US stroke patients receiving better and more timely care

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One in four acute ischaemic stroke patients treated with a time-dependent clot-busting drug were quickly transferred from an emergency department or smaller community hospital to a certified stroke centre, according to research presented at the American Stroke Association’s International Stroke Conference 2015 (Nashville, USA, 11–13 February, 2015). This study will also be published simultaneously in the American Heart Association’s journal Stroke.

Intravenous tissue-plasminogen activator, or (tPA), is a clot-busting drug that restores blood flow to the brain. If administered within three hours of the start of a stroke, tPA may significantly improve a patient’s chances of recovery. Even though it is the only FDA-approved treatment for acute ischaemic stroke, rates of its administration are low, according to the presentation.

“One in four is a very good number, and while we do not know the best target, there may be room for improvement,” said Kevin N Sheth, lead study author and chief of the Neurocritical Care and Emergency Neurology Division at Yale School of Medicine in New Haven, USA. “We have to understand geographic and community variation in usage of inter-hospital transfer of tPA patients, and why some communities may use it more than other communities. Ultimately, the goal is to have any patient that presents to their initial hospital anywhere in the country be able to receive tPA.”

To look at these variations in stroke care, researchers analysed data on 44,667 ischaemic stroke patients (median age 72; 49% women) who received tPA in less than three hours at 1,440 hospitals between 2003 and 2010.

Researchers compared patients who arrived at the hospital, received tPA and were later admitted there to those patients who received tPA at the arriving hospital and then were transferred to a certified stroke centre.

Among the 25% who were transferred to certified stroke centres they found:

  • Most were younger, more often male, and more often white.
  • Transferred patients were more likely to arrive during off-hours (7am–5pm, Monday–Friday).
  • Hospitals that accepted transferred patients were bigger with more beds, were more likely to be academic medical centres, have achieved certification as a designated stroke centre, and have maintained a higher volume of stroke cases per year.
  • Hospitals that accepted transferred stroke patients were more common in the Midwest.

Researchers said their study suggests that more patients are getting critical medication before being transferred to a certified stroke centre. When it comes to stroke, every hour counts in moving a stroke patient to a facility equipped with experts, proper diagnostic equipment and treatment. Not all facilities have this, particularly smaller community hospitals, and different hospitals vary on how quickly stroke patients receive tPA. There is also a wide variation in the type of patients who are transferred from smaller community hospitals to designated stroke centres.

Sheth said he was surprised that intracranial haemorrhage was higher among transferred stroke patients, a finding that warrants further study. “We do not know the initial stroke severity for these patients and it is unclear why some patients were chosen to be transferred to a stroke centre and others were not, though it is possible the sicker patients were the ones who were transferred to another facility,” he said. Why some geographic regions transfer stroke patients more than others and how can this transfer approach help facilitate increased use of tPA also needs further study, Sheth said.