Tissue plasminogen activator use: evaluation and initial management of ischemic stroke from an Iowa hospital perspective

How can we improve stroke thrombolysis rates? A review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care

BACKGROUND

Thrombolysis using intravenous (IV) tissue plasminogen activator (tPA) is one of few evidence-based acute stroke treatments, yet achieving high rates of IV tPA delivery has been problematic. The 4.5-h treatment window, the complexity of determining eligibility criteria and the availability of expertise and required resources may impact on treatment rates, with barriers encountered at the levels of the individual clinician, the social context and the health system itself. The review aimed to describe health system factors associated with higher rates of IV tPA administration for ischemic stroke and to identify whether system-focussed interventions increased tPA rates for ischemic stroke.

METHODS

Published original English-language research from four electronic databases spanning 1997-2014 was examined. Observational studies of the association between health system factors and tPA rates were described separately from studies of system-focussed intervention strategies aiming to increase tPA rates. Where study outcomes were sufficiently similar, a pooled meta-analysis of outcomes was conducted.

RESULTS

Forty-one articles met the inclusion criteria: 7 were methodologically rigorous interventions that met the Cochrane Collaboration Evidence for Practice and Organization of Care (EPOC) study design guidelines and 34 described observed associations between health system factors and rates of IV tPA. System-related factors generally associated with higher IV tPA rates were as follows: urban location, centralised or hub and spoke models, treatment by a neurologist/stroke nurse, in a neurology department/stroke unit or teaching hospital, being admitted by ambulance or mobile team and stroke-specific protocols. Results of the intervention studies suggest that telemedicine approaches did not consistently increase IV tPA rates. Quality improvement strategies appear able to provide modest increases in stroke thrombolysis (pooled odds ratio = 2.1, p = 0.05).

CONCLUSIONS

In order to improve IV tPA rates in acute stroke care, specific health system factors need to be targeted. Multi-component quality improvement approaches can improve IV tPA rates for stroke, although more thoughtfully designed and well-reported trials are required to safely increase rates of IV tPA to eligible stroke patients.

Optimizing the management of acute ischaemic stroke: a review of the utilization of intravenous recombinant tissue plasminogen activator (tPA)

WHAT IS KNOWN AND OBJECTIVE

Thrombolysis using intravenous tissue plasminogen activator (tPA) is the only available evidence-based treatment for acute ischaemic stroke; however, its current utilization is very low. Therefore, the aim of this article is to review the literature regarding the use of intravenous tPA for the treatment of acute ischaemic stroke. The review will also compare utilization rates of thrombolysis in different centres across the world and identify key reasons for the underutilization of thrombolysis in stroke.

METHODS

MEDLINE, EMBASE, International Pharmaceutical Abstracts (IPA) and Google Scholar were searched for relevant original articles, review papers and other publications over the publication period 1995-2012.

RESULTS AND DISCUSSION

The National Institute of Neurological Disorders and Stroke (NINDS) (1995, N = 624 patients) and ECASS III (2008, N = 821 patients) are two pivotal randomized controlled trials providing evidence for the use of intravenous tPA within 3 h or 3-4.5 h from stroke onset, respectively. Both trials have shown that tPA administration decreases disability at 90 days from stroke. Furthermore, a recent pooled analysis of randomized controlled trials (2010, N = 3670 patients) supports these results, highlighting that early stroke treatment is associated with better outcomes, especially when treatment is started within 90 min of stroke onset (but suggesting that the benefit could be afforded within a 4.5-h time window). Three major observational trials, STARS (2000, N = 389 patients), CASES (2005, N = 1135 patients) and SITS-MOST (2007, N = 6483 patients), have reported acceptable safety and efficacy in clinical practice. However, only a small proportion of acute ischaemic stroke patients receive tPA in clinical practice, because of the limited availability of tPA-utilizing sites and suboptimal use of tPA in sites where it is available.

WHAT IS NEW AND CONCLUSION

tPA reduces disability in stroke patients. Moreover, acceptable safety has been demonstrated in routine clinical practice. However, tPA is significantly underutilized, and specific efforts are needed to encourage appropriate implementation of the stroke treatment guidelines to optimize the use of this important therapy.

Proportion of patients treated with thrombolysis in a centralized versus a decentralized acute stroke care setting

BACKGROUND AND PURPOSE

Today, treatment of acute stroke consists of tissue-type plasminogen activator (tPA), admission to a stroke unit, and aspirin. Although tPA treatment is the most effective, there is substantial undertreatment. Centralized care may affect rate, timing, and outcome of thrombolysis compared to decentralized treatment in community hospitals. The present study aimed to assess the impact of organizational models on the proportion of patients undergoing tPA treatment.

METHODS

A prospective, multicenter, observational study among 13 hospitals in the North of the Netherlands was conducted. In the centralized model, tPA treatment for 4 hospitals was administered in 1 stroke center. The decentralized model comprised 9 community hospitals. Primary outcome was the proportion of patients treated with tPA. Secondary outcome measures were proportion of patients arriving within 4.5 hours, safety, 90-day functional outcome, and onset-to-door, door-to-needle, and onset-to-needle times. Potential confounders were adjusted using logistic regression analysis.

RESULTS

Two hundred eighty-three and 801 ischemic stroke patients were enrolled in the centralized and decentralized settings. Numbers of patients treated with tPA were 62 (21.9%) and 113 (14.1%) (OR, 1.72; 95% CI, 1.22-2.43). Adjusting for potential confounders did not alter results (OR, 2.03; 95% CI, 1.39-2.96). In the centralized setting, significantly more patients arrived at the hospital within the 4.5-hour time window (P<0.01), and shorter door-to-needle times were reached (35 versus 47 minutes). Other secondary outcome measures did not differ across setting.

CONCLUSIONS

In a centralized setting, the results demonstrate a 50% increased likelihood of treatment. Prehospital factors seem to contribute to this result.