1
|
Rodriguez N, Prasad S, Olson DM, Bandela S, Gealogo Brown G, Kwon Y, Gebreyohanns M, Jones EM, Ifejika NL, Stone S, Anderson JA, Savitz SI, Cruz-Flores S, Warach SJ, Goldberg MP, Birnbaum LA. Door to needle time trends after transition to tenecteplase: A Multicenter Texas stroke registry. J Stroke Cerebrovasc Dis 2024; 33:107774. [PMID: 38795796 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 03/22/2024] [Accepted: 05/16/2024] [Indexed: 05/28/2024] Open
Abstract
BACKGROUND Tenecteplase (TNK) is considered a promising option for the treatment of acute ischemic stroke (AIS) with the potential to decrease door-to-needle times (DTN). This study investigates DTN metrics and trends after transition to tenecteplase. METHODS The Lone Star Stroke (LSS) Research Consortium TNK registry incorporated data from three Texas hospitals that transitioned to TNK. Subject data mapped to Get-With-the-Guidelines stroke variables from October 1, 2019 to March 31, 2023 were limited to patients who received either alteplase (ALT) or TNK within the 90 min DTN times. The dataset was stratified into ALT and TNK cohorts with univariate tables for each measured variable and further analyzed using descriptive statistics. Logistic regression models were constructed for both ALT and TNK to investigate trends in DTN times. RESULTS In the overall cohort, the TNK cohort (n = 151) and ALT cohort (n = 161) exhibited comparable population demographics, differing only in a higher prevalence of White individuals in the TNK cohort. Both cohorts demonstrated similar clinical parameters, including mean NIHSS, blood glucose levels, and systolic blood pressure at admission. In the univariate analysis, no difference was observed in median DTN time within the 90 min time window compared to the ALT cohort [40 min (30-53) vs 45 min (35-55); P = .057]. In multivariable models, DTN times by thrombolytic did not significantly differ when adjusting for NIHSS, age (P = .133), or race and ethnicity (P = .092). Regression models for the overall cohort indicate no significant DTN temporal trends for TNK (P = .84) after transition; nonetheless, when stratified by hospital, a single subgroup demonstrated a significant DTN upward trend (P = 0.002). CONCLUSION In the overall cohort, TNK and ALT exhibited comparable temporal trends and at least stable DTN times. This indicates that the shift to TNK did not have an adverse impact on the DTN stroke metrics. This seamless transition is likely attributed to the similarity of inclusion and exclusion criteria, as well as the administration processes for both medications. When stratified by hospital, the three subgroups demonstrated variable DTN time trends which highlight the potential for either fatigue or unpreparedness when switching to TNK. Because our study included a multi-ethnic cohort from multiple large Texas cities, the stable DTN times after transition to TNK is likely applicable to other healthcare systems.
Collapse
Affiliation(s)
| | - Sidarrth Prasad
- University of Texas Southwestern Medical Center, United States.
| | - DaiWai M Olson
- University of Texas Southwestern Medical Center, United States
| | - Sujani Bandela
- The University of Texas Health Science Center at San Antonio, United States
| | | | - Yoon Kwon
- University of Texas Southwestern Medical Center, United States
| | | | - Erica M Jones
- University of Texas Southwestern Medical Center, United States
| | - Nneka L Ifejika
- University of Texas Southwestern Medical Center, United States
| | - Suzanne Stone
- University of Texas Southwestern Medical Center, United States
| | | | - Sean I Savitz
- University of Texas Health Science Center at Houston, United States
| | | | - Steven J Warach
- Dell Medical School, The University of Texas at Austin, United States
| | - Mark P Goldberg
- The University of Texas Health Science Center at San Antonio, United States
| | - Lee A Birnbaum
- The University of Texas Health Science Center at San Antonio, United States
| |
Collapse
|
2
|
Ormseth CH, Sheth KN, Saver JL, Fonarow GC, Schwamm LH. The American Heart Association's Get With the Guidelines (GWTG)-Stroke development and impact on stroke care. Stroke Vasc Neurol 2017; 2:94-105. [PMID: 28959497 PMCID: PMC5600018 DOI: 10.1136/svn-2017-000092] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 04/26/2017] [Indexed: 01/06/2023] Open
Abstract
The American Heart Association’s Get With the Guidelines (GWTG)-Stroke programme has changed stroke care delivery in the USA since its establishment in 2003. GWTG is a voluntary registry and continuous quality improvement initiative that collects data on patient characteristics, hospital adherence to guidelines and inpatient outcomes. Implementation of the programme saw increased provision of evidence-based care and improved patient outcomes. This review will describe the development of the programme and discuss the impact on stroke outcomes and transformation of stroke care delivery that followed its implementation.
