Hospitalization Costs for Acute Ischemic Stroke Patients Treated With Intravenous Thrombolysis in the United States Are Substantially Higher Than Medicare Payments

Background and Purpose: Multiple studies have established that intravenous thrombolysis with alteplase improves outcome after acute ischemic stroke. However, assessment of thrombolysis’ efficacy in stroke patients with atrial fibrillation (AF) has yielded mixed results. We sought to determine the association of alteplase with mortality, hemorrhagic transformation (HT), infarct volume, and mortality in patients with AF and acute ischemic stroke. Methods: We retrospectively analyzed consecutive acute ischemic stroke patients with AF included in the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study, which pooled data from 8 comprehensive stroke centers in the United States. 1889 (90.6%) had available 90-day follow up data and were included. For our primary analysis we used a cohort of 1367/1889 (72.4%) patients who did not undergo mechanical thrombectomy (MT). Secondary analyses were repeated in the patients that underwent MT (n=522). Binary logistic regression was used to determine whether alteplase use was independently associated with risk of HT, final infarct volume, and 90-day mortality, respectively, adjusting for potential confounders. Results: In our primary analyses we found that alteplase use was independently associated with an increased risk for HT (adjusted OR 2.14, 95% CI 1.49 - 3.07, p <0.001) but overall reduced risk of 90-day mortality (adjusted OR 0.58, 95% CI 0.39 - 0.87, p = 0.009). Among patients undergoing MT, alteplase use was associated with a trend towards a reduction in 90-day mortality (adjusted OR 0.68 95% CI 0.45 - 1.04, p = 0.077). In the subgroup of patients prescribed DOAC treatment (n = 327; 24 received alteplase), alteplase treatment was associated with a trend towards smaller infarct size (< 10 mL), (adjusted OR 0.40, 95% CI 0.15 - 1.12, p = 0.082) without a significant difference in the odds of 90-day mortality (adjusted OR 0.51, 95% CI 0.12 - 2.13, p = 0.357) or hemorrhagic transformation (adjusted OR 0.27, 95% CI 0.03 - 2.07, p = 0.206). Conclusion: Thrombolysis with intravenous alteplase was associated with reduced 90-day mortality in AF patients with acute ischemic stroke not undergoing MT. Further study is required to assess the safety and efficacy of alteplase in AF patients undergoing MT and those on DOACs.

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Disparities in the Use of Mechanical Thrombectomy Alone Compared with Adjunctive Intravenous Thrombolysis in Acute Ischemic Stroke in the United States

American Journal of Neuroradiology ◽

10.3174/ajnr.a7332 ◽

2021 ◽

Author(s):

W. Wahood ◽

A.A. Rizvi ◽

Y. Alexander ◽

M.A. Alvi ◽

K.R. Rajjoub ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Intravenous Thrombolysis ◽

The United States

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Abstract WP31: A Comparison of Outcomes Associated With Mechanical Thrombectomy in Acute Ischemic Stroke Patients Performed Within and Outside Clinical Trials in the United States

Stroke ◽

10.1161/str.50.suppl_1.wp31 ◽

2019 ◽

Vol 50 (Suppl_1) ◽

Author(s):

Adnan I Qureshi ◽

Baljinder Singh ◽

Wei Huang ◽

Ahmed A Malik

Keyword(s):

United States ◽

Clinical Trials ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

The United States ◽

Stroke Patients

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Outcomes of Homeless Ischemic Stroke Patients Receiving Intravenous Thrombolysis in the United States

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2021.105862 ◽

2021 ◽

Vol 30 (8) ◽

pp. 105862

Author(s):

Ganesh Asaithambi ◽

Emily H. Marino ◽

Bridget M. Ho ◽

Megan E. Tipps

Keyword(s):

United States ◽

Ischemic Stroke ◽

Intravenous Thrombolysis ◽

The United States ◽

Stroke Patients

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Abstract 196: Thrombolytic Treatment using Drip and Ship Treatment Paradigm among Acute Ischemic Stroke Patients in the United States: Outcomes and impact on regional thrombolytic utilization and referral patterns

Stroke ◽

10.1161/str.43.suppl_1.a196 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Wondwossen G Tekle ◽

Saqib A Chaudhry ◽

Habib Qaiser ◽

Ameer E Hassan ◽

Gustavo J Rodriguez ◽

...

