Lessons Learned From the Historical Trends on Thrombolysis Use for Acute Ischemic Stroke Among Medicare Beneficiaries in the United States.

Tong Meng,Abd Al-Rahman Traboulsi,Amber W Trickey,Jeffrey L Saver,Loretta Matheson,Prasanthi Govindarajan,Alex H S Harris,Todd Wagner,Sarah Rosenthal

doi:10.3389/fneur.2022.827965

Abstract

BackgroundThe most recent time trends on intravenous thrombolysis (IVT) utilization for acute ischemic stroke was reported in 2011 using the Get with the Guidelines. Our objectives are to assess and validate the change in IVT utilization through 2014 in a national sample of Medicare beneficiaries and to examine the effect of patient, stroke center designation, and geography on IVT utilization.MethodsWe built a comprehensive national stroke registry by combining patient-level, stroke center status, and geographical characteristics, using multiple data sources. Using multiple national administrative databases from 2007 to 2014, we generated a mixed-effect logistic regression model to characterize the independent associations of patient, hospital, and geographical characteristics with IVT in 2014.ResultsUse of IVT increased consistently from 2.8% in 2007 to 7.7% in 2014, P < 0.001. Between group differences persisted, with lower odds of use in patients who were ≥86 years (aOR 0.74, 95% CI 0.65–0.83), Black (aOR 0.73, 95% CI 0.61–0.87), or treated at a rural hospital (aOR 0.88, 95% CI 0.77–1.00). Higher odds of use were observed in patients who arrived by ambulance (aOR 2.67, 95% CI 2.38–3.00), were treated at a hospital certified as a stroke center (aOR 1.96, 95% CI 1.68–2.29), or were treated at hospitals located in the most socioeconomically advantaged areas (aOR 1.27, 95% CI 1.05–1.54).ConclusionsBetween 2007 and 2014, the frequency of IVT for patients with acute ischemic stroke increased substantially, though differences persisted in the form of less frequent treatment associated with certain characteristics. These findings can inform ongoing efforts to optimize the delivery of IVT to all AIS patients nationwide.

Highlights

Stroke center certification data were derived from the Joint Commission [18], Healthcare Facilities Accreditation Program (HFAP) [19] and Det Norske Veritas (DNV) [20]
Two-thirds of patients were transported by emergency medical services (EMS) for the stroke episode
Additional features associated with lower rates of intravenous thrombolysis (IVT) use were fewer comorbid health conditions, arrival by private vehicle/walk-in, treatment at a hospital in the South, a hospital of smaller size, and a hospital not certified as a stroke center

Summary

Introduction

Stroke is the leading cause of serious long-term disability and the fifth leading cause of mortality in the US [1]. Reperfusion to minimize ischemic stroke-related disability and mortality is achieved through intravenous thrombolysis (IVT) treatment and through mechanical thrombectomy procedures for large vessel strokes [2]. There was a steady but slow increase in IVT use as reported by previous studies using registry data and Medicare claims data [5, 6]. The most recent national assessment of temporal trends from 2003 to 2011 was reported by Get with the Guidelines study team. In the early 2010s, the frequency of IVT use remained suboptimal, with more than one-fifth of patients documented as fully eligible for treatment not receiving thrombolytic therapy even at the most committed, registry-participating hospitals [6]. The most recent time trends on intravenous thrombolysis (IVT) utilization for acute ischemic stroke was reported in 2011 using the Get with the Guidelines. Our objectives are to assess and validate the change in IVT utilization through 2014 in a national sample of Medicare beneficiaries and to examine the effect of patient, stroke center designation, and geography on IVT utilization

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