Speed of Stroke Treatment Lags for Most in U.S.

LOS ANGELES — Barely more than a quarter of all U.S. acute stroke patients eligible for treatment with intravenous tissue plasminogen activator received the drug within an hour after arriving at the hospital, according to a registry of more than 1,000 U.S. hospitals dedicated to evidence-based stroke care during 2003–2009.

Among the 641 hospitals in the registry that treated at least 10 stroke patients with intravenous tPA within 3 hours of symptom onset, only 7% of the hospitals achieved a door-to-needle time of 60 minutes or less in a majority of their patients, Dr. Gregg C. Fonarow said at the conference. U.S. guidelines call for administering tPA to eligible stroke patients within an hour of their arrival at primary or comprehensive stroke centers.

The analysis also showed that the patients who appropriately received IV tPA within an hour of hospitalization had a significant 1.8% absolute reduction in in-hospital mortality, from 10.4% in patients whose tPA dose was delayed beyond 1 hour to 8.6%. The results “identify substantial opportunities for improvement in the speed of tPA therapy,” said Dr. Fonarow, professor of medicine and associate chief of cardiology University of California, Los Angeles.

Further analysis showed that after adjustment for possible confounders, every 15-minute reduction in the door-to-needle time for tPA linked with a significant 5% relative reduction in in-hospital mortality.

Patients who received intravenous tPA within an hour of arrival also had a significantly higher rate of discharge to a rehabilitation facility and a reduced rate of needing discharge to a nursing facility or another hospital, and significantly fewer tPA complications, including a 0.9% reduction in symptomatic intracranial hemorrhages, from 5.6% in patients who received tPA beyond 1 hour to 4.7% in those treated within 1 hour.

The analysis used data collected during April 2003–September 2009 on nearly 600,000 patients with an acute ischemic stroke admitted to one of 1,259 U.S. hospitals participating in the Get With the Guidelines stroke registry of the American Heart Association and the American Stroke Association.

The analysis included only the 25,504 patients who received tPA within 3 hours of their symptom onset at 1,082 hospitals in the registry. Throughout the 6.5 years of the study, the door-to-needle time averaged 79 minutes, with 6,790 patients (27%) receiving tPA within an hour. During the study period, average door-to-needle time improved modestly, from 85 minutes in 2003 to 75 minutes in 2009.

Concurrent with Dr. Fonarow's report, the results were published online (Circulation 2011 Feb. 10 [doi:10.1161/CIRCULATIONAHA.110.974675]).

Dr. Fonarow has been a consultant to Pfizer, Merck, Schering Plough, Bristol Myers Squibb, and Sanofi-Aventis. He is an employee of the University of California, which holds a patent on retriever devices for treating acute stroke.

Only 7% of the hospitals achieved a door-to-needle time of 60 minutes or less in most of their patients.

Source DR. FONAROW

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Blunt Motivators May Speed tPA Use

It's a mistake to think that there is a one-size-fits-all intervention that will improve and speed up tPA use at all hospitals. The big stick approach stands a better chance of working, one that involves regulatory agencies or payers. If there were a stroke DRG (diagnosis-related group) that said stroke patients should receive tPA within 30 minutes, hospitals would figure out how to do it pretty quickly.

The 1.8% improved in-hospital mortality that Dr. Fonarow reports for patients treated with tPA within an hour of arriving at the hospital is significant, but I suspect the mortality improvement did not completely result from faster tPA treatment. Faster tPA use may be a marker for hospitals that are better organized and do a lot of things better for their stroke patients, which together maximize the stroke patients' survival.

WILLIAM J. MEURER, M.D., is a neurologist and emergency medicine physician at the University of Michigan in Ann Arbor. He reported having no disclosures.

LOS ANGELES — Barely more than a quarter of all U.S. acute stroke patients eligible for treatment with intravenous tissue plasminogen activator received the drug within an hour after arriving at the hospital, according to a registry of more than 1,000 U.S. hospitals dedicated to evidence-based stroke care during 2003–2009.

Among the 641 hospitals in the registry that treated at least 10 stroke patients with intravenous tPA within 3 hours of symptom onset, only 7% of the hospitals achieved a door-to-needle time of 60 minutes or less in a majority of their patients, Dr. Gregg C. Fonarow said at the conference. U.S. guidelines call for administering tPA to eligible stroke patients within an hour of their arrival at primary or comprehensive stroke centers.

The analysis also showed that the patients who appropriately received IV tPA within an hour of hospitalization had a significant 1.8% absolute reduction in in-hospital mortality, from 10.4% in patients whose tPA dose was delayed beyond 1 hour to 8.6%. The results “identify substantial opportunities for improvement in the speed of tPA therapy,” said Dr. Fonarow, professor of medicine and associate chief of cardiology University of California, Los Angeles.

Further analysis showed that after adjustment for possible confounders, every 15-minute reduction in the door-to-needle time for tPA linked with a significant 5% relative reduction in in-hospital mortality.

Patients who received intravenous tPA within an hour of arrival also had a significantly higher rate of discharge to a rehabilitation facility and a reduced rate of needing discharge to a nursing facility or another hospital, and significantly fewer tPA complications, including a 0.9% reduction in symptomatic intracranial hemorrhages, from 5.6% in patients who received tPA beyond 1 hour to 4.7% in those treated within 1 hour.

The analysis used data collected during April 2003–September 2009 on nearly 600,000 patients with an acute ischemic stroke admitted to one of 1,259 U.S. hospitals participating in the Get With the Guidelines stroke registry of the American Heart Association and the American Stroke Association.

