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.