DaiWai M. Olson

Timeliness of Tissue-Type Plasminogen Activator Therapy in Acute Ischemic Stroke Patient Characteristics, Hospital Factors, and Outcomes Associated With Door-to-Needle Times Within 60 Minutes

Background— The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time dependent, and guidelines recommend an arrival to treatment initiation (door-to-needle) time of ≤60 minutes. Methods and Results— Data from acute ischemic stroke patients treated with tPA within 3 hours of symptom onset in 1082 hospitals participating in the Get With the Guidelines–Stroke Program from April 1, 2003, to September 30, 2009 were studied to determine frequency, patient and hospital characteristics, and temporal trends in patients treated with door-to-needle times ≤60 minutes. Among 25 504 ischemic stroke patients treated with tPA, door-to-needle time was ≤60 minutes in only 6790 (26.6%). Patient factors most strongly associated with door-to-needle time ≤60 minutes were younger age, male gender, white race, or no prior stroke. Hospital factors associated with ≤60 minute door-to-needle time included greater annual volumes of tPA-treated stroke patients. The proportion of patients with door-to-needle times ≤60 minutes varied widely by hospital (0% to 79.2%) and increased from 19.5% in 2003 to 29.1% in 2009 (P<0.0001). Despite similar stroke severity, in-hospital mortality was lower (adjusted odds ratio, 0.78; 95% confidence interval, 0.69 to 0.90; P<0.0003) and symptomatic intracranial hemorrhage was less frequent (4.7% versus 5.6%; P<0.0017) for patients with door-to-needle times ≤60 minutes compared with patients with door-to-needle times >60 minutes. Conclusions— Fewer than one-third of patients treated with intravenous tPA had door-to-needle times ≤60 minutes, with only modest improvement over the past 6.5 years. These findings support the need for a targeted initiative to improve the timeliness of reperfusion in acute ischemic stroke.Background— The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time dependent, and guidelines recommend an arrival to treatment initiation (door-to-needle) time of ≤60 minutes.nnMethods and Results— Data from acute ischemic stroke patients treated with tPA within 3 hours of symptom onset in 1082 hospitals participating in the Get With the Guidelines–Stroke Program from April 1, 2003, to September 30, 2009 were studied to determine frequency, patient and hospital characteristics, and temporal trends in patients treated with door-to-needle times ≤60 minutes. Among 25 504 ischemic stroke patients treated with tPA, door-to-needle time was ≤60 minutes in only 6790 (26.6%). Patient factors most strongly associated with door-to-needle time ≤60 minutes were younger age, male gender, white race, or no prior stroke. Hospital factors associated with ≤60 minute door-to-needle time included greater annual volumes of tPA-treated stroke patients. The proportion of patients with door-to-needle times ≤60 minutes varied widely by hospital (0% to 79.2%) and increased from 19.5% in 2003 to 29.1% in 2009 ( P 60 minutes.nnConclusions— Fewer than one-third of patients treated with intravenous tPA had door-to-needle times ≤60 minutes, with only modest improvement over the past 6.5 years. These findings support the need for a targeted initiative to improve the timeliness of reperfusion in acute ischemic stroke.nn# Clinical Perspective {#article-title-23}

Secondary preventive medication persistence and adherence 1 year after stroke

Objective: Data on long-term use of secondary prevention medications following stroke are limited. The Adherence eValuation After Ischemic stroke–Longitudinal (AVAIL) Registry assessed patient, provider, and system-level factors influencing continuation of prevention medications for 1 year following stroke hospitalization discharge. Methods: Patients with ischemic stroke or TIA discharged from 106 hospitals participating in the American Heart Association Get With The Guidelines–Stroke program were surveyed to determine their use of warfarin, antiplatelet, antihypertensive, lipid-lowering, and diabetes medications from discharge to 12 months. Reasons for stopping medications were ascertained. Persistence was defined as continuation of all secondary preventive medications prescribed at hospital discharge, and adherence as continuation of prescribed medications except those stopped according to health care provider instructions. Results: Of the 2,880 patients enrolled in AVAIL, 88.4% (2,457 patients) completed 1-year interviews. Of these, 65.9% were regimen persistent and 86.6% were regimen adherent. Independent predictors of 1-year medication persistence included fewer medications prescribed at discharge, having an adequate income, having an appointment with a primary care provider, and greater understanding of why medications were prescribed and their side effects. Independent predictors of adherence were similar to those for persistence. Conclusions: Although up to one-third of stroke patients discontinued one or more secondary prevention medications within 1 year of hospital discharge, self-discontinuation of these medications is uncommon. Several potentially modifiable patient, provider, and system-level factors associated with persistence and adherence may be targets for future interventions.

