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Implementation Science
Published in: Implementation Science 1/2015

Open Access 01-12-2015 | Systematic review

How can we improve stroke thrombolysis rates? A review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care

Authors: Christine L. Paul, Annika Ryan, Shiho Rose, John R. Attia, Erin Kerr, Claudia Koller, Christopher R. Levi

Published in: Implementation Science | Issue 1/2015

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Abstract

Background

Thrombolysis using intravenous (IV) tissue plasminogen activator (tPA) is one of few evidence-based acute stroke treatments, yet achieving high rates of IV tPA delivery has been problematic. The 4.5-h treatment window, the complexity of determining eligibility criteria and the availability of expertise and required resources may impact on treatment rates, with barriers encountered at the levels of the individual clinician, the social context and the health system itself. The review aimed to describe health system factors associated with higher rates of IV tPA administration for ischemic stroke and to identify whether system-focussed interventions increased tPA rates for ischemic stroke.

Methods

Published original English-language research from four electronic databases spanning 1997–2014 was examined. Observational studies of the association between health system factors and tPA rates were described separately from studies of system-focussed intervention strategies aiming to increase tPA rates. Where study outcomes were sufficiently similar, a pooled meta-analysis of outcomes was conducted.

Results

Forty-one articles met the inclusion criteria: 7 were methodologically rigorous interventions that met the Cochrane Collaboration Evidence for Practice and Organization of Care (EPOC) study design guidelines and 34 described observed associations between health system factors and rates of IV tPA. System-related factors generally associated with higher IV tPA rates were as follows: urban location, centralised or hub and spoke models, treatment by a neurologist/stroke nurse, in a neurology department/stroke unit or teaching hospital, being admitted by ambulance or mobile team and stroke-specific protocols. Results of the intervention studies suggest that telemedicine approaches did not consistently increase IV tPA rates. Quality improvement strategies appear able to provide modest increases in stroke thrombolysis (pooled odds ratio = 2.1, p = 0.05).

