Hub-and-Spoke Stroke System: Enhancing Acute Ischemic Stroke Care in the Philippines

The incidence of stroke in the Philippines is on the rise and is anticipated to further increase in the coming decade. Contributing factors include limited awareness of the disease, concerns about expensive hospitalization, and delays in seeking medical consultation. As a significant vascular event, stroke ranks as the second leading cause of death in the country wherein ischemic stroke accounts for 70% of cases, while hemorrhagic stroke comprises the remaining 30% [1].

As a developing nation, the distribution of stroke specialists and access to relevant diagnostic services for stroke diagnosis are unequally distributed. In the year 2021, stroke care is overseen by around 500 board-certified adult neurologists [2], equating to one neurologist for approximately every 227,000 people. This ratio is considerably lower than the World Health Organization’s recommended ratio of 106 neurologists per 100,000 population. Moreover, there is an imbalanced concentration of neurologists, with as much as 52% practicing in the center of Metro Manila, the capital of the Philippines. Consequently, effective interagency referral becomes crucial in the stroke chain of survival. Several strategies have successfully achieved round-the-clock coverage for acute stroke, encompassing regional and telemedicine services. The management of stroke disposition continues to be a prevalent challenge, particularly in primary health care settings, and these are attributed to insufficient imaging resources, the capacity to administer recombinant tissue plasminogen activator (r-tPA), and limited access to neurosurgical care [3].

In 2005, Fisher introduced stroke telemedicine, incorporating the Hub-and-Spoke model concept [4, 5]. A network is established with the tertiary center acting as the hub positioned at the center, connecting with primary centers as spokes [6]. The collaboration between the hub and spoke hospitals forms the basis for enhancing stroke care. This system aims to optimize stroke care by bridging the gap between the centers, ensuring that the best available stroke care is extended to patients in primary centers and rural settings [7]. This system aims to optimize stroke care by closing the distance between centers and delivering the highest quality stroke care to patients in primary centers and rural areas [8]. The emergence of technologies, such as telestroke [9], improves communication and decision-making in acute stroke care. This is particularly crucial in third-world countries like the Philippines, where challenges such as a shortage of medical personnel, limited access to stroke-capable centers, and communication barriers impede the timely management of stroke [10]. The authors seek to share their experience with the implementation of the Hub-and-Spoke model in acute stroke care in the Philippines.

This is a retrospective single-center review assessing the service delivery and outcomes of acute ischemic stroke patients transferred within the Hub-and-Spoke stoke system framework. Data were collected through the Hub-and-Spoke referral system spanning from July 2021 to August 2023. A written informed consent to participate in the Hub-and-Spoke database and study was obtained from all patients and from all vulnerable patients’ parent/spouse/legal guardian/next of kin.

These spoke hospitals are located within a 40-kilometer radius from the hub, with an average travel time of 30 min. However, many of these spoke hospitals lack the capacity for neuroimaging and basic neurologic care. The participating hospitals reached a consensus, establishing criteria for patient transfers, encompassing cases such as (a) brain attacks occurring within a time frame of <4.5 h, (b) potential neurosurgical cases requiring procedures like decompressive hemicraniectomy, hematoma evacuation, and cerebrospinal fluid diversion, (c) subarachnoid hemorrhage cases necessitating vasospasm monitoring and definitive clipping or coiling, (d) instances of clinical deterioration requiring neurological intensive care, (e) acute ischemic strokes and transient ischemic attacks requiring etiological workup, and (f) stable patients capable of enduring transfer with a minimum Glasgow Coma Scale (GCS) score of 6.

Communication between the centers is facilitated through telephone calls and cellular phone applications, enabling the endorsement of patients to the receiving physician, while neuroimaging is conveyed via phone applications or email for review by the medical professionals at the hub hospital. Patient transfers to the hub hospital are facilitated through ambulance conduction or emergency medical services, with accompanying medical personnel provided by the spoke hospital. Regular educational meetings are scheduled to provide updates on patient statuses and address ongoing issues. This systematic approach ensures effective communication, streamlined transfers, and continuous education to enhance the quality of acute stroke care. However, in the context of this document, our attention is specifically directed toward individuals, experiencing acute ischemic stroke.

Hospital staff undergoes training to identify common stroke manifestations, including limb weakness, slurred speech, dizziness, and vision disturbances. Before transfer, a quick history and laboratory tests are conducted to expedite thrombolysis. Standard care practices, such as blood pressure control, are implemented, following the stroke chain survival elements to ensure effective coordination. The physician from the spoke hospital initiates communication through cellphone via phone calls and social applications capable of sending files (documents, laboratories, images) with the hub hospital before the transfer.

Upon arrival, patients undergo assessment for potential thrombolysis. Immediate neuroimaging involves a non-contrast computed tomography scan to differentiate between ischemic and hemorrhagic strokes. Neuroimaging follows one of three pathways: (1) if available, neuroimaging is performed at the referring hospital, (2) immediate transfer to the hub hospital for neuroimaging, or (3) referral to a diagnostic center or any facility capable of neuroimaging followed by transfer to the hub hospital. The Hub-and-Spoke stroke systems pathway can be seen in Fig. 1.

