Rate Of Thrombolytic Use Research Articles

A Nationwide Analysis of Ischemic Stroke Outcomes in Patients with COVID-19 (P14-5.001)

<h3>Objective:</h3> To compare the baseline risk factors, use of reperfusion therapies, and in-hospital outcomes of acute ischemic stroke (AIS) between patients with and without COVID-19 infection. <h3>Background:</h3> The effect of COVID-19 infection on the outcomes of AIS is unknown. <h3>Design/Methods:</h3> Hospitalizations due to AIS with or without COVID-19 were identified from the Nationwide Inpatient Sample. Logistic/linear regression were used to compare the outcomes between the groups. <h3>Results:</h3> There were 380,580 hospitalizations due to AIS from April to December 2020, of which 7,570 (2%) had COVID-19. Patients with COVID-19 were younger, more likely to be Black or Hispanic, had a lower prevalence of hypertension, hyperlipidemia, and tobacco use, and a higher prevalence of diabetes and congestive heart failure. Stroke severity, assessed using the Stroke Administrative Severity Index, was comparable between the two groups. Patients with COVID-19 were more likely to undergo mechanical thrombectomy (MT) (9.1% versus 6.5%, p&lt;0.001), however, the rates of thrombolytic use were comparable to patients without COVID-19 (14.1% versus 12.6%, p 0.072). Patients with COVID-19 had higher in-hospital mortality [odds ratio (OR) 3.0, 95% confidence intervals (CI) 2.6–3.6] and were less likely to discharge to home (OR: 0.6, 95% CI: 0.5–0.7). They also had longer length of hospital stay and higher hospital charges. These differences remained significant even after adjustment for baseline differences and in the subgroup analyses of patients treated with thrombolytics or MT, except for the likelihood of discharge to home which was comparable between the groups among patients treated with MT. <h3>Conclusions:</h3> In this nationwide analysis of AIS hospitalizations, patients with COVID-19 had a higher in-hospital mortality and worse discharge outcomes as compared to those without COVID-19 despite comparable stroke severity and comparable or higher rates of acute reperfusion therapies between the two groups. Future studies looking into the specific mechanisms of worse stroke outcomes in COVID-19 infection are needed. <b>Disclosure:</b> Dr. Garg has nothing to disclose.

Short‐Term Outcomes of Acute Stroke During COVID‐19 by Race and Ethnicity in the United States: The Society of Vascular and Interventional Neurology Multicenter Collaboration

Background The COVID‐19 pandemic has disproportionately affected Black and Hispanic communities, whose stroke care has been previously shown to experience existing disparities. We sought to evaluate how these disparities in stroke care and in‐hospital mortality have been affected by the COVID‐19 pandemic. Methods In this retrospective observational cohort study, we evaluated stroke hospitalizations in the Society of Vascular and Interventional Neurology COVID‐19 registry. We compared stroke characteristics between non‐Hispanic White, non‐Hispanic Black, and Hispanic patients pre–COVID‐19 and post–COVID‐19 (March–July 2019 versus March–July 2020) and evaluated whether racial and ethnic differences present before the pandemic were exacerbated during the pandemic. Our primary outcome was in‐hospital mortality/discharge to hospice, and secondary outcomes were acute treatment use. Results Of the 4908 included patients, numerically fewer non‐Hispanic White and Hispanic patients were evaluated during COVID‐19. Non‐Hispanic White and non‐Hispanic Black patients with large‐vessel occlusion were more likely to undergo thrombectomy ( P &lt;0.01 for both) when compared with the pre–COVID‐19 epoch. In‐hospital mortality/hospice rates were higher during COVID‐19 (12.8% versus 9.9%; P &lt;0.01), with higher rates observed across all race and ethnic groups, although the odds of death/hospice during the pandemic period became nonsignificant after multivariable adjustment (adjusted odds ratio, 1.23 [95% CI, 0.95–1.62]; P =0.12). Conclusions There was an increase in mortality/hospice discharges among all races during the COVID‐19 period. There were no noted racial or ethnic differences in rates of thrombolytic use, thrombectomy, or mortality within racial groups prepandemic compared with during the pandemic. Although other studies have demonstrated deepening disparities in these outcomes during COVID‐19, our data suggest that declines in stroke presentations and use of acute stroke therapies were not a uniform phenomenon. Disparities in stroke care were differentially affected in thrombolytic versus endovascular therapies and among non‐Hispanic Black and Hispanic patients.