Conclusions

In order to improve IV tPA rates in acute stroke care, specific health system factors need to be targeted. Multi-component quality improvement approaches can improve IV tPA rates for stroke, although more thoughtfully designed and well-reported trials are required to safely increase rates of IV tPA to eligible stroke patients.
Literature
1.
Lopez AD, Mathers CD, Ezatti M, Jamieson DT, Murray DJL. Global burden of disease and risk factors. New York/Washington: Oxford University Press and the World Bank; 2006.CrossRef
2.
Mackay J, Mensah G. The atlas of heart disease and stroke. Geneva: WHO; 2004.
3.
Agency for Healthcare Research and Quality. Household component summary table. In: Medical Expenditure Panel Survey. U.S. Department of Health and Human Services. 2012. http://​meps.​ahrq.​gov/​mepsweb/​. Accessed 12 Nov 2012.
4.
Australian Bureau of Statistics. Cardiovascular disease in Australia: a snapshot, 2004-05. Canberra: ABS; 2006.
5.
Australian Institute of Health and Welfare. Australia’s health 2006. Report. Canberra: AIHW; 2006. Report No.:1032-6138.
6.
Deloitte Access Economics. The economic impact of stroke in Australia. Melbourne: NSF; 2013.
7.
National Stroke Foundation. National stroke audit—acute services clinical audit report 2011. Report. Melbourne: NSF; 2011.
8.
Hankey GJ, Jamrozik K, Broadhurst RJ, Forbes S, Anderson CS. Long-term disability after first-ever stroke and related prognostic factors in the Perth Community Stroke Study, 1989–1990. Stroke. 2002;33(4):1034–40.CrossRefPubMed
9.
Saver J, Fonarow G, Smith E, Reeves M, Grau-Sepulveda M, Pan W, et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA. 2013;309(23):2480–8.CrossRefPubMed
10.
Hacke W, Kaste M, Bluhmki E, Brozman M, Dávalos A, Guidetti D, et al. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med. 2008;359(13):1317–29.CrossRefPubMed
11.
Ahmed N, Wahlgren N, Grond M, Hennerici M, Lees KR, Mikulik R, et al. Implementation and outcome of thrombolysis with alteplase 3–4.5 h after an acute stroke: an updated analysis from SITS-ISTR. Lancet Neurol. 2010;9(9):866–74.CrossRefPubMed
12.
Strbian D, Michel P, Ringleb P, Numminen H, Breuer L, Bodenant M, et al. Relationship between onset-to-door time and door-to-thrombolysis time: a pooled analysis of 10 dedicated stroke centers. Stroke. 2013;44(10):2808–13.CrossRefPubMed
13.
Quain DA, Parsons MW, Loudfoot AR, Spratt NJ, Evans MK, Russell ML, et al. Improving access to acute stroke therapies: a controlled trial of organised pre-hospital and emergency care. Med J Aust. 2008;189(8):429–33.PubMed
14.
Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ. 2008;337.
15.
Bunch ME, Nunziato EC, Labovitz DL. Barriers to the use of intravenous tissue plasminogen activator for in-hospital strokes. J Stroke Cerebrovasc Dis. 2012;21(8):808–11.CrossRefPubMed
16.
Johnson M, Bakas T. A review of barriers to thrombolytic therapy: implications for nursing care in the emergency department. J Neurosci Nurs. 2010;42(2):88–94.CrossRefPubMed
17.
Kwan J, Hand P, Sandercock P. A systematic review of barriers to delivery of thrombolysis for acute stroke. Age Ageing. 2004;33(2):116–21.CrossRefPubMed
18.
Upchurch GR, Dimick JB, Wainess RM, Eliason JL, Henke PK, Cowan JA, et al. Diffusion of new technology in health care: the case of aorto-iliac occlusive disease. Surgery. 2004;136(4):812–8.CrossRefPubMed
19.
Jaffe AB, Newell RG, Stavins RN. A tale of two market failures: technology and environmental policy. Ecol Econ. 2005;54(2):164–74.CrossRef
20.
Michie S, van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci. 2011;6(1):42.CrossRefPubMedPubMedCentral
21.
Adeoye O, Hornung R, Khatri P, Kleindorfer D. Recombinant tissue-type plasminogen activator use for ischemic stroke in the United States: a doubling of treatment rates over the course of 5 years. Stroke. 2011;42(7):1952–5.CrossRefPubMedPubMedCentral
22.
Bergman M, Ori Y, Blumberger N, Salman H. An alternative facility for a stroke unit in a community hospital. Eur J Intern Med. 2011;22(5):505–8.CrossRefPubMed
23.