The analysis included only the 25,504 patients who received tPA within 3 hours of their symptom onset at 1,082 hospitals in the registry. Throughout the 6.5 years of the study, the door-to-needle time averaged 79 minutes, with 6,790 patients (27%) receiving tPA within an hour. During the study period, average door-to-needle time improved modestly, from 85 minutes in 2003 to 75 minutes in 2009.

Concurrent with Dr. Fonarow's report, the results were published online (Circulation 2011 Feb. 10 [doi:10.1161/CIRCULATIONAHA.110.974675]).

Dr. Fonarow has been a consultant to Pfizer, Merck, Schering Plough, Bristol Myers Squibb, and Sanofi-Aventis. He is an employee of the University of California, which holds a patent on retriever devices for treating acute stroke.

Only 7% of the hospitals achieved a door-to-needle time of 60 minutes or less in most of their patients.

Source DR. FONAROW

View on the News

Blunt Motivators May Speed tPA Use

It's a mistake to think that there is a one-size-fits-all intervention that will improve and speed up tPA use at all hospitals. The big stick approach stands a better chance of working, one that involves regulatory agencies or payers. If there were a stroke DRG (diagnosis-related group) that said stroke patients should receive tPA within 30 minutes, hospitals would figure out how to do it pretty quickly.

The 1.8% improved in-hospital mortality that Dr. Fonarow reports for patients treated with tPA within an hour of arriving at the hospital is significant, but I suspect the mortality improvement did not completely result from faster tPA treatment. Faster tPA use may be a marker for hospitals that are better organized and do a lot of things better for their stroke patients, which together maximize the stroke patients' survival.

WILLIAM J. MEURER, M.D., is a neurologist and emergency medicine physician at the University of Michigan in Ann Arbor. He reported having no disclosures.

LOS ANGELES — Barely more than a quarter of all U.S. acute stroke patients eligible for treatment with intravenous tissue plasminogen activator received the drug within an hour after arriving at the hospital, according to a registry of more than 1,000 U.S. hospitals dedicated to evidence-based stroke care during 2003–2009.

Among the 641 hospitals in the registry that treated at least 10 stroke patients with intravenous tPA within 3 hours of symptom onset, only 7% of the hospitals achieved a door-to-needle time of 60 minutes or less in a majority of their patients, Dr. Gregg C. Fonarow said at the conference. U.S. guidelines call for administering tPA to eligible stroke patients within an hour of their arrival at primary or comprehensive stroke centers.

The analysis also showed that the patients who appropriately received IV tPA within an hour of hospitalization had a significant 1.8% absolute reduction in in-hospital mortality, from 10.4% in patients whose tPA dose was delayed beyond 1 hour to 8.6%. The results “identify substantial opportunities for improvement in the speed of tPA therapy,” said Dr. Fonarow, professor of medicine and associate chief of cardiology University of California, Los Angeles.

Further analysis showed that after adjustment for possible confounders, every 15-minute reduction in the door-to-needle time for tPA linked with a significant 5% relative reduction in in-hospital mortality.

Patients who received intravenous tPA within an hour of arrival also had a significantly higher rate of discharge to a rehabilitation facility and a reduced rate of needing discharge to a nursing facility or another hospital, and significantly fewer tPA complications, including a 0.9% reduction in symptomatic intracranial hemorrhages, from 5.6% in patients who received tPA beyond 1 hour to 4.7% in those treated within 1 hour.

The analysis used data collected during April 2003–September 2009 on nearly 600,000 patients with an acute ischemic stroke admitted to one of 1,259 U.S. hospitals participating in the Get With the Guidelines stroke registry of the American Heart Association and the American Stroke Association.

The analysis included only the 25,504 patients who received tPA within 3 hours of their symptom onset at 1,082 hospitals in the registry. Throughout the 6.5 years of the study, the door-to-needle time averaged 79 minutes, with 6,790 patients (27%) receiving tPA within an hour. During the study period, average door-to-needle time improved modestly, from 85 minutes in 2003 to 75 minutes in 2009.

Concurrent with Dr. Fonarow's report, the results were published online (Circulation 2011 Feb. 10 [doi:10.1161/CIRCULATIONAHA.110.974675]).

Dr. Fonarow has been a consultant to Pfizer, Merck, Schering Plough, Bristol Myers Squibb, and Sanofi-Aventis. He is an employee of the University of California, which holds a patent on retriever devices for treating acute stroke.

Only 7% of the hospitals achieved a door-to-needle time of 60 minutes or less in most of their patients.

Source DR. FONAROW

View on the News

Blunt Motivators May Speed tPA Use

It's a mistake to think that there is a one-size-fits-all intervention that will improve and speed up tPA use at all hospitals. The big stick approach stands a better chance of working, one that involves regulatory agencies or payers. If there were a stroke DRG (diagnosis-related group) that said stroke patients should receive tPA within 30 minutes, hospitals would figure out how to do it pretty quickly.

The 1.8% improved in-hospital mortality that Dr. Fonarow reports for patients treated with tPA within an hour of arriving at the hospital is significant, but I suspect the mortality improvement did not completely result from faster tPA treatment. Faster tPA use may be a marker for hospitals that are better organized and do a lot of things better for their stroke patients, which together maximize the stroke patients' survival.

WILLIAM J. MEURER, M.D., is a neurologist and emergency medicine physician at the University of Michigan in Ann Arbor. He reported having no disclosures.