Collapse
Affiliation(s)
- Cora H Ormseth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeffrey L Saver
- Department of Neurology, UCLA Medical Center, Los Angeles, California, USA
| | - Gregg C Fonarow
- Department of Cardiology, UCLA Medical Center, Los Angeles, California, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| |
Collapse
|
3
|
Evidence-Based Policy Making: Assessment of the American Heart Association’s Strategic Policy Portfolio. Circulation 2016; 133:e615-53. [DOI: 10.1161/cir.0000000000000410] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
|
4
|
de Havenon A, Sultan-Qurraie A, Hannon P, Tirschwell D. Development of regional stroke programs. Curr Neurol Neurosci Rep 2015; 15:544. [PMID: 25763758 DOI: 10.1007/s11910-015-0544-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The organization of stroke care has undergone a dramatic evolution in the USA over the last two decades. Beginning with the recommendation for Primary Stroke Centers (PSCs) in 1994, there has been a concerted effort by physicians, the American Heart Association/American Stroke Association (AHA/ASA), National Institutes of Health (NIH), and state legislatures to advance an evidence-based system of care with several tiers of stroke centers. At the apex of this structure are Regional Stroke Centers (RSCs), which do not have official recognition like PSCs and Comprehensive Stroke Centers (CSCs), but their existence as a hub for the many disparate spokes of stroke care in their region is increasingly necessary. Observational evidence suggests that this approach is improving the delivery of stroke care and reducing costs in the USA. Similar efforts are being made in Europe and Asia with encouraging results. The RSC model has the potential to lead to more uniform evidence-based stroke medicine, but many challenges exist.
Collapse
Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah, 175 N. Medical Dr, Salt Lake City, UT, 84132, USA,
| | | | | | | |
Collapse
|
5
|
Boudreau DM, Guzauskas GF, Chen E, Lalla D, Tayama D, Fagan SC, Veenstra DL. Cost-Effectiveness of Recombinant Tissue-Type Plasminogen Activator Within 3 Hours of Acute Ischemic Stroke. Stroke 2014; 45:3032-9. [DOI: 10.1161/strokeaha.114.005852] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Despite the availability of results from multiple newer clinical trials and changing healthcare costs, the cost-effectiveness of recombinant tissue-type plasminogen activator (r-tPA) for treatment of acute ischemic stroke within 0 to 3 hours of symptom onset was last evaluated in 1998 for the United States Using current evidence, we evaluate the long-term cost-effectiveness of r-tPA administered 0 to 3 hours after acute ischemic stroke onset versus no r-tPA.
Methods—
A disease-based decision model to project lifetime outcomes of patients after acute ischemic stroke by r-tPA treatment status from the US payer perspective was developed. Model inputs were derived from a recent meta-analysis of r-tPA trials, cohort studies, and health state preference studies. Cost data, inflated to 2013 dollars, were based on drug wholesale acquisition cost and the literature. To compare r-tPA to no r-tPA, we calculated incremental total direct costs, incremental quality-adjusted life years, and incremental cost-effectiveness ratios. We performed 1-way and probabilistic sensitivity analyses to evaluate uncertainty in the results.
Results—
r-tPA resulted in a gain of 0.39 quality-adjusted life years (95% confidence range, 0.16–0.66) on average per patient and a lifetime cost-saving of $25 000 (95% confidence range, −$42 500 to −$11 000) compared with no r-tPA. In probabilistic sensitivity analyses, r-tPA was dominant compared with no r-tPA in ≈100% of simulations. The model was sensitive to inputs for r-tPA efficacy, healthcare costs for disabled patients, mortality rates for disabled and nondisabled patients, and quality of life estimates.
Conclusions—
Our analysis supports earlier economic evaluations that r-tPA is a cost-effective method to treat stroke. Appropriate use of r-tPA should be prioritized nationally.