Dick AP, Straka J. IV tPA for acute ischemic stroke: results of the first 101 patients in a community practice. Neurologist. 2005;11(5):305–8.CrossRefPubMed
24.
Slaght SJ, Weir NU, Lovett JK. The workload of stroke thrombolysis: a prospective study in a district general hospital setting. Acute Med. 2011;10(1):10–2.PubMed
25.
Douglas VC, Tong DC, Gillum LA, Zhao S, Brass LM, Dostal J, et al. Do the brain attack coalition’s criteria for stroke centers improve care for ischemic stroke? Neurology. 2005;64(3):422–7.CrossRefPubMed
26.
Prabhakaran S, McNulty M, O’Neill K, Ouyang B. Intravenous thrombolysis for stroke increases over time at primary stroke centers. Stroke. 2012;43(3):875–7.CrossRefPubMed
27.
Ranta A, Chan C, Rump D, Cariga P, Anderson L. Safety and efficacy of stroke thrombolysis at a secondary provincial hospital in New Zealand. N Z Med J. 2012;125(1358):35–43.PubMed
28.
Salami S, Kolluru A, Al-Najafi S, Stover C, Mar A, Szpunar S, et al. Utilization and outcome of thrombolytic therapy for acute ischemic stroke: the St. John Hospital code stroke experience. J Clin Outcomes Manag. 2011;18(4):165–9.
29.
30.
Nelson RE, Saltzman GM, Skalabrin EJ, Demaerschalk B, Majersik JJ. The cost-effectiveness of telestroke in the treatment of acute ischemic stroke. Neurology. 2011;77(17):1590–8.CrossRefPubMedPubMedCentral
31.
Schwamm LH, Audebert HJ, Amarenco P, Chumbler NR, Frankel MR, George MG, et al. Recommendations for the implementation of telemedicine within stroke systems of care: a policy statement from the American Heart Association. Stroke. 2009;40:2635–60.CrossRefPubMed
32.
Schwamm LH, Fonarow GC, Reeves MJ, Pan W, Frankel MR, Smith EE, et al. Get With The Guidelines-Stroke is associated with sustained improvement in care for patients hospitalized with acute stroke or transient ischemic attack. Circulation. 2009;119(1):107–15.CrossRefPubMed
33.
van Wijngaarden JDH, Dirks M, Niessen LW, Huijsman R, Dippel DWJ. Do centres with well-developed protocols, training and infrastructure have higher rates of thrombolysis for acute ischemic stroke? QJM. 2011;104(9):785–91.CrossRefPubMed
34.
FDA. Alteplase product approval information—licensing action 6/18/96. 04/02/2009 ed: U.S. Food and Drug Administration; 1996.
35.
Adams HP, Brott TG, Furlan AJ, Gomez CR, Grotta J, Helgason CM, et al. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke: a statement for healthcare professionals from a special writing group of the stroke council. Am Heart Assoc Circ. 1996;94(5):1167–74.
36.
Popay J, Roberts H, Sowden A, Petticrew M, Arai L, Rodgers M, et al. Guidance on the conduct of narrative synthesis in systematic reviews, A product from the ESRC methods programme version. 2006. p. 1.
37.
38.
Demaerschalk BM, Bobrow BJ, Raman R, Kiernan T-EJ, Aguilar MI, Ingall TJ, et al. Stroke team remote evaluation using a digital observation camera in Arizona: the initial Mayo Clinic experience trial. Stroke. 2010;41(6):1251–8.CrossRefPubMedPubMedCentral
39.
Meyer BC, Raman R, Hemmen T, Obler R, Zivin JA, Rao R, et al. Efficacy of site-independent telemedicine in the STRokE DOC trial: a randomised, blinded, prospective study. Lancet Neurol. 2008;7(9):787–95.CrossRefPubMedPubMedCentral
40.
Theiss S, Günzel F, Storm A, Hausn P, Isenmann S, Klisch J, et al. Using routine data for quality assessment in NeuroNet telestroke care. J Stroke Cerebrovasc Dis. 2013;22(7):984–90.CrossRefPubMed
41.
Dirks M, Koudstaal PJ, Dippel DWJ, Niessen LW, van Wijngaarden JDH, Franke CL, et al. Effectiveness of thrombolysis with intravenous alteplase for acute ischemic stroke in older adults. J Am Geriatr Soc. 2011;59(11):2169–71.CrossRefPubMed
42.
Morgenstern LB, Bartholomew LK, Grotta JC, Staub L, King M, Chan W. Sustained benefit of a community and professional intervention to increase acute stroke therapy. Arch Intern Med. 2003;163(18):2198–202.CrossRefPubMed
43.
Scott PA, Meurer WJ, Frederiksen SM, Kalbfleisch JD, Xu Z, Haan MN, et al. A multilevel intervention to increase community hospital use of alteplase for acute stroke (INSTINCT): a cluster-randomised controlled trial. Lancet Neurol. 2013;12(2):139–48.CrossRefPubMed