A total of 132 stroke patients were transferred, but for the interest of this study, acute ischemic stroke patients will be highlighted. The total number of acute ischemic stroke patients was 42, as seen on Table 1. Among them, 76% (32) were eligible for r-tPA. Out of the 32 patients, 72% (23) of them were given r-tPA with concomitant transcranial Doppler ultrasound (sonothrombolysis). Among the 42 acute ischemic stroke patients, 42.8% (18/42) had neuroimaging done in 4 capable spoke hospitals (Navotas City Hospital, Bulacan Medical Center, Gat Andres Hospital, and Tondo Medical Center), 9.5% (4/42) had imaging in a diagnostic facility prior to transfer to the hub and 47.6% (20/42) were done in the hub hospital.

Functional outcomes were evaluated using the modified Rankin Scale (mRS) score seen on Tables 2 and 3. Patients administered r-tPA displayed an average NIHSS score of 12 (range: 6–22), with 95% of cases presenting as moderate strokes and only 5% classified as severe strokes. The functional outcomes at 3-month follow-up revealed a 65% mRS score of 0, a 26% mRS score of 1, and the remaining 4.5% each for mRS scores 2 and 3. These findings indicate a substantial increase in thrombolysis rates for patients utilizing the 24-h Hub-and-Spoke model. In comparison, data from a 2014 study by Navarro et al. [1] in the Philippines indicated a thrombolysis rate of only 1.4%, which escalated to 11% in 2021 according to Collantes et al. [10]. Our Hub-and-Spoke network data exhibit a thrombolysis rate of 17.4% for all transferred patients (132 total transfers) from July 2021 to August 2023.

In individuals experiencing acute ischemic stroke who did not receive r-tPA, the mean NIHSS was observed to be 17 (range: 2–32). The majority of cases were categorized as moderate strokes, comprising 68.4%, followed by severe strokes at 21% and mild strokes at 10%. Subsequent to this cohort of patients, the mRS scores at 3-month follow-up were distributed as follows: 7 patients (36.8%) achieved mRS 0, 3 patients (15.7%) had mRS 1, 2 patients (10.5%) had mRS 2, 1 patient (5.5%) had mRS 3, 3 patients (15.7%) had mRS 4, 1 patient (5.5%) had mRS 5, and 2 patients (10.5%) had mRS 6.

Having seen the data of the Hub-and-Spoke network in acute ischemic stroke patients highlights a significant enhancement in thrombolysis accessibility, surgical management for stroke, and especially neurological care for stroke patients. This quality improvement was achieved with a modest increase in overall admissions since the time of the COVID pandemic. A systematic review by Price et al. [11], comparing thrombolysis rates across various service configurations, emphasized the superiority of regional collaborations over local services, resulting in significantly higher thrombolysis rates. The Hub-and-Spoke model, by enabling broader access to stroke care and thrombolysis, effectively minimizes the workload burden of the hub and even the spoke hospital while ensuring that the majority of stroke patients receive care closer to their homes.

Recommendations for improving the Hub-and-Spoke network include strategies for advancing our services may encompass engaging various stakeholders. Establishing forums in diverse cities or municipalities, involving stakeholders from the grassroots level up to local chief executives, can foster collaboration and support. Intensifying training programs for ambulance drivers and staff at spoke hospitals, specifically for handling emergency neurologic cases, will enhance service delivery. Additionally, providing training for doctors in spoke hospitals on utilizing the NIHSS score to accurately assess stroke severity will contribute to more precise labeling of strokes.

Acute ischemic stroke diagnostics and management especially timely thrombolysis delivery are crucial for reducing disability and improving outcomes. Our data strongly indicate that the Hub-and-Spoke model can significantly elevate thrombolysis rates, provide timely and appropriate neurological care, and decrease mortality and morbidity while effectively managing admissions to the hub hospital. This underscores the model’s crucial role in optimizing stroke care and serves as a valuable paradigm for healthcare improvement initiatives in the country. The collaborative effort among stroke physicians and healthcare practitioners in both hub and spoke hospitals, driven by a shared goal of improving care, proved instrumental. This noncompetitive collaboration eased resistance to change, especially considering the neurologic service with stakeholders involved.

We would like to thank the people behind the spoke hospitals who made it possible to improve our service delivery among our stroke patients.

This study protocol was reviewed and approved by the Institutional Review Board of the Jose R. Reyes Memorial Medical Center with IRB number 2023-193. A written informed consent to participate in the Hub-and-Spoke database and study was obtained from all patients and from all vulnerable patients’ parent/spouse/legal guardian/next of kin.

The authors have no conflicts of interest to declare.

This study was not supported by any sponsor or funder.

Dr. Jose C. Navarro: initiative in implementing the Hub-and-Spoke stroke system; Dr. Laurence Kristoffer J. Batino, Dr. Mark Timothy T. Cinco, and Dr. Jose C. Navarro: conceptualization and writing the initial manuscript; Dr. Laurence Kristoffer J. Batino and Dr. Mark Timothy T. Cinco: collection of data and analysis; Dr. Jose C. Navarro and Dr. Laurence Kristoffer J. Batino: validation and final review. Dr. Laurence Kristoffer J. Batino: final editing.

All data generated or analyzed during this study are included in this article. Further inquiries can be directed to the corresponding author.