Keyword(s):

United States ◽

Ischemic Stroke ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

The United States ◽

Thrombolytic Treatment ◽

Stroke Patients ◽

Referral Patterns ◽

Hospital Outcomes ◽

Treatment Paradigm

Background: While single center and regional estimates of thrombolytic administration using drip and ship treatment paradigm are available, patient outcomes, thrombolytic utilization, cost, and referral patterns has not been assessed in United States. Objective: To provide national estimates of patients treated with thrombolytics using drip and ship paradigm and determine the impact of drip and ship treatment on regional thrombolytic utilization, treatment cost, and referral patterns of acute stroke patients in a large cohort. Methods: We determined the proportion of patients treated with drip and ship paradigm among all acute ischemic stroke patients treated with thrombolytic treatment and obtained comparative in-hospital outcomes from the Nationwide Inpatient Survey (NIS) data files from October 2008 to December 2009. All the in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis. Thrombolytic utilization, hospitalization cost, and patterns of referral related to drip and ship treatment of acute stroke were estimated. Results: Of the 26,814 ischemic stroke patients who received thrombolytic treatment, 5144 (19%) were treated using drip and ship paradigm. Seventy nine percent of all the drip and ship treated patients were referred to urban teaching hospitals for further care, and 7% of them received follow up endovascular treatment at the referral facility. States with higher proportion of patients treated using the drip and ship paradigm had higher rates of thrombolytic utilization (3.1% vs. 2.4%, p<0.001). After adjusting for age, gender, presence of hypertension, diabetes mellitus, renal failure, and hospital teaching status, outcomes of patients treated with drip and ship paradigm was similar to those who received thrombolytic and stayed in the same facility: self care (odds ratio [OR], 1.055, 95% confidence interval [CI], 0.910-1.224, p=0.4779); death(OR , 0.821 95% CI, 0.619- 1.088, p=0.1688); and nursing home discharge (OR, 1.023, 95% CI, 0.880- 1.189, p=0.7659) at discharge. Drip and ship paradigm was associated with shorter hospital stay (mean [days, SE] 5.9± 0.18 vs. 7.4 ± 0.15, p<0.001), and lower cost of hospitalization (mean total charges [$, SE) 57,000 ± 3,324 vs. 83,000 ± 3,367, p<0.001). Conclusions: One out of every five patients who received thromboytic treatment in United States is currently treated using drip and ship paradigm with comparable adjusted rates of favorable outcomes. There was a higher rates of thrombolytic utilization in States where drip and ship was more commonly implemented.

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Abstract 3994: Obese Patients Receiving Intravenous Thrombolysis in Acute Ischemic Stroke Have lower Rates of Intracerebral hemorrhage and Mortality

Stroke ◽

10.1161/str.43.suppl_1.a3994 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Ameer Hassan ◽

Mikayel Grigoryan ◽

Saqib Chaudhry ◽

Adnan Qureshi

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Multivariate Logistic Regression Analysis ◽

Intravenous Thrombolysis ◽

International Classification Of Diseases ◽

The United States ◽

Obese Patients ◽

Stroke Patients ◽

Intravenous Tissue Plasminogen Activator ◽

Classification Of Diseases

Background: The current recommended dose of intravenous tissue plasminogen activator (IV rt-PA) for ischemic stroke patients weighing >100 kg is fixed at 90 mg and thus obese patients receive less than the recommend 0.9mg/kg dosage. We hypothesized that obese patients receive a lower dose of thrombolytics and they will have a lower rates of intracerebral hemorrhages (ICH), but lower rates of clinical benefit from IV rt-PA. Objective: To determine the relationship between obesity and clinical outcomes among acute ischemic stroke patients receiving IV rt-PA. Methods: Data were obtained from all states within the United States that contributed to the Nationwide Inpatient Sample. All patients admitted to US hospitals between 2002 and 2009 with a primary discharge diagnosis of stroke treated with IV thrombolysis (identified by the International Classification of Diseases, Ninth Revision procedure codes) were included. We analyzed whether the presence of obesity was associated with clinical outcome and ICH with multivariate logistic regression analysis after adjusting for potential confounders. Results: Of the 84,727 patients with ischemic stroke treated with IV rt-PA, 5,437 (6.4%) had concurrent obesity. The ICH rates between obese and non-obese patients was 4.3% versus 6.1% (p=0.005). After adjusting for age, sex, hypertension, diabetes mellitus, renal failure, hospital teaching status, and ICH, the presence of obesity was not associated with increased rates of self-care (odds ratio [OR] 0.929, 95% confidence interval [CI] 0.815-1.063, p=0.27), but was associated with decreased rates of mortality (OR 0.78, 95% CI 0.61 - 0.94, p=0.045) at discharge. Conclusion: Obese patients undergoing IV t-PA treatment for acute ischemic stroke appear to have lower rates of ICHs and mortality presumably due to lower weight adjusted thrombolytic dose.

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