state relatively little, as hospitals pay the COs, and the COs are responsible for most of the labor involved. The state no longer plays the resource-intensive role of certifier, but rather can focus on setting the best standards. It needs only manage the records, as provided by the COs, and coordinate the stakeholder meetings to generate and update the standards (though this can be a challenging endeavor in itself). Such a system allows for state-specific standards that deal with each state’s unique needs and also, eventually, allows scientific conclusions to be drawn regarding the pros and cons of each state’s experience.

Whatever solutions are enacted, it is paramount, as Dr Codman acknowledged many years ago, that the process includes transparency. The public, patients with a stroke, and emergency service providers all deserve to know what it means to call a center comprehensive, thrombectomy capable, or primary. Fundamentally the ERS was about transparency. Current stroke center certification falls well short of providing adequate clarity to the public it serves. To broadly enact these changes will not be easy, but I am confident Dr Codman would feel the effort is worthwhile … and so do I.