"Barrier-to-use" review boosts thrombolytic use in community hospitals

Megan Brooks

January 09, 2013

Ann Arbor, MI - Identifying and addressing barriers to alteplase use in acute ischemic stroke patients led to a modest increase in thrombolytic use in nonspecialty acute-care community hospitals in Michigan, researchers report [1].

Use of thrombolytic therapy in this setting was also safe. "Safety is another important take-home point," Dr Phillip A Scott (University of Michigan, Ann Arbor), an emergency physician who led the trial, noted in an interview.

"Many of the trials that have been done before involved delivery of thrombolytics by stroke teams. This study shows that in the community setting the safety, particularly with respect to symptomatic intracranial hemorrhage, matches historical numbers by specialized stroke teams," he said.

The findings from the Increasing Stroke Treatment through Interventional Change Tactics (INSTINCT) trial were published online December 21, 2012 in Lancet Neurology.

The INSTINCT t rial

Twelve matched pairs of hospitals participated in this cluster-randomized trial. Participating hospitals discharged at least 100 patients per year who had had a stroke, had fewer than 100 000 visits to the emergency department per year, and were not academic comprehensive stroke centers.

Within pairs, the hospitals were allocated to intervention or control groups. Between January and December 2007, intervention hospitals implemented a multicomponent intervention that included qualitative and quantitative assessment of barriers to alteplase use and ways to address the barriers.

The researchers say they uncovered several key barriers to thrombolytic use in participating hospitals, including delay in patients' presentation, communication with radiology departments, and poor availability of neurologists (many hospitals had only one or two neurologists, who typically worked in private, office-based community practices). Familiarity with treatment guidelines and physician motivation were also barriers. All of these barriers, with the exception of presentation delay, were addressed by one or more intervention elements.

The primary outcome was change in alteplase use in patients with stroke in emergency departments between the preintervention period (January 2005 to December 2006) and the postintervention period (January 2008 to January 2010). Overall, 745 of 40 823 acute ischemic patients received intravenous alteplase treatment.

In the intention-to-treat analysis, the proportion of patients treated with alteplase increased between the preintervention and postintervention periods in intervention hospitals to a greater extent than in control hospitals. However, the difference between groups was not significant.

In intervention hospitals, the number treated increased from 89 (1.25%) of 7119 patients in the preintervention period to 235 (2.79%) of 8419 in the postintervention period. In control hospitals, the number treated rose from 99 (1.25%) of 7946 to 194 (2.10%) of 9222.

In the target-population analysis, the increase in alteplase use in intervention hospitals was significantly greater than in control hospitals (1.00% to 2.62% vs 1.09% to 1.72%) but was still clinically modest (RR 1.68, p=0.02).

"It's a mixed story here," Scott said. "When we look at the target population of hospitals that we were interested in influencing, which is really community hospitals that do not have large resources like academic stroke centers, we were able to increase the use of [tissue plasminogen activator] tPA in acute ischemic stroke by over 100%—essentially doubling the rate.

"That is very encouraging, and the fact that it was done with very traditional inexpensive technologies is also very encouraging," Scott said.

"We would have liked to have seen a bigger increase," he admitted, "and the study was powered for a bigger increase, so I think there is significantly more work to be done to increase hospital tPA use."

In a statement, Dr Scott Janis (National Institute of Neurological Disorders and Stroke) said, "This study, while finding only modest improvements, provides encouraging evidence that intensive professional education at community hospitals has the potential to improve the use of tPA in acute stroke care. Importantly, it lays the groundwork for future strategies that should be explored to develop evidence-based interventions that would improve patient access to this proven therapy following stroke."

The INSTINCT investigators are now working on subsequent analyses to help pinpoint key factors in boosting rates of tPA use among eligible stroke patients. Scott said, however, "It's going to be hard to tease out; different hospitals actually needed different elements, so it depended on where a hospital's deficits were."

Gap "remains substantial"

The coauthors of a Comment in Lancet Neurology point out that only 1.2% of patients with acute stroke in the study were given alteplase in the preintervention phase [2].

"Thus, almost 20 years after the drug's effectiveness was first shown, the gap between how many patients could be given alteplase and how many actually are treated remains substantial," write Drs M aaike Dirks and Diederik W Dippe l (Erasmus MC University Medical Center, Rotterdam, the Netherlands).

Clearly, continued efforts are needed to find better ways to treat more tPA-eligible patients, Scott said. "We are still only treating about 2% to 3% of patients. Some data suggest that perhaps as many as 8% to 11% of patients are eligible.

"We'd like to see if we can we leverage the prehospital [emergency medical service] EMS environment to provide better stroke care in the early phase and better notification to the receiving hospitals so these patients can be identified further up in the chain of treatment," Scott said.

"Perhaps most important, doctors and other healthcare workers need to take responsibility for the implementation of thrombolysis and other effective treatments," Dirks and Dippel write in their Comment. "To lose patients because no effective treatments are available is distressing, but to lose patients because an effective treatment is not properly implemented seems even worse. A lot of work remains to be done."

Scott receives grant funding from the National Institutes of Health and the Michigan Department of Community Health and provides paid expert medical-legal review for Beck and Amsden ; Robbins, Kaplan, Miller and Ciresi ; Williams Venker and Sanders ; and Hinshaw and Culbertson . A complete list of disclosures for the INSTINCT investigators is listed in the paper . Dirks and Dippel have no releva nt disclosures.


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