Introduction:
Thrombolytic therapy was approved over a decade ago for the treatment of acute ischemic stroke, yet administration remains infrequent in clinical practice partly due to pre- and in-hospital delays and patient contraindications. Reports of urban-rural differences in eligibility for and treatment with tPA are few. Understanding differences by hospital location may help identify quality improvement strategies unique to particular hospital systems, particularly those in non-metropolitan areas of North Carolina in which nearly one-third of the population resides.
Methods:
We included all acute ischemic strokes in the NC Stroke Care Collaborative, a voluntary state-wide quality improvement program, from Jan 2008 - Aug 2012 with valid, non-missing times from symptom onset to hospital arrival. Location of the 60 participating hospitals was classified as metropolitan, micropolitan, or smalltown using Rural-Urban Commuting Area codes. Rates of intravenous tPA eligibility and receipt were calculated by hospital location. Pre-hospital (onset to arrival) and CT (arrival to CT interpretation) delay times were compared using Wilcoxon tests. Reasons for non-eligibility by hospital location were compared using chi-squared statistics.
Results:
We identified 16,050 ischemic stroke patients (13,913 metropolitan, 1897 micropolitan, and 240 smalltown). Pre-hospital delay was longer among patients treated at smalltown compared with metropolitan hospitals (median hours [IQR] 3.8 [1.0-9.9] vs. 3.3 [1.3-8.2], p=0.04) but the proportion arriving within 2 hours of symptom onset was similar (38%). CT delay was slightly longer for patients at metropolitan compared with smalltown hospitals (1.1 [0.6-1.7] vs. 0.8 [0.5-1.2]; p<0.0001). Thirty-eight percent (2004 of 5276) of patients arriving within 2 hours were eligible for tPA at metropolitan hospitals compared with 41% (304 of 741) at micropolitan and 46% (42 of 92) at smalltown hospitals (p=0.1). Patients in smalltown compared with metropolitan hospitals had higher rates of ineligibility due to advanced age (5% vs. 3%) and family/patient refusal (9% vs. 3%), whereas patients in metropolitan hospitals had higher rates of contraindications (35% vs. 12%) and rapid improvement/symptom resolution (20% vs. 12%). Rece ipt of tPA among eligible patients was highest in metropolitan (70%, 1399 of 2004) compared with micropolitan (37%, 113 of 304) and smalltown hospitals (33%, 14 of 42; p<0.001).
Conclusion:
Receipt of tPA within 3 hours of symptom onset remains below guideline recommendations. Pre-hospital and CT delay times and eligibility for tPA were largely similar across hospital locations. Despite this, tPA administration was considerably lower at smalltown hospitals compared with hospitals in urban settings, suggesting the need for quality improvements targeted at smalltown hospitals that may have less stroke care capability.
Evaluation of the North Carolina Stroke Care Program.
