Barriers to Stroke Thrombolysis in a Geographically Defined Population

Abstract

Objective: Barriers to thrombolysis are rather assessed for hospitalized stroke patients than among geographically defined populations. In a population-based approach, we assessed (1) the utilization rate of stroke thrombolysis in the community, and (2) the significance of the chosen stroke care provider as a potential barrier to thrombolysis. Methods: We performed a databank-based post hoc analysis, derived from data ascertained in a prospective, population-based stroke study among the permanent residents of the canton Basel-City, Switzerland. For the cohort with an onset assessment interval (OAI) ≤3 h, we compared thrombolyzed with nonthrombolyzed patients concerning demographic variables, the National Institutes of Health stroke scale (NIHSS) score, OAI, risk factors, and the type of stroke care provider. For patients without thrombolysis despite an OAI ≤3 h, barriers to thrombolysis were compiled. Results: Among 269 patients, 49 had an OAI ≤3 h (18% of all patients and 38% of those 128 patients with exactly known time of onset). Fourteen patients received thrombolysis, amounting to a utilization rate of 5.2% (95% CI 2.9–8.6) for all patients and 29% (95% CI 17–43) for the OAI ≤3-hour cohort. For the latter, thrombolyzed differed from nonthrombolyzed patients in higher NIHSS score and type of stroke care provider, but not in demographic variables, OAI, or risk factors. Fourteen of 40 patients (35%) primarily admitted to the stroke unit received thrombolysis, compared with none of 9 patients primarily treated elsewhere (p < 0.04). In the OAI ≤3-hour cohort, mild or regressing stroke severity (48%), admission to hospitals not offering thrombolysis (20%), computed tomography or laboratory contraindications (17%) and severe comorbidity (14%) were barriers to thrombolysis. Conclusion: In this geographically defined population, every 20th stroke patient received thrombolysis. Only a minority of patients had an OAI ≤3 h, rendering late admission the most common barrier to thrombolysis. In the OAI ≤3-hour cohort, admission to hospitals not offering thrombolysis prompted exclusion from thrombolysis as often as established contraindications. Thus, acute stroke patients should solely be brought to hospitals providing thrombolysis.

Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke

“…Significant comorbidity was cited as the main exclusion criterion for alteplase in 8.3% to 14% of eligible stroke patients in prior studies. 120,280 Another study found that 9 of 73 patients (12.3%) were excluded on basis of poor prognosis (8 of whom had preexisting dementia). 281 Several comorbid conditions bear discussion, including severe renal or hepatic disease (discussed above), dementia, recrudescence, and active malignancy.…”

Stroke Severity, Its Correlates and Impact on Thrombolysis in a Population-Based Study

“…The subgroup of non-stroke unit patients sought medical attention even later – half of them later than 4 days. These long OAIs indicate the need for more sustained public information, taking into account that late presentation was the most important barrier to thrombolysis [20]. …”

“…defined as the time lag between first stroke symptoms or – in cases of unknown onset – the point in time when the patient was last seen symptom-free and the clinical assessment of stroke) [20], type of stroke care provider (dichotomized in stroke unit care vs. no stroke unit care; the latter comprised both hospitalization in all other hospitals and non-hospital stroke management), and thrombolytic treatment (intravenous or intra-arterial) was prospectively ascertained as part of the epidemiological study [16, 17]. Stroke etiology was determined applying TOAST criteria [1] by one single rater [17].…”

The Probability of Restenosis, Contralateral Disease Progression, and Late Neurologic Events following Carotid Endarterectomy: A Long-Term Follow-Up Study

“…The University Hospital is the only healthcare provider that has neurology, neurosurgery and vascular surgery departments within the canton of Basel City, Switzerland (37.1 km 2 ). It serves 188,015 inhabitants (census 2002) [13]. For patients living in the region but not actually in the canton of Basel City, other healthcare providers offer CEA, too.…”