Outcomes in Mild or Rapidly Improving Stroke Not Treated With Intravenous Recombinant Tissue-Type Plasminogen Activator Findings From Get With The Guidelines-Stroke

Background and Purpose— Mild or rapidly improving stroke is a frequently cited reason for not giving intravenous recombinant tissue-type plasminogen activator (rtPA), but some of these patients may have poor outcomes. We used data from a large nationwide study (Get With The Guidelines–Stroke) to determine risk factors for poor outcomes after mild or improving stroke at hospital discharge. Methods— Between 2003 and 2009, there were 29 200 ischemic stroke patients (from 1092 hospitals) arriving within 2 hours after symptom onset with mild or rapidly improving stroke symptoms as the only contraindication to rtPA. Logistic regression was used to determine the independent predictors of discharge to home. Results— Among 93 517 patients arriving within 2 hours, 31.2% (29 200) did not receive rtPA solely because of mild/improving stroke. Among the 29 200 mild/improving cases, 28.3% were not discharged to home, and 28.5% were unable to ambulate without assistance at hospital discharge. The likelihood of home discharge was strongly related to initial National Institutes of Health Stroke Scale score (P<0.001). In multivariable-adjusted analysis, patients not discharged to home were more likely to be older, female, and black; have a higher National Institutes of Health Stroke Scale score and vascular risk factors; and were less likely to be taking lipid-lowering medication before admission. Conclusions— In this large, nationwide study, a sizeable minority of patients who did not receive intravenous rtPA solely because of mild/improving stroke had poor short-term outcomes, raising the possibility that stroke-related disability is relatively common, even in “mild” stroke. A controlled trial of reperfusion therapy in this population may be warranted.

Are Quality Improvements in the Get With The Guidelines-Stroke Program Related to Better Care or Better Data Documentation?

Background— Increased compliance with performance measures could reflect better care or better data documentation. We examined trends in the documentation of eligibility criteria, treatment contraindications, and missing data in the Get With The Guidelines-Stroke program to quantify their contribution to increased performance measure compliance. Methods and Results— Data on 569 883 ischemic stroke admissions to 1028 GWTG-Stroke hospitals between April 2003 and September 2009 were obtained. Seven measures were examined: intravenous recombinant tissue plasminogen activator therapy, early antithrombotics, deep vein thrombosis prophylaxis, anticoagulants for atrial fibrillation/flutter, discharge antithrombotics, lipid therapy, and smoking cessation. Within each target population, the proportion of subjects treated, not treated, not treated because of contraindications, or with missing data were generated by calendar year. There were minimal changes in the size of the target populations for 6 of the measures; however, the size of the deep vein thrombosis prophylaxis population was reduced ≈5% in 2008 because of a format change to the data collection form. All measures showed significant increases in the proportion of eligible subjects treated across the study period. These increases occurred without major shifts in contraindications or missing data, with the exception of anticoagulation for atrial fibrillation/flutter where the increase occurred in conjunction with a decline in contraindications. Similar findings were seen when the data were examined by the duration of hospital participation in the program. Conclusions— These findings suggest that the majority of performance improvement in the Get With The Guidelines-Stroke program represent an increase in the number of patients with stroke treated and not changes to the underlying target populations or documentation of contraindications or missing data.

