Utilization of Intravenous Tissue-Type Plasminogen Activator for Ischemic Stroke at Academic Medical Centers

Johnston, S. Claiborne; Fung, Lawrence; Gillum, Leslie A.; Smith, Wade S.; Brass, Lawrence M.; Lichtman, Judith H.; Brown, Adrienne S.

doi:10.1161/01.str.32.5.1061

Cited by 168 publications

(132 citation statements)

References 48 publications

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“…However, a large proportion of patients are admitted or notified after the 3-h time window [2]. Only a minority of patients with ischemic stroke actually receive this treatment because of the lack of approval for the use of thrombolytic agent after 3-h time window [3][4][5][6]. Despite the fact that promising data regarding the reduction of disability following the use of rt-PA between 3 and 6 h of stroke symptom onset have been reported, thrombolytic therapy beyond the 3-h time window should be performed only as part of an institutional protocol [7][8][9][10].…”

Section: Introductionmentioning

confidence: 99%

Combined Intravenous and Intraarterial Revascularization Therapy Using MRI Perfusion/Diffusion Mismatch Selection for Acute Ischemic Stroke at 3–6 h After Symptom Onset

Han

Kim

et al. 2008

Neurocrit Care

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Section: Introductionmentioning

confidence: 99%

Combined Intravenous and Intraarterial Revascularization Therapy Using MRI Perfusion/Diffusion Mismatch Selection for Acute Ischemic Stroke at 3–6 h After Symptom Onset

Han

Kim

et al. 2008

Neurocrit Care

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“…Some previous studies have shown that black patients receive IV rt‐PA 1/5 to 3/4 as often as white patients,8, 9, 21, 22, 23, 24 but other studies have reported no difference in rates of treatment 25, 26. Data for Hispanic patients are also conflicting.…”

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confidence: 97%

“…Low treatment rates are partially explained by delayed hospital arrival, but provider‐level factors may also contribute 6. Utilization of rt‐PA varies further by age, socioeconomic status, hospital size and case volume, geography, and use of emergency medical services (EMS) 7, 8, 9, 10, 11, 12…”

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confidence: 99%

Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers

Aparicio

Carr

Kasner

et al. 2015

JAHA

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BackgroundPrimary stroke centers (PSCs) utilize more recombinant tissue plasminogen activator (rt‐PA) than non‐PSCs. The impact of PSCs on racial disparities in rt‐PA use is unknown.Methods and ResultsWe used data from the Nationwide Inpatient Sample from 2004 to 2010, limited to states that publicly reported hospital identity and race. Hospitals certified as PSCs by The Joint Commission were identified. Adults with a diagnosis of ischemic stroke were analyzed. Rt‐PA use was defined by the International Classification of Diseases, 9th Revision procedure code 99.10. Discharges (304 152 patients) from 26 states met eligibility criteria, and of these 71.5% were white, 15.0% black, 7.9% Hispanic, and 5.6% other. Overall, 24.7% of white, 27.4% of black, 16.2% of Hispanic, and 29.8% of other patients presented to PSCs. A higher proportion received rt‐PA at PSCs than non‐PSCs in all race/ethnic groups (white 7.6% versus 2.6%, black 4.8% versus 2.0%, Hispanic 7.1% versus 2.4%, other 7.2% versus 2.5%, all P<0.001). In a multivariable model adjusting for year, age, sex, insurance, medical comorbidities, a diagnosis‐related group–based mortality risk indicator, ZIP code median income, and hospital characteristics, blacks were less likely to receive rt‐PA than whites at non‐PSCs (odds ratio=0.58, 95% CI 0.50 to 0.67) and PSCs (odds ratio=0.63, 95% CI 0.54 to 0.74) and Hispanics were less likely than whites to receive rt‐PA at PSCs (odds ratio=0.77, 95% CI: 0.63 to 0.95). In the fully adjusted model, interaction between race and presentation to a PSC for likelihood of receiving rt‐PA did not reach significance (P=0.98).ConclusionsRacial disparities in intravenous rt‐PA use were not reduced by presentation to PSCs. Black patients were less likely to receive thrombolytic treatment than white patients at both non‐PSCs and PSCs. Hispanic patients were less likely to be seen at PSCs relative to white patients and were less likely to receive intravenous rt‐PA in the fully adjusted model.

