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Use of tPA has been substantially higher in primary stroke centers certified by the Joint Commission compared with other facilities, although the gap has narrowed recently, a researcher said here.
Since the commission began certifying stroke centers in 2003, use of tPA at certified centers has ranged from 6% to nearly 8%, with a gradual increase through 2009, according to an analysis of National Inpatient Sample (NIS) data reported by Michael Mullen, MD, of the University of Pennsylvania.
The percentage was markedly lower in noncertified stroke centers throughout the study period, Mullen told attendees at the American Academy of Neurology's annual meeting. In 2009, the most recent year for NIS data, 3.3% of stroke patients at noncertified centers received tPA, he said. But that represented a substantial increase over time -- in 2004, only about 1.4% of patients got tPA.
Moreover, Mullen pointed out, certified stroke centers were different in many ways that would suggest a higher likelihood of administering thrombolytic therapies.
Certified centers were far more likely to be located in teaching hospitals and to be in nonrural areas, and they also were more likely to treat large numbers of patients annually, he reported:
- Teaching hospital: 61.5% of certified centers, 35.1% of noncertified centers
- Rural location: 1.6% of certified centers, 15.8% of noncertified centers
- ≥300 cases per year: 69.0% of certified centers, 29.6% of noncertified centers
Still, after adjusting for these factors as well as patient age, sex, race, comorbidities, insurance type, income (by ZIP code), and mortality propensity, the probability of getting tPA was still significantly higher in the certified stroke centers, with an odds ratio of 1.87 for the entire 6 years of the study (95% CI 1.62 to 2.17).
In line with the increase in tPA use in noncertified centers during the study period, the odds ratio for receiving tPA in certified centers declined -- from 2.95 in 2004 (95% CI 1.74 to 5.00) to 1.68 in 2009 (95% CI 1.36 to 2.16).
Mullen and colleagues had pulled NIS data on all patients with a primary diagnosis of ischemic stroke in states that publicly report hospitals' identity -- more than 320,000 patients, including about 63,000 treated in Joint Commission-certified centers.
A total of 37 states participate in the NIS but only 25 included hospital names in their stroke data from 2004 to 2009, with one additional state providing these data in 2009.
Clinicians have heard different stories about whether Joint Commission certification implies better care or outcomes. A report last year in the Journal of the American Medical Association found a significantly lower death rate in stroke patients admitted to certified centers.
But certification hinges on the ability to provide tPA, not on demonstrated adherence to guidelines or improvements in outcomes, and many clinicians remain skeptical about the benefits of tPA in stroke patients, especially those who come to the hospital later than 90 minutes after symptom onset.
Mullen said a notable lack in the NIS data is information on time to arrival -- a key factor in determining whether tPA is administered.
Silliman said it was encouraging to see that the rate of tPA used in noncertified centers had doubled during the study period. Mullen speculated that some of these centers may have participated in state-level certification programs or made other efforts to adopt guideline-recommended treatments.
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