44.
Fonarow GC, Smith EE, Saver JL, Reeves MJ, Hernandez AF, Peterson ED, et al. Improving door-to-needle times in acute ischemic stroke: the design and rationale for the American Heart Association/American Stroke Association’s target: stroke initiative. Stroke. 2011;42(10):2983–9.CrossRefPubMed
45.
Power M, Tyrrell PJ, Rudd AG, Tully MP, Dalton D, Marshall M, et al. Did a quality improvement collaborative make stroke care better? A cluster randomized trial. Implement Sci. 2014;9(40):9pp.
46.
Demaerschalk BM, Raman R, Ernstrom K, Meyer BC. Efficacy of telemedicine for stroke: pooled analysis of the Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC) and STRokE DOC Arizona telestroke trials. Telemed J E Health. 2012;18(3):230–7.CrossRefPubMedPubMedCentral
47.
Atun R. Health systems, systems thinking and innovation. Health Policy Plan. 2012;27 suppl 4:iv4–8.CrossRefPubMed
48.
Kunisawa S, Morishima T, Ukawa N, Ikai H, Otsubo T, Ishikawa KB, et al. Association of geographical factors with administration of tissue plasminogen activator for acute ischemic stroke. J Am Heart Assoc. 2013;2(5), e000336.CrossRefPubMedPubMedCentral
49.
Hsieh CY, Chen CH, Chen YC, Kao Yang YH. National survey of thrombolytic therapy for acute ischemic stroke in Taiwan 2003–2010. J Stroke Cerebrovasc Dis. 2013;22(8):e620–7.CrossRefPubMed
50.
Kunisawa S, Kobayashi D, Lee J, Otsubo T, Ikai H, Yokota C, et al. Factors associated with the administration of tissue plasminogen activator for acute ischemic stroke. J Stroke Cerebrovasc Dis. 2014;23(4):724–31.CrossRefPubMed
51.
Albright KC, Schott TC, Jafari N, Wohlford-Wessels MP, Finnerty EP, Jacoby MRK. Tissue plasminogen activator use: Evaluation and initial management of ischemic stroke from an Iowa Hospital perspective. J Stroke Cerebrovasc Dis. 2005;14(3):127–35.CrossRefPubMed
52.
Leyden JM, Chong WK, Kleinig T, Lee A, Field JB, Jannes J. A population-based study of thrombolysis for acute stroke in South Australia. Med J Aust. 2011;194(3):111–5.PubMed
53.
Acharya AB, Nyirenda JC, Higgs GB, Bloomfield MS, Cruz-Flores S, Connor LT, et al. Distance from home to hospital and thrombolytic utilization for acute ischemic stroke. J Stroke Cerebrovasc Dis. 2011;20(4):295–301.CrossRefPubMed
54.
Kozera G, Chwojnicki K, Gojska-Grymajło A, Gasecki D, Schminke U, Nyka WM. Pre-hospital delays and intravenous thrombolysis in urban and rural areas. Acta Neurol Scand. 2012;126:171–7.CrossRefPubMed
55.
Nasr DM, Brinjikji W, Cloft HJ, Rabinstein AA. Utilization of intravenous thrombolysis is increasing in the United States. Int J Stroke. 2013;8(8):681–8.CrossRefPubMed
56.
Reed SD, Cramer SC, Blough DK, Meyer K, Jarvik JG. Treatment with tissue plasminogen activator and inpatient mortality rates for patients with ischemic stroke treated in community hospitals. Stroke. 2001;32(8):1832–40.CrossRefPubMed
57.
Lahr MMH, Luijckx G-J, Vroomen PCAJ, van der Zee D-J, Buskens E. Proportion of patients treated with thrombolysis in a centralized versus a decentralized acute stroke care setting. Stroke. 2012;43(5):1336–40.CrossRefPubMed
58.
Charipar R, Charipar E. Administration of tissue plasminogen activator for acute ischemic stroke in a rural Wisconsin hospital. Wis Med J. 2008;107(4):176–80.
59.
Wang Y, Liao X, Zhao X, Wang DZ, Wang C, Nguyen-Huynh MN, et al. Using recombinant tissue plasminogen activator to treat acute ischemic stroke in China: analysis of the results from the Chinese National Stroke Registry (CNSR). Stroke. 2011;42(6):1658–64.CrossRefPubMed
60.
Eriksson M, Jonsson F, Appelros P, Asberg KH, Norrving B, Stegmayr B, et al. Dissemination of thrombolysis for acute ischemic stroke across a nation: experiences from the Swedish stroke register, 2003 to 2008. Stroke. 2010;41(6):1115–22.CrossRefPubMed
61.
Heuschmann PU, Berger K, Misselwitz B, Hermanek P, Leffmann C, Adelmann M, et al. Frequency of thrombolytic therapy in patients with acute ischemic stroke and the risk of in-hospital mortality: the German Stroke Registers Study Group. Stroke. 2003;34(5):1106–13.CrossRefPubMed
62.
