Background:Prior regional or single-center studies have noted that 4-7% of eligible acute ischemic stroke (AIS) patients decline intravenous tissue plasminogen activator (tPA). We sought to determine the prevalence of tPA declination in a nationwide registry of AIS patients and to investigate differences in declination by race-ethnicity.Methods:We used the Get With The Guidelines-Stroke registry to identify AIS patients eligible for tPA and admitted to participating hospitals between January 1, 2016 and March 28, 2019. We compared patient demographics and admitting hospital characteristics between tPA-eligible patients who received and those who declined tPA. Using multivariable logistic regression, we determined patient and hospital factors associated with tPA declination.Results:Among 177,115 tPA-eligible acute ischemic stroke patients at 1,976 sites, 6,545 patients (3.7%) had tPA declination as the sole documented reason for not receiving tPA. Patients declining treatment were slightly older, more likely to be female, arrived more often at “off-hours” and earlier after symptom onset, and were more likely to present to primary stroke centers. Compared with non-Hispanic White, non-Hispanic Black race-ethnicity was independently associated with increased (aOR 1.21, 95% CI 1.11-1.31), Asian race-ethnicity with decreased (aOR 0.72, 95% CI 0.58-0.88), and Hispanic ethnicity (any race) with similar odds of tPA declination (OR 0.98, 95% CI 0.86-1.13) in multivariable analysis.Conclusions:Though the overall prevalence of tPA declination is low, eligible non-Hispanic Black patients are more likely and Asian patients less likely to decline tPA than non-Hispanic White patients. Reducing rates of tPA declinations among non-Hispanic Black patients may be an opportunity to address disparities in stroke care.
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