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“…This is contrary to US-based research which found that African American and minority patients were significantly less likely to receive thrombolytic treatment for acute ischaemic stroke. 112,113 Although efforts were made to exclude any diagnostic uncertainty, these findings may be related to a perception of increased diagnostic certainty of stroke, given the evidence of increased rates among this ethnic group. However, social desirability bias may help to account for the findings, with clinicians overcompensating to avoid being seen as denying treatment based on race.…”

Section: Patient Ethnicitymentioning

confidence: 99%

Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment

Thomson

Brún

Flynn

et al. 2017

Health Serv Deliv Res

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BackgroundIntravenous thrombolysis for patients with acute ischaemic stroke is underused (only 80% of eligible patients receive it) and there is variation in its use across the UK. Previously, variation might have been explained by structural differences; however, continuing variation may reflect differences in clinical decision-making regarding the eligibility of patients for treatment. This variation in decision-making could lead to the underuse, or result in inappropriate use, of thrombolysis.ObjectivesTo identify the factors which contribute to variation in, and influence, clinicians’ decision-making about treating ischaemic stroke patients with intravenous thrombolysis.MethodsA discrete choice experiment (DCE) using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted to better understand the influence of patient-related and clinician-related factors on clinical decision-making. An online DCE was developed following an iterative five-stage design process. UK-based clinicians involved in final decision-making about thrombolysis were invited to take part via national professional bodies of relevant medical specialties. Mixed-logit regression analyses were conducted.ResultsA total of 138 clinicians responded and opted to offer thrombolysis in 31.4% of cases. Seven patient factors were individually predictive of the increased likelihood of offering thrombolysis (compared with reference levels in brackets): stroke onset time of 2 hours 30 minutes (50 minutes); pre-stroke dependency modified Rankin Scale score (mRS) of 3 (mRS4); systolic blood pressure (SBP) of 185 mmHg (140 mmHg); stroke severity scores of National Institutes of Health Stroke Scale (NIHSS) 5 without aphasia, NIHSS 14 and NIHSS 23 (NIHSS 2 without aphasia); age 85 years (65 years); and Afro-Caribbean (white). Factors predictive of not offering thrombolysis were age 95 years; stroke onset time of 4 hours 15 minutes; severe dementia (no memory problems); and SBP of 200 mmHg. Three clinician-related factors were predictive of an increased likelihood of offering thrombolysis (perceived robustness of the evidence for thrombolysis; thrombolysing more patients in the past 12 months; and high discomfort with uncertainty) and one factor was predictive of a decreased likelihood of offering treatment (clinicians’ being comfortable treating patients outside the licensing criteria).LimitationsWe anticipated a sample size of 150–200. Nonetheless, the final sample of 138 is good considering that the total population of eligible UK clinicians is relatively small. Furthermore, data from the Royal College of Physicians suggest that our sample is representative of clinicians involved in decision-making about thrombolysis.ConclusionsThere was considerable heterogeneity among respondents in thrombolysis decision-making, indicating that clinicians differ in their thresholds for treatment across a number of patient-related factors. Respondents were significantly more likely to treat 85-year-old patients than patients aged 68 years and this probably reflects acceptance of data from Third International Stroke Trial that report benefit for patients aged > 80 years. That respondents were more likely to offer thrombolysis to patients with severe stroke than to patients with mild stroke may indicate uncertainty/concern about the risk/benefit balance in treatment of minor stroke. Findings will be disseminated via peer-review publication and presentation at national/international conferences, and will be linked to training/continuing professional development (CPD) programmes.Future workThe nature of DCE design means that only a subset of potentially influential factors could be explored. Factors not explored in this study warrant future research. Training/CPD should address the impact of non-medical influences on decision-making using evidence-based strategies.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Utilization of Intravenous Tissue-Type Plasminogen Activator for Ischemic Stroke at Academic Medical Centers

Abstract: Background and Purpose-We sought to measure the overall rate of usage of tissue-type plasminogen activator (tPA) for ischemic stroke at academic medical centers, and to determine whether ethnicity was associated with usage. Methods-Between

Cited by 168 publications

References 48 publications

Combined Intravenous and Intraarterial Revascularization Therapy Using MRI Perfusion/Diffusion Mismatch Selection for Acute Ischemic Stroke at 3–6 h After Symptom Onset

Combined Intravenous and Intraarterial Revascularization Therapy Using MRI Perfusion/Diffusion Mismatch Selection for Acute Ischemic Stroke at 3–6 h After Symptom Onset

Racial Disparities in Intravenous Recombinant Tissue Plasminogen Activator Use Persist at Primary Stroke Centers

Factors that influence variation in clinical decision-making about thrombolysis in the treatment of acute ischaemic stroke: results of a discrete choice experiment

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