Abstract WMP30: How To Beat The Metrics With Telestroke: A Community Hospital Primary Stroke Center Experience

Background and Issues: A community hospital primary stroke center (PSC) faced many challenges including inconsistent local neurology coverage as well as inefficient in-hospital workflows. This led to a decrease in number of patients treated with IV thrombolytics, a decline in meeting stroke metrics, and challenges in maintaining PSC certification. Purpose: To implement a Telestroke system of care that would provide advanced acute stroke management in a community hospital with the goal of improved stroke workflows, stroke metrics, and quality of care. Methods: In 2019 a 172-bed community hospital PSC collaborated with a Telestroke program at a Comprehensive Stroke Center. This collaboration led to significant changes including ED physician leadership, standardized protocols with an increase in stroke alerts, EMS engagement, pre-mixing thrombolytics, dedicated stroke coordinator and education of all key personnel. The primary outcome measures were volume of stroke alerts, rate of thrombolytic use, and median door to needle before and after telemedicine implementation. Results: After one year of Telestroke utilization, the number of stroke alerts increased from 88 in 2018 to 256 in 2020 (290% increase). The number of patients receiving thrombolytics increased by 440% (10 in 2018 to 44 in 2020). Median door to needle time decreased from 56 mins in 2018 to 41 mins in 2020, an improvement of 15 minutes. Conclusions: Telestroke is a consistent and effective way to assess patients with suspected acute stroke in a community hospital setting. Key factors to its successful implementation include dedicated ED physician leadership, consistent protocol application, education and data sharing for motivation and continuous process improvement. In conclusion, Telestroke use increased access to stroke neurologists and improved thrombolysis rates and stroke outcomes.

Abstract T MP72: Temporal Trends in Public Awareness of Stroke Warning Signs and Risk Factors

Introduction: Delay in seeking medical attention after stroke symptom onset is the most common reason for low rates of thrombolytic use for ischemic stroke. This may be related to poor recognition of stroke symptoms or lack of awareness of time-sensitive stroke treatments. We describe public knowledge of stroke warning signs (WS) and risk factors (RF), and changes over time. Methods: Survey respondents were drawn from our biracial population of 1.3 million using random-digit dialing in 1995, 2000, 2005, and 2011 to reflect the age, race, and gender distribution of stroke patients, based on an ongoing stroke incidence study in the same region. Participants were asked open-ended questions regarding stroke WS and RF. Comparisons over time were made using Armitage test for trend, and multiple logistic regression was used to adjust for covariates. Results: Over the study period, 8245 surveys were completed. As shown in the figure, knowledge of 3 correct WS improved steadily over time from 5.4% to 22.6% (p&lt;0.001), and knowledge of 3 correct RF has also improved over time from 2.6% to 5.8% (p&lt;0.001), but has remained relatively low. These improvements in knowledge persisted after controlling for differences in age and education between study periods. Conclusions: Public awareness of stroke WS and RF steadily improved from 1995 to 2011. These findings highlight the success of increasing community awareness of stroke WS and RF. Further research is needed to determine if increased stroke awareness leads to changes in care-seeking health behavior and improved stroke prevention. Figure 1: Comparison of Knowledge of Stroke Warning Signs and Risk Factors between Survey Years, Greater Cincinnati/Northern Kentucky Population

Abstract T MP24: Are There Disparities in Thrombolytic Treatment and Mortality in Acute Ischemic Stroke in the Hispanic Population Living in Border States versus Non-Border States?

