Today's Neurology Residents Comfortable Using tPA

Megan Brooks

August 04, 2011

August 4, 2011 — A new survey suggests that neurology residents' experience and comfort in administering tissue-type plasminogen activator (tPA) for acute ischemic stroke increased significantly during the last decade, according to a report published online August 4 in Stroke.

"This is good news,” Brett Cucchiara, MD, assistant professor of neurology, University of Pennsylvania Medical Center in Philadelphia, told Medscape Medical News.

What's behind the trend? "Probably a number of things," Dr. Cucchiara said. For example, there's been "a general increase in tPA usage and awareness across the country as the treatment has become more widespread and accepted," he explained.

"Stroke teams have been increasingly established, especially since the advent of JCAHO [Joint Commission for the Accreditation of Healthcare Organizations, now called simply the Joint Commission] certification of primary stroke centers. Some of our data suggest that the presence of a stroke team is associated with a greater level of comfort using tPA amongst residents, probably due to more formal training and greater exposure to thrombolytic therapy," Dr. Cucchiara said.

What a Difference a Decade Makes

Back in 2000, Dr. Cucchiara and colleagues surveyed 287 graduating neurology residents and found that a significant number were not getting adequate training in thrombolytic therapy for stroke; many reported limited experience and comfort using tPA.

"We wanted to see if things had improved over the past decade; they have, dramatically, with near universal experience with thrombolytic therapy amongst neurology residents and much greater comfort level with using this treatment," Dr. Cucchiara told Medscape Medical News.

Similar to the 2000 survey, the 2010 survey involved 286 US neurology residents in their final year of training. Ninety-four percent of the 2010 class said they felt comfortable treating with tPA on their own, up from 73% in 2000; 99% said they had watched tPA being administered, compared with 88% in 2000; 95% had personal experience administering tPA, compared with 80% 10 years earlier; and 98% had been involved in post-tPA care, up from 89% in 2000.

The 2010 survey also revealed a substantial increase in residents with formal training in using the National Institutes of Health Stroke Scale (92% vs 65% in 2000). In 2010, 93% of residents surveyed said they had dedicated stroke teams at their institutions, compared with 84% in 2000.

All comparisons were significant, with P values less than or equal to .001.

Findings 'Reassuring'

Medscape Medical News asked Philip B. Gorelick, MD, MPH, FACP, director of the Center for Stroke Research, University of Illinois College of Medicine at Chicago, for his thoughts on this updated survey.

"The findings," he said, "are reassuring and to be expected as there has been a proliferation of vascular neurologists and primary stroke center–certified hospitals that may be concentrated at medical centers with graduate medical education programs in neurology and with emphasis on vascular neurology."

Echoing Dr. Cucchiara's words, Dr. Gorelick said the findings are "good news as they suggest that we are successful in our training of a new generation of neurologists who are willing to and capable of treating acute ischemic stroke patients with intravenous thrombolytic therapy."

The survey is not without limitations, Dr. Cucchiara and colleagues emphasize. Chief among them — its reliance on self-assessment rather than objective evidence of resident competence in using tPA.

It's also possible, the study authors point out, that residents more interested and comfortable treating acute stroke patients might be more likely to be trusted using tPA independently, thus confounding the relation between experience and comfort. It's also possible that residents with less experience with tPA may have been less apt to respond to the survey, thus overestimating experience and confidence.

"The authors provide a balanced view of potential study limitations," Dr. Gorelick said, "however, the findings are plausible and suggest success in our graduate medical education training of neurology residents."

The study authors, he said, "are to be congratulated for a timely and important communication."

The study authors and Dr. Gorelick have disclosed no relevant financial relationships.

Stroke. Published online August 4, 2011. Abstract

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