Collapse
Affiliation(s)
- Denise M. Boudreau
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Gregory F. Guzauskas
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Er Chen
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Deepa Lalla
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Darren Tayama
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - Susan C. Fagan
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| | - David L. Veenstra
- From the University of Washington, Seattle (D.M.B., G.F.G., D.L.V.); Genentech, Inc South San Francisco, CA (E.C., D.T.); Palo Alto Outcomes Research, CA (D.L.); and University of Georgia College of Pharmacy, Athens (S.C.F.)
| |
Collapse
|
6
|
Livesay SL. Clinical Review and Implications of the Guideline for the Early Management of Patients With Acute Ischemic Stroke. AACN Adv Crit Care 2014. [DOI: 10.4037/nci.0000000000000017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Stroke is the fourth leading cause of death and the leading cause of significant, long-term disability in the United States. Clinicians’ knowledge and use of evidence to guide the care of patients with ischemic stroke are paramount to improving patient outcomes. The recently updated “Guidelines for the Early Management of Patients With Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association” provides clinicians with evidence-based, expert consensus to guide the recognition and early management of patients with acute ischemic stroke. The guideline provides 115 recommendations for the management of patients with acute ischemic stroke, including 24 new recommendations and 51 revised recommendations divided into 14 major topic areas. This article reviews the recommendations and related literature and provides suggestions for use and implementation of the guideline within a stroke program of care.
Collapse
Affiliation(s)
- Sarah L. Livesay
- Sarah L. Livesay is Assistant Professor, University of Texas Health Science Center, 6901 Berner Ave, SON 786, Houston, TX 77007
| |
Collapse
|
7
|
Lee JT, Chung WT, Lin JD, Peng GS, Muo CH, Lin CC, Wen CP, Wang IK, Tseng CH, Kao CH, Hsu CY. Increased risk of stroke after septicaemia: a population-based longitudinal study in Taiwan. PLoS One 2014; 9:e89386. [PMID: 24586739 PMCID: PMC3931764 DOI: 10.1371/journal.pone.0089386] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Accepted: 01/20/2014] [Indexed: 11/18/2022] Open
Abstract
Inflammation and infection have been noted to increase stroke risk. However, the association between septicaemia and increased risk of stroke remains unclear. This population-based cohort study, using a National Health Insurance database, aimed to investigate whether patients with septicaemia are predisposed to increased stroke risk. The study included all patients hospitalised for septicaemia for the first time between 2000 and 2003 without prior stroke. Patients were followed until the end of 2010 to evaluate incidence of stroke. An age-, gender- and co-morbidities-matched cohort without prior stroke served as the control. Cox's proportional hazards regressions were used to assess differences in stroke risk between groups. Based on hazard ratios (HRs), patients with septicaemia had greater stroke risk, especially in the younger age groups (age <45: HR = 4.16, 95% CI: 2.39-7.24, p<0.001; age 45-64: HR = 1.76, 95% CI: 1.41-2.19, p<0.001; age ≥ 65: HR = 1.05, 95% CI: 0.91-1.22, p>0.05). Haemorrhagic stroke was the dominant type (ischaemic stroke: HR = 1.20, 95% CI: 1.06-1.37, p<0.01; haemorrhagic stroke: HR = 1.82, 95% CI: 1.35-2.46, p<0.001) and patients without co-morbidities were at slightly higher risk (without co-morbidities: HR = 1.49, 95% CI: 1.02-2.17, p<0.05; with co-morbidities: HR = 1.24, 95% CI: 1.10-1.41, p<0.001). The impact of septicaemia on stroke risk was highest within 6 months of the event and gradually declined over time. Our results suggest that septicaemia is associated with an increase in stroke risk, which is greatest in haemorrhagic stroke. Closer attention to patients with history of septicaemia may be warranted for stroke preventive measures, especially for younger patients without co-morbidities.
Collapse
Affiliation(s)
- Jiunn-Tay Lee
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
- * E-mail:
| | - Wen Ting Chung
- Graduate Institute of Clinical Medicine, Taipei Medical University, Taipei, Taiwan, Republic of China
| | - Jin-Ding Lin
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Giia-Sheun Peng
- Department of Neurology, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, Republic of China
| | - Chih-Hsin Muo
- Department of Public Health, China Medical University Hospital, Taichung, Taiwan, Republic of China
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Che-Chen Lin
- Management Office for Health Data, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Chi-Pang Wen
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan, Republic of China
| | - I-Kuan Wang
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan, Republic of China
- Department of Internal Medicine, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China
- Division of Kidney Disease, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Chun-Hung Tseng
- Department of Internal Medicine, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Chia-Hung Kao
- Graduate Institute of Clinical Medicine Science and School of Medicine, College of Medicine, China Medical University, Taichung, Taiwan, Republic of China
- Department of Nuclear Medicine and PET Center, China Medical University Hospital, Taichung, Taiwan, Republic of China
| | - Chung Y. Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taichung, Taiwan, Republic of China
| |
Collapse
|