Background: Recent studies have found an underutilization of hospital in-patient care for coronary artery disease in Hispanics living in Border States. Objective: To identify acute treatment disparities in acute ischemic stroke Hispanic patients and determine the effect of such disparity on patient outcomes. Methods: We identified Hispanic and non-Hispanic acute ischemic stroke patients from the Nationwide Inpatient Sample-2011 data files. We determined the rate of utilization of thrombolytics and outcomes according to patient’s demographic and clinical characteristics and whether or not they lived in a Border state (defined as California, Arizona, New Mexico and Texas). Results: A total of 34,904 Hispanic patients were admitted with ischemic stroke; of those 21,130 were admitted in Border states and 13,774 in non-Border states. Patient demographics, risk factors, complications and discharge disposition are included in the Tables below. There was a significantly lower rate of thrombolytic use in Hispanic patients (1013 (4.8%) and non-Hispanics (5326 (5.7%, p=0.05). After adjusting for age, gender, and other confounding risk factors, Hispanics were 30% more likely to suffer in-hospital mortality versus there non-Hispanic counter-parts in Border states [OR 1.3 (1.1-1.6) p=0.009], which was not apparent in the non-Border states [OR 1.0 (0.8-1.2) p=0.9]. Conclusions: There was an underutilization of thrombolytics and higher mortality in the Hispanic population admitted in Border States but not in non-Border States. Further studies are warranted to better understand the associated factors.

Impact of Telemedicine Implementation in Thrombolytic Use for Acute Ischemic Stroke: The University of Pittsburgh Medical Center Telestroke Network Experience

Intravenous thrombolysis is the only therapy for acute ischemic stroke that is approved by the US Food and Drug Association. The use of telemedicine in stroke makes it possible to bring the expertise of academic stroke centers to underserved areas, potentially increasing the quality of stroke care. All consecutive admissions for stroke were reviewed for 1 year before telemedicine implementation and for variable periods thereafter. A retrospective review identified 2588 admissions for acute stroke between March 2005 and December 2008 at 12 hospitals participating in a telestroke network, including 919 patients before telemedicine was available and 1669 patients after telemedicine was available. The primary outcome measure was the rate of intravenous tissue plasminogen activator (IV tPA) use before and after telemedicine implementation. One hundred thirty-nine patients received IV tPA in both study phases, with 26 (2.8%) patients treated before starting telemedicine and 113 (6.8%) after starting telemedicine (P < .001). Incorrect treatment decisions occurred 7 times (0.39%), with 2 (0.2%) pretelemedicine and 5 (0.3%) posttelemedicine (P = .70). Arrivals within 3 hours from symptom onset were more frequent in the posttelemedicine compared to the pretelemedicine phases (55 [6%] vs 159 [9.5%]; P = .002). Among the patients treated with IV tPA, symptomatic intracranial hemorrhage occurred in 2 patients (1 [10.7%] pretelemedicine vs 1 [1.8%] posttelemedicine; P = .34). Telestroke implementation was associated with an increased rate of thrombolytic use in remote hospitals within the telemedicine network.

Abstract 3141: Elderly Ischemic Stroke Patients are Less Likely to be Treated with Rt-PA

Intro: Numerous reports have found that overall, rates of rt-PA treatment are low. Previously we have reported the rate of eligibility for rt-PA treatment to be approximately 8% of ischemic stroke patients,, but that eligibility actually significantly increases with age. However, we hypothesize that treatment with rt-PA in practice is actually utilized less among the elderly. We sought to describe treatment rates by decade within the Premier database. Methods: This analysis utizlied the Premier database, a representative sampling of US hospitals that includes approx. 15% of hospital discharges, with access to pharmacy records Study period was FY 2009-2010. Cases potentially eligible for rt-PA treatment based on diagnosis were defined as those patient visits within DRGs 61-66 who did not have a transient ischemic attack (TIA) or hemorrhagic stroke discharge ICD-9 code (430, 431, 432, and 435). Cases receiving thrombolysis were identified by having an ICD-9 code of 99.10, which denotes thrombolytic use, OR who had pharmacy billing codes for thrombolytic therapy, limited to alteplase (activase), 50 mg and 100 mg vials. Rates of thrombolytic use were stratified by fiscal year. Results: There were 101567 ischemic stroke cases included in this analysis, which were 16.2% black, 63.7% white, and 20.1% other, with a mean age of 71.2 (SD=15). During each study year, the overall rates of tpa treatment were 4.2% and 4.7% for 2009 and 2010. Rates of thrombolysis use stratified by age of the patient are presented in the Table . Overall there was a statistically significant decrease in treatment rates with increasing age (p&lt;0.001) after adjustment for race and gender. Discussion: Despite previously shown higher rates of eligibility, elderly patients are significantly less likely to be treated with rt-PA than younger aged patients. Whether this represents ageism by the healthcare system, or unmeasured/undocumented co-morbidities or exclusions requires further study.