Jeng J-S, Tang S-C, Deng I-C, Tsai L-K, Yeh S-J, Yip P-K. Stroke center characteristics which influence the administration of thrombolytic therapy for acute ischemic stroke: a national survey of stroke centers in Taiwan. J Neurol Sci. 2009;281:24–7.CrossRefPubMed
63.
Kansara A, Chaturvedi S, Bhattacharya P. Thrombolysis and outcome of young stroke patients over the last decade: insights from the Nationwide Inpatient Sample. J Stroke Cerebrovasc Dis. 2013;22(6):799–804.CrossRefPubMed
64.
Nilanont Y, Nidhinandana S, Suwanwela NC, Hanchaiphiboolkul S, Pimpak T, Tatsanavivat P, et al. Quality of acute ischemic stroke care in Thailand: a prospective multicenter countrywide cohort study. J Stroke Cerebrovasc Dis. 2014;23(2):213–9.CrossRefPubMed
65.
Hills NK, Johnston SC. Why are eligible thrombolysis candidates left untreated? Am J Prev Med. 2006;31(6 Suppl 2):S210–6.CrossRefPubMed
66.
Bray BD, Campbell J, Cloud GC, Hoffman A, Tyrrell PJ, Wolfe CDA, et al. Bigger, faster?: associations between hospital thrombolysis volume and speed of thrombolysis administration in acute ischemic stroke. Stroke. 2013;44(11):3129–35.CrossRefPubMed
67.
Engelter ST, Gostynski M, Papa S, Ajdacic-Gross V, Lyrer PA. Barriers to stroke thrombolysis in a geographically defined population. Cerebrovasc Dis. 2007;23(2-3):211–5.CrossRefPubMed
68.
Moradiya Y, Crystal H, Valsamis H, Levine SR. Thrombolytic utilization for ischemic stroke in US hospitals with neurology residency program. Neurology. 2013;81(23):1986–95.CrossRefPubMedPubMedCentral
69.
70.
Madej-Fermo OP, Staff I, Fortunato G, Abbott L, McCullough LD. Impact of emergency department transitions of care on thrombolytic use in acute ischemic stroke. Stroke. 2012;43(4):1067–74.CrossRefPubMed
71.
Hoh BL, Chi Y-Y, Waters MF, Mocco J, Barker 2nd FG. Effect of weekend compared with weekday stroke admission on thrombolytic use, in-hospital mortality, discharge disposition, hospital charges, and length of stay in the Nationwide Inpatient Sample Database, 2002 to 2007. Stroke. 2010;41(10):2323–8.CrossRefPubMed
72.
Keyhani S, Arling G, Williams LS, Ross JS, Ordin DL, Myers J, et al. The use and misuse of thrombolytic therapy within the Veterans Health Administration. Med Care. 2012;50(1):66–73.CrossRefPubMed
73.
Iguchi Y, Kimura K, Watanabe M, Shibazaki K, Aoki J. Utility of the Kurashiki prehospital stroke scale for hyperacute stroke. Cerebrovasc Dis. 2011;31(1):51–6.CrossRefPubMed
74.
McKinney JS, Mylavarapu K, Lane J, Roberts V, Ohman-Strickland P, Merlin MA. Hospital prenotification of stroke patients by emergency medical services improves stroke time targets. J Stroke Cerebrovasc Dis. 2013;22(2):113–8.CrossRefPubMed
75.
Lin CB, Peterson ED, Smith EE, Saver JL, Liang L, Xian Y, et al. Emergency medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke. Circ Cardiovasc Qual Outcomes. 2012;5(4):514–22.CrossRefPubMed
76.
Nagaraja N, Bhattacharya P, Norris G, Coplin W, Narayanan S, Xavier A, et al. Arrival by ambulance is associated with acute stroke intervention in young adults. J Neurol Sci. 2012;316(1-2):168–9.CrossRefPubMed
77.
78.
Joux J, Olindo S, Girard-Claudon A, Chausson N, Saint-Vil M, Signate A, et al. Prehospital transfer medicalization increases thrombolysis rate in acute ischemic stroke. A French stroke unit experience. Clin Neurol Neurosurg. 2013;115(9):1583–5.CrossRefPubMed
79.
Ekundayo OJ, Saver JL, Fonarow GC, Schwamm LH, Xian Y, Zhao X, et al. Patterns of emergency medical services use and its association with timely stroke treatment findings from Get With The Guidelines-Stroke. Circ Cardiovasc Qual Outcomes. 2013;6(3):262–9.CrossRefPubMed
Metadata
Title
How can we improve stroke thrombolysis rates? A review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care
Authors
Christine L. Paul
Annika Ryan
Shiho Rose
John R. Attia
Erin Kerr
Claudia Koller
Christopher R. Levi
Publication date
01-12-2015
Publisher
BioMed Central
Published in
Implementation Science / Issue 1/2015
Electronic ISSN: 1748-5908
DOI
https://doi.org/10.1186/s13012-016-0414-6

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