Antithrombotic Therapy Use at Discharge and 1 Year in Patients With Atrial Fibrillation and Acute Stroke Results From the AVAIL Registry

Background and Purpose— Current American Heart Association/American Stroke Association guidelines identify warfarin use as a class IA indication in patients with atrial fibrillation (AF) and ischemic stroke (IS) or transient ischemic attack (TIA). However, few studies have examined factors associated with long-term antithrombotic therapy use in IS/TIA patients with AF. Methods— We utilized the Get With The Guidelines–Stroke national quality improvement registry and the Adherence eValuation After Ischemic Stroke Longitudinal (AVAIL) Registry to examine patterns of antithrombotic use at discharge and at 12 months in IS/TIA patients with AF. A multivariate logistic regression model was developed to identify predictors of warfarin use in this patient population at 12 months. Results— Of the 2460 IS/TIA patients, 291 (11.8%) had AF, of which 5.5% of patients were discharged on aspirin alone, 49.1% on warfarin alone, 1.4% on clopidogrel alone, 34.7% on warfarin plus aspirin, 2.1% on aspirin plus clopidogrel, and 1.0% on aspirin plus clopidogrel plus warfarin. Paradoxically, there was a decrease in the rate of warfarin use in patients with a CHADS2 score >3. The only factor associated with warfarin use at 12-month follow-up was male gender (adjusted odds ratio, 2.27; confidence interval, 1.22–4.35; P=0.01). Conclusions— Overall, the use of warfarin therapy is high at discharge in IS/TIA patients with AF; however, there was a decrease in the rate of warfarin use in patients with a CHADS2 score >3. Compared to women, men were more likely to be on warfarin at 1 year after the index stroke event. Therefore, opportunities exist to improve antithrombotic use in all IS/TIA patients with AF.

Improvement in use of anticoagulation therapy in patients with ischemic stroke: Results from Get With The Guidelines–Stroke

BACKGROUNDnAnticoagulation therapy reduces thromboembolic events in patients with atrial fibrillation (AF) and has a class I indication for ischemic stroke patients with AF and no contraindications. We determined the patient and hospital level characteristics associated with an increased use of anticoagulation, including participation in the Get With The Guidelines-Stroke (GWTG-Stroke) Program.nnnMETHODSnWe assessed the use of anticoagulation at hospital discharge in eligible AF patients with stroke or transient ischemic attack (TIA) at 1,354 participating hospitals between April 1, 2003, and April 1, 2010.nnnRESULTSnPatients with AF (n = 197,778) represented 20.5% of patients with ischemic stroke/TIA. Among patients with AF, 47.6% (n = 94,119) were deemed eligible for anticoagulation, and of these, 94.0% were discharged on therapy. Older patients, African American or Hispanic patients, and those with diabetes were less likely to receive anticoagulation. Hospitals with a higher volume of patients with stroke were more likely to treat with anticoagulation. The Joint Commission Primary Stroke Centers were also more likely to treat eligible patients (odds ratio 2.16, 95% CI 1.82-2.56, P < .0001). From 2003 to 2010, contraindications to anticoagulation therapy declined from 69.7% to 28.4% (P < .0001 for trend). Anticoagulation among eligible patients improved from 88.4% to 95.2% (P < .0001) for 7 years of participation. Time in GWTG-Stroke was associated with improved anticoagulation use (adjusted odds ratio per year in program, 1.11, 95% CI 1.06-1.16, P < .001).nnnCONCLUSIONSnUse of anticoagulation among stroke patients with AF has increased to very high levels overall in GWTG-Stroke over time. Future efforts should focus on improving use among selected populations.

A qualitative assessment of practices associated with shorter door-to-needle time for thrombolytic therapy in acute ischemic stroke

ABSTRACT Early treatment with intravenous (IV) recombinant tissue plasminogen activator/alteplase (tPA) is associated with improved outcomes for patients with an acute ischemic stroke. Thus, rapid triage and treatment of stroke patients are essential, with a goal of door-to-needle time of no more than 60 minutes. We sought to identify best practices associated with faster treatment among hospitals participating in Get With the Guidelines—Stroke. Qualitative telephone interviews were conducted to elicit strategies being used by these centers to assess, treat, and monitor stroke patients treated with IV tPA. We sequentially carried out these interviews until we no longer identified novel factors. Interviews were conducted with 13 personnel at 7 top-performing U.S. hospitals. With the use of a hermeneutic–phenomenological framework, 5 distinct domains associated with rapid IV tPA delivery were identified. These included (a) communication and teamwork, (b) process, (c) organizational culture, (d) performance monitoring and feedback, and (e) overcoming barriers.