Impact of Emergency Department Transitions of Care on Thrombolytic Use in Acute Ischemic Stroke

In-hospital mortality is higher for certain medical conditions based on the time of presentation to the emergency department. The primary goal of this study was to determine whether patients with acute ischemic stroke who arrived to the emergency department during a nursing shift change had similar rates of thrombolytic use and functional outcomes compared with patients presenting during nonshift change hours. A retrospective review of patients with acute ischemic stroke presenting to the emergency department of a primary stroke center from 2005 through 2010. The time to notify the stroke team, perform a head CT scan, and to start intravenous or intra-arterial thrombolysis was assessed. Thrombolysis rates, mortality rate, discharge disposition, change in the National Institutes of Health Stroke Scale, and change in modified Barthel Index at 3 and 12 months were assessed. Of 3133 patients with acute ischemic stroke, 917 met criteria for inclusion. Arrival during nursing shift change, weekends, and July through September had no impact on process times, thrombolysis rates, and functional outcomes. Arrival at night did result in longer time to intra-arterial but not to intravenous thrombolysis, higher mortality rate, and smaller gain in functional status as measured by the modified Barthel Index at 3 months. The degree of emergency department "busyness" also did not influence tissue-type plasminogen activator treatment times. Presentation during a nursing shift change, a time of transition of care, did not delay thrombolytic use in eligible patients with acute ischemic stroke. Presentation with acute ischemic stroke at night did result in delays of care for patients undergoing interventional therapies.

Stroke Team Remote Evaluation Using a Digital Observation Camera in Arizona

Background and Purpose— Telemedicine techniques can be used to address the rural–metropolitan disparity in acute stroke care. The Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) trial reported more accurate decision making for telemedicine consultations compared with telephone-only and that the California-based research network facilitated a high rate of thrombolysis use, improved data collection, low risk of complications, low technical complications, and favorable assessment times. The main objective of the STRokE DOC Arizona TIME (The Initial Mayo Clinic Experience) trial was to determine the feasibility of establishing, de novo, a single-hub, multirural spoke hospital telestroke research network across a large geographical area in Arizona by replicating the STRokE DOC protocol. Methods— Methods included prospective, single-hub, 2-spoke, randomized, blinded, controlled trial of a 2-way, site-independent, audiovisual telemedicine system designed for remote examination of adult patients with acute stroke versus telephone consultation to assess eligibility for treatment with intravenous thrombolysis. The primary outcome measure was whether the decision to give thrombolysis was correct. Secondary outcomes were rate of thrombolytic use, 90-day functional outcomes, incidence of intracerebral hemorrhages, and technical observations. Results— From December 2007 to October 2008, 54 patients were assessed, 27 of whom were randomized to each arm. Mean National Institutes of Health Stroke Scale score at presentation was 7.3 (SD 6.2) points. No consultations were aborted; however, technical problems (74%) were prevalent in the telemedicine arm. Overall, the correct treatment decision was established in 87% of the consultations. Both modalities, telephone (89% correct) and telemedicine (85% correct), performed well. Intravenous thrombolytic treatment was used in 30% of the telemedicine and telephone consultations. Good functional outcomes at 90 days were not significantly different. There were no statistically significant differences in mortality (4% in telemedicine and 11% in telephone) or rates of intracerebral hemorrhage (4% in telemedicine and 0% in telephone). Conclusions— It is feasible to extend the original STRokE DOC trial protocol to a new state and establish an operational single-hub, multispoke rural hospital telestroke research network in Arizona. The trial was not designed to have sufficient power to detect a difference between the 2 consultative modes: telemedicine and telephone-only. Whether by telemedicine or telephone consultative modalities, there were appropriate treatment decisions, high rates of thrombolysis use, improved data collection, low rates of intracerebral hemorrhage, and equally favorable time requirements. The learning curve was steep for the hub and spoke personnel of the new telestroke network, as reflected by frequent technical problems. Overall, the results support the effectiveness of highly organized and structured stroke telemedicine networks for extending expert stroke care into rural remote communities lacking sufficient neurological expertise.

