Rate of Utilization and Determinants of Withdrawal of Care in Acute Ischemic Stroke Treated With Thrombolytics in USA

Abstract

Our current practices for utilization of thrombolytics are based on results of clinical trials with no or restricted use of "withdrawal of care" among treated patients. The increasing use of "withdrawal of care" in routine practice may lead to suboptimal outcomes among acute ischemic stroke patients. We determined the frequency of "withdrawal of care" and determined demographic and clinical characteristics, and in-hospital outcomes among thrombolytic-treated ischemic stroke patients stratified by use of "withdrawal of care" using National Inpatient Sample data files from 2002 to 2010. "Withdrawal of care" during hospitalization was instituted in 4287 (3.3%) of the 130,437 acute ischemic stroke patients treated with thrombolytics. In the stepwise logistic regression analysis, women [odds ratio (OR) 1.2, 95% confidence interval (CI), (1.0-1.5)], presence of atrial fibrillation [OR 1.2, 95% CI, (1.0-1.5)], hemiplegia/hemiparesis [OR 1.4, 95% CI, (1.1-1.7)], aphasia [OR 1.2, 95% CI, (1.0-1.5)], and postthrombolytic intracerebral hemorrhage (OR 1.5, 95% CI, 1.1-1.8) were significant predictors of "withdrawal of care" among thrombolytic-treated ischemic stroke patient. Hospitals located in the west region [OR 1.7, 95% CI, (1.2-2.4)], and teaching hospitals [OR 1.4, 95% CI, (1.0-1.8)] were more likely to use withdrawal of care. In-hospital mortality (61% vs. 9.0%, P≤0.0001) were higher among those with "withdrawal of care." Several individual-related and institution-related factors were associated with the use of "withdrawal of care" among thrombolytic-treated ischemic stroke patients. The excessively high mortality and resource utilization mandates a more evidence based policy for "withdrawal of care" in these patients.