Stroke: tPA Used More Frequently in Teaching Hospitals, Elderly

Yogesh Moradiya MBBS From the Neurosciences Critical Care Division Johns Hopkins University, Baltimore, MD; Interview with:
Yogesh Moradiya MBBS
From the Neurosciences Critical Care Division
Johns Hopkins University, Baltimore, MD; What are the main findings of the study?

Answer: We studied 712,433 stroke cases in 6,839 hospital samples in United States over 11-year study period (2000-2010) and found that hospitals with neurology residency training program treated stroke patients with tissue plasminogen activator (tPA) more frequently than other teaching or non-teaching hospitals. The higher tPA utilization in hospitals with neurology residencies was independent of patient age, gender, ethnicity, insurance status, comorbidities, hospital geographic location, stroke case volume, calendar year and the Joint Commission Primary Stroke Center certification. Were any of the findings unexpected?

Answer:   A notable finding of the study was the striking difference in the tPA utilization disparity among elderly compared to that among younger patients. While the tPA rates for patients younger than 45 yeas were similar in hospitals with neurology residencies to those in other teaching and non-teaching hospitals, for patients 85 years or older, the adjusted tPA rate in hospitals with neurology residencies was 2-fold higher compared to other teaching hospitals and 3-fold higher compared to non-teaching hospitals. What should clinicians and patients take away from your report?

Answer: Identification of barriers to the underutilized tPA treatment is important for targeted interventions. Our finding of hospital academic status as an independent factor linked to tPA utilization can potentially influence organizational operations and quality of care metrics. Several unmeasured factors such as presence of fellowship trained vascular neurologists, 24/7 in-hospital neurology coverage for acute stroke cases and tendency for evidence based treatment may have directly or indirectly influenced tPA utilization in hospitals with neurology residencies.

It is important for our patients to realize that we do not recommend to search for a hospital with neurology residency when they experience stroke like symptoms in order to improve likelihood of getting tPA treatment based on our results. Acute stroke is an emergency condition and calling the emergency medical services is the most appropriate action to take which ensures prompt transport to the nearest hospital with required facilities for stroke treatment. What recommendations do you have for future research as a result of this study?

Answer: Future research should focus on the factors directly responsible for the differences in the tPA utilization such as determining whether initial assessment and decision to treat stroke patients in hospitals with neurology residencies are made by the residents, vascular neurology fellows, general neurology attendings or vascular neurologists. Factors responsible for low tPA utilization rate for elderly stroke patients in other teaching and non-teaching hospitals may include relative inexperience and resultant hesitation of physicians in using disability preventing but potentially dangerous tPA treatment and should be explored further.


Thrombolytic utilization for ischemic stroke in US hospitals with neurology residency program

Yogesh Moradiya, MD, Howard Crystal, MD, Helen Valsamis, MD
and Steven R. Levine, MD

Published online before print November 1, 2013, doi: 10.1212/01.wnl.0000436946.08647.b5 Neurology 

Last Updated on April 19, 2014 by Marie Benz MD FAAD