Letter by Duyff and Groeneveld Regarding Article, “Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting”

Abstract

HomeStrokeVol. 43, No. 8Letter by Duyff and Groeneveld Regarding Article, “Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Duyff and Groeneveld Regarding Article, “Proportion of Patients Treated With Thrombolysis in a Centralized Versus a Decentralized Acute Stroke Care Setting” Ruurd F. Duyff, MD and Carel Groeneveld, MD Ruurd F. DuyffRuurd F. Duyff Department of Neurology Ziekenhuis De Tjongerschans Heerenveen The Netherlands (Duyff, Groeneveld) Search for more papers by this author and Carel GroeneveldCarel Groeneveld Department of Neurology Ziekenhuis De Tjongerschans Heerenveen The Netherlands (Duyff, Groeneveld) Search for more papers by this author Originally published7 Jun 2012https://doi.org/10.1161/STROKEAHA.112.660167Stroke. 2012;43:e73Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 To the Editor:Being one of the centers participating in the study, we read the article by Lahr et al,1 published online March 16, 2012 in Stroke, with great interest. They concluded that patients are more likely to be treated with thrombolysis in a centralized setting.We would like to make some remarks and add some recent figures from our own institution. First, of course, the authors are to be commended for their collaborative effort to investigate such a complex issue.In this case, the region functions as an instrumental variable,2 the assumption being that the regions are completely comparable in sociodemographic variables and burden of disease, etc. Almost certainly, this assumption is not correct, so there is potential for confounding and the authors hint at some disparities themselves. We would like to draw attention to the fact that the decentralized region is more rural, maybe accounting for the finding that in the decentralized model, use of emergency medical services and high prioritization were significantly lower.1The main difference in our view is the fact that in the decentralized setting, significantly fewer patients arrived in time for tissue-type plasminogen activator treatment, only 28% versus 44% in the centralized setting; whereas the proportion of patients arriving within 4.5 hours after stroke onset who were actually treated with tissue-type plasminogen activator was exactly the same: 50%. Also, functional outcome and complications were similar. This is a remarkable feat, considering it was achieved by many smaller community hospitals compared with 1 tertiary stroke center. It is, however, in line with the findings of the SITS-MOST study.3 As the authors also state, the proportion of patients treated in the decentralized model was higher than was reported previously, and we think it is likely to grow. From our own stroke registry, we have the figure for 2011: 20% of all patients presenting with ischemic stroke were treated with alteplase and the median door-to-needle time was only 35 minutes; these figures compare very favorably with national and international data.1,4,5Another significant finding was the shorter onset-to-door time in the decentralized model, even after compensating for the longer door-to-needle time and leading to a slightly shorter onset-to-needle time in the decentralized model (120 minutes versus 124 minutes, not significant); this is of course the result of significantly shorter travel distances to hospital. Combined with shortening door-to-needle times in community hospitals like ours, this leads to shorter onset-to-needle times and possibly better outcome in the decentralized setting, although this remains to be investigated.We would like to stress the importance of the prehospital factors, as these caused the main differences between the models; public awareness needs to be raised so more patients can benefit from treatment. For policymakers, this should be the main finding of this study and not the hasty conclusion that thrombolysis treatment should be centralized everywhere. This would not only do us wrong, but also other community hospitals like ours, which happen to have 24-hour dedicated stroke care.Essentially, intravenous thrombolysis is a low-tech treatment that can be administered safely in hospitals that are near the patient.3,5Ruurd F. Duyff, MDCarel Groeneveld, MD Department of Neurology Ziekenhuis De Tjongerschans Heerenveen The NetherlandsSources of FundingNone.DisclosuresNone.FootnotesStroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited. Include a completed copyright transfer agreement form (available online at http://stroke.ahajournals.org and http://submit-stroke.ahajournals.org).Correspondence to Ruurd F. Duyff, MD, Ziekenhuis De Tjongerschans, Neurology, Thialfweg 44, Heerenveen 8441 PW, Netherlands. E-mail [email protected]nl