The growing shortage of vascular neurologists in the era of health reform: planning is brain!

T he incidence of stroke has surpassed 800 000 cases each year, and acute stroke has become the leading cause of disability in the United States. Given that a person's chronological age is a primary risk factor, 1 and the United States will be experiencing exponential growth in the elderly population over the next 20 years, the incidence of stroke will grow substantially and the demand for dedicated stroke care will increase accordingly. 2 In this report, we consider contemporary evidence-based practices for stroke care, the supply of vascular neurologists (VNs) and neurointerventionalists (NIs), potential causes for the supply–demand imbalance, and solutions aimed to increasing the supply of VNs within the ongoing healthcare reform effort. Evidence-based practices for stroke include medical interventions applicable to every patient and invasive endovascular interventions applicable only to a smaller subset of qualified patients. One of the most common evidence-based medical approaches for treating acute stroke includes use of recom-binant tissue plasminogen activator in eligible patients given within 4.5 hours of when they were last seen normal, 3 a treatment that is delivered most effectively within dedicated acute care stroke units with established clinical pathways for secondary prevention and management. 4 In 2003, the Primary Stroke Center Certification program of the Joint Commission initiated an effort to increase the number of units with expertise in delivering evidence-based medical stroke care. 5 A key component of these units is a stroke team, offering 24/7 coverage by physicians with advanced knowledge of evaluating and treating acute vascular diseases and who are able to recommend best emergent and preventive management. 6 It has since become best practice in stroke treatment and management 7 to incorporate these stroke units within a regional hub and spoke network in which the unit (ie, the hub) supports satellite clinics with video-based telemedicine 8 or telephonic consultation. Given the improvements in patient care (measured in terms of decreasing complications and increasing compliance with guidelines), these hub and spoke models have proliferated across the United States. There now are almost 1000 certified primary stroke centers operating in 49 states. 5 Although the American Stroke Association does not explicitly mandate that a neurologist be the sole provider of care to patients with acute stroke, best practices indicate that VNs should play the leading role in stroke units. The American Board of Psychiatry and Neurology began certifying VNs in the United States in 2005 as a …