Temporal Trends in Public Awareness of Stroke

Delay in seeking medical attention after stroke symptom onset is the most important reason for low rates of thrombolytic use for ischemic stroke (IS) in the United States. This may be related to poor recognition of stroke symptoms, or to lack of awareness of time-sensitive stroke treatments. We describe public knowledge of t-PA as a treatment for IS, as well as changes over time in knowledge of stroke warning signs (WS) and risk factors (RF). Survey respondents were drawn from our biracial population of 1.3 million using random-digit dialing in 1995, 2000, and 2005 to reflect the age, race, and gender distribution of stroke patients, based on an ongoing stroke incidence study in the same region. They were asked open-ended questions regarding stroke WS, RF, and, in 2005, specific questions regarding t-PA. Comparisons over time were made using chi(2) analysis, and were corrected for multiple comparisons. Over the 10-year study period, 6209 surveys were completed. Knowledge of WS and RF improved between 1995 and 2000. Between 2000 and 2005, knowledge did not improve significantly; however, there was a significant improvement in knowledge of 3 warning signs (12% in 1995 vs 16% in 2005, P=0.0004). In 2005, only 3.6% of those surveyed were able to independently name t-PA or "clot buster" when asked: "Suppose you were having a stroke. Do you know of any medication your doctor could give you into the vein to increase your chance of recovering from a stroke?"-although 19% claimed to have heard of t-PA once it was mentioned to them. Despite numerous national stroke public awareness campaigns, public knowledge of stroke WS and RF has not improved over the last 5 years. In addition, knowledge of t-PA as a treatment for IS is extremely poor. Public awareness messages in the future should focus on the possibility of urgent treatments, in addition to stroke WS and RF, so the public can translate their knowledge into action and present to medical attention more quickly. This may be the highest yield approach to increasing rates of treatment of IS with t-PA.

Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study

To increase the effective use of thrombolytics for acute stroke, the expertise of vascular neurologists must be disseminated more widely. We prospectively assessed whether telemedicine (real-time, two-way audio and video, and digital imaging and communications in medicine [DICOM] interpretation) or telephone was superior for decision making in acute telemedicine consultations. From January, 2004, to August, 2007, patients older than 18 years who presented with acute stroke symptoms at one of four remote spoke sites were randomly assigned, through a web-based, permuted blocks system, to telemedicine or telephone consultation to assess their suitability for treatment with thrombolytics, on the basis of standard criteria. The primary outcome measure was whether the decision to give thrombolytic treatment was correct, as determined by central adjudication. Secondary outcomes were the rate of thrombolytic use, 90-day functional outcomes (Barthel index [BI] and modified Rankin scale [mRS]), the incidence of intracerebral haemorrhages, and technical observations. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00283868. 234 patients were assessed prospectively. 111 patients were randomised to telemedicine, and 111 patients were randomised to telephone consultation; 207 completed the study. Mean National Institutes of Health stroke scale score at presentation was 9.5 (SD 8.1) points (11.4 [8.7] points in the telemedicine group versus 7.7 [7.0] points in the telephone group; p=0.002). One telemedicine consultation was aborted for technical reasons, although it was included in the analyses. Correct treatment decisions were made more often in the telemedicine group than in the telephone group (108 [98%] vs 91 [82%], odds ratio [OR] 10.9, 95% CI 2.7-44.6; p=0.0009). Intravenous thrombolytics were used at an overall rate of 25% (31 [28%] telemedicine vs 25 [23%] telephone, 1.3, 0.7-2.5; p=0.43). 90-day functional outcomes were not different for BI (95-100) (0.6, 0.4-1.1; p=0.13) or for mRS score (0.6, 0.3-1.1; p=0.09). There was no difference in mortality (1.6, 0.8-3.4; p=0.27) or rates of intracerebral haemorrhage after treatment with thrombolytics (2 [7%] telemedicine vs 2 [8%] telephone, 0.8, 0.1-6.3; p=1.0). However, there were more incomplete data in the telephone group than in the telemedicine group (12%vs 3%, 0.2, 0.1-0.3; p=0.0001). The authors of this trial report that stroke telemedicine consultations result in more accurate decision making compared with telephone consultations and can serve as a model for the effectiveness of telemedicine in other medical specialties. The more appropriate decisions, high rates of thrombolysis use, improved data collection, low rate of intracerebral haemorrhage, low technical complications, and favourable time requirements all support the efficacy of telemedicine for making treatment decisions, and might enable more practitioners to use this medium in daily stroke care.

National US Estimates of Recombinant Tissue Plasminogen Activator Use

Current US estimates of recombinant tissue plasminogen activator (rt-PA) use have been based either on extrapolation of regional studies or on administrative database estimates, both of which may have inherent biases. We sought to compare the utilization of rt-PA in acute ischemic stroke in the MEDPAR database to another national hospital database with drug utilization information. Cases were defined as DRG 14,15, and 524 and ICD-9 code 99.1, which indicates cerebral thrombolysis, for fiscal year 2001 to 2004. Additionally, the Premier database was queried for rt-PA utilization documented in pharmacy records in those patients admitted for stroke. Change over time and difference between databases were tested using Poisson regression. When comparing databases, rt-PA use, as identified by ICD-9 code 99.1, was only documented in 0.95% of stroke cases in 2004 in MEDPAR, and 1.2% in the Premier database, which slightly increased by 0.04% to 0.09% over time. Analysis of pharmacy billing records increased the estimate to 1.82%. Exclusion of cases younger than 65 years excluded 43% of cases treated with rt-PA. In 2004, 12.7% of cases receiving thrombolytic had either a TIA or a hemorrhagic stroke ICD-9 code. We estimate the rate of rt-PA use in the United States to be 1.8% to 2.1% of ischemic stroke patients. The rate of thrombolytic use for ischemic stroke was slightly increasing between 2001 and 2004 at a rate of 0.04% to 0.09% per year. A significant proportion of patients treated with rt-PA are likely miscoded as either TIA or hemorrhagic stroke. We conservatively estimate that 10,800 to 12,600 patients received rt-PA in 2004.

Regional and Racial Variations in the Use of Thrombolytic Therapy for Acute Stroke at US Academic Medical Centers: The UHC Stroke Benchmarking Project

P198 BACKGROUND: Few national data are available regarding current status stroke thrombolytic use in the US. This information is important to identify trends in acute stroke management and potential barriers to therapy. To address this issue, the UHC Stroke Benchmarking Project recently assessed the status of thrombolytic therapy in a survey of academic medical centers around the country. METHODS: Between 11/17/99 and 12/27/99, a comprehensive questionnaire was retrospective completed on a consecutive sample of acute stroke patients admitted to each participating hospital. Extensive demographic information regarding the use of thrombolytic therapy in these patients was also obtained. RESULTS: 42 hospitals participated in the study. The hospitals were evenly distributed between the Northeast (n=11), Midwest (n=10), South (n=9) and West (n=12). Overall, of the 1196 patients included in the study, 66 (5.5%) received thrombolytic treatment (55 IV, 11 IA). 190 patients were considered IV thrombolytic eligible, and 32.8% of these received thrombolytic treatment. There were significant regional and racial variations in thrombolytic use. The rate of thrombolytic use was lowest in the South (1.2%) and highest in the MW (9.5%). 64.3% of thrombolytic eligible patients received treatment in the MW, while only 7.7% of eligible patients received treatment in the South (OR 10.3, CI 2.4–44.5, p&lt;0.005). Logistic regression analysis also revealed that Caucasians had a significantly greater probability of treatment than non-Caucasians (OR 3.7 CI 1.4–9.9, p=0.0056). Conclusion: At academic medical centers, a low proportion of patients receive thrombolytic therapy. Moreover, these data indicate that there are significant regional and race specific differences in thrombolytic therapy which should be addressed in order to increase the rate of thrombolytic use nationwide. The UHC database could be a useful mechanism by which monitor such changes in acute stroke care.

Regional and Racial Variations in the Use of Thrombolytic Therapy for Acute Stroke at US Academic Medical Centers: The UHC Stroke Benchmarking Project

P198 BACKGROUND: Few national data are available regarding current status stroke thrombolytic use in the US. This information is important to identify trends in acute stroke management and potential barriers to therapy. To address this issue, the UHC Stroke Benchmarking Project recently assessed the status of thrombolytic therapy in a survey of academic medical centers around the country. METHODS: Between 11/17/99 and 12/27/99, a comprehensive questionnaire was retrospective completed on a consecutive sample of acute stroke patients admitted to each participating hospital. Extensive demographic information regarding the use of thrombolytic therapy in these patients was also obtained. RESULTS: 42 hospitals participated in the study. The hospitals were evenly distributed between the Northeast (n=11), Midwest (n=10), South (n=9) and West (n=12). Overall, of the 1196 patients included in the study, 66 (5.5%) received thrombolytic treatment (55 IV, 11 IA). 190 patients were considered IV thrombolytic eligible, and 32.8% of these received thrombolytic treatment. There were significant regional and racial variations in thrombolytic use. The rate of thrombolytic use was lowest in the South (1.2%) and highest in the MW (9.5%). 64.3% of thrombolytic eligible patients received treatment in the MW, while only 7.7% of eligible patients received treatment in the South (OR 10.3, CI 2.4–44.5, p Conclusion: At academic medical centers, a low proportion of patients receive thrombolytic therapy. Moreover, these data indicate that there are significant regional and race specific differences in thrombolytic therapy which should be addressed in order to increase the rate of thrombolytic use nationwide. The UHC database could be a useful mechanism by which monitor such changes in acute stroke care.

Translation of clinical trials into practice: a European population-based study of the use of thrombolysis for acute myocardial infarction

Summary Background There is conclusive evidence from clinical trials that thrombolytic therapy reduces mortality in acute myocardial infarction (AMI). But still only a minority of patients admitted with AMI receive a thrombolytic drug. We have looked at a sample of AMI patients from several centres to study which factors limit the widespread use of thrombolytic therapy. Methods From eleven European countries, we drew a sample of 4035 patients who were discharged or died in hospital with a diagnosis of AMI between January, 1993, and June, 1994. From the medical records, we obtained the observed rate of thrombolytic use, and we defined the shortfall as the proportion of patients with no contraindication but who did not receive a thrombolytic. Findings Thrombolytic treatment had been used in 13-52% (median 36%) of the patients. Among untreated patients, we identified three groups of similar size: those whose symptom onset was more than 12 h (or unknown) before presentation; those causing diagnostic difficulty at presentation and/or lacking ECG criteria for treatment; and those with no apparent reason for withholding thrombolytic treatment (ie, the shortfall, which was 20%). Logistic regression analysis in all patients without contraindications showed that older patients and women were less likely to receive thrombolytic treatment. The adjusted odds ratio for female sex was 0·69 (95% Cl 0·53-0·89), and that for age 65-74, for instance (versus 0-44), was 0·55 (0·34-0·89). These factors of age and sex were independent, and we noted that older patients and women were underrepresented in the clinical trials of thrombolytic therapy for AMI. Interpretation We confirmed that only about one-third of patients admitted to European hospitals with AMI receive a thrombolytic drug. Allowing for delays to presentation and difficulty of early diagnosis, the maximum rate of thrombolysis is about 55%. The lower use of thrombolysis in the elderly may be due to their under-representation in the clinical trials; the sex difference is unexplained.