Medication coaching program for patients with minor stroke or TIA: A pilot study

BackgroundPatients who are hospitalized with a first or recurrent stroke often are discharged with new medications or adjustment to the doses of pre-admission medications, which can be confusing and pose safety issues if misunderstood. The purpose of this pilot study was to assess the feasibility of medication coaching via telephone after discharge in patients with stroke.MethodsTwo-arm pilot study of a medication coaching program with 30 patients (20 intervention, 10 control). Consecutive patients admitted with stroke or TIA with at least 2 medications changed between admission and discharge were included. The medication coach contacted intervention arm patients post-discharge via phone call to discuss risk factors, review medications and triage patients’ questions to a stroke nurse and/or pharmacist. Intervention and control participants were contacted at 3u2009months for outcomes. The main outcomes were feasibility (appropriateness of script, ability to reach participants, and provide requested information) and participant evaluation of medication coaching.ResultsThe median lengths of the coaching and follow-up calls with requested answers to these questions were 27 minutes and 12 minutes, respectively, and participant evaluations of the coaching were positive. The intervention participants were more likely to have seen their primary care provider than were control participants by 3u2009months post discharge.ConclusionsThis medication coaching study executed early after discharge demonstrated feasibility of coaching and educating stroke patients with a trained coach. Results from our small pilot showed a possible trend towards improved appointment-keeping with primary care providers in those who received coaching.

Timeliness of Tissue-Type Plasminogen Activator Therapy in Acute Ischemic Stroke

Background— The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time dependent, and guidelines recommend an arrival to treatment initiation (door-to-needle) time of ≤60 minutes. Methods and Results— Data from acute ischemic stroke patients treated with tPA within 3 hours of symptom onset in 1082 hospitals participating in the Get With the Guidelines–Stroke Program from April 1, 2003, to September 30, 2009 were studied to determine frequency, patient and hospital characteristics, and temporal trends in patients treated with door-to-needle times ≤60 minutes. Among 25 504 ischemic stroke patients treated with tPA, door-to-needle time was ≤60 minutes in only 6790 (26.6%). Patient factors most strongly associated with door-to-needle time ≤60 minutes were younger age, male gender, white race, or no prior stroke. Hospital factors associated with ≤60 minute door-to-needle time included greater annual volumes of tPA-treated stroke patients. The proportion of patients with door-to-needle times ≤60 minutes varied widely by hospital (0% to 79.2%) and increased from 19.5% in 2003 to 29.1% in 2009 (P<0.0001). Despite similar stroke severity, in-hospital mortality was lower (adjusted odds ratio, 0.78; 95% confidence interval, 0.69 to 0.90; P<0.0003) and symptomatic intracranial hemorrhage was less frequent (4.7% versus 5.6%; P<0.0017) for patients with door-to-needle times ≤60 minutes compared with patients with door-to-needle times >60 minutes. Conclusions— Fewer than one-third of patients treated with intravenous tPA had door-to-needle times ≤60 minutes, with only modest improvement over the past 6.5 years. These findings support the need for a targeted initiative to improve the timeliness of reperfusion in acute ischemic stroke.Background— The benefits of intravenous tissue-type plasminogen activator (tPA) in acute ischemic stroke are time dependent, and guidelines recommend an arrival to treatment initiation (door-to-needle) time of ≤60 minutes.nnMethods and Results— Data from acute ischemic stroke patients treated with tPA within 3 hours of symptom onset in 1082 hospitals participating in the Get With the Guidelines–Stroke Program from April 1, 2003, to September 30, 2009 were studied to determine frequency, patient and hospital characteristics, and temporal trends in patients treated with door-to-needle times ≤60 minutes. Among 25 504 ischemic stroke patients treated with tPA, door-to-needle time was ≤60 minutes in only 6790 (26.6%). Patient factors most strongly associated with door-to-needle time ≤60 minutes were younger age, male gender, white race, or no prior stroke. Hospital factors associated with ≤60 minute door-to-needle time included greater annual volumes of tPA-treated stroke patients. The proportion of patients with door-to-needle times ≤60 minutes varied widely by hospital (0% to 79.2%) and increased from 19.5% in 2003 to 29.1% in 2009 ( P 60 minutes.nnConclusions— Fewer than one-third of patients treated with intravenous tPA had door-to-needle times ≤60 minutes, with only modest improvement over the past 6.5 years. These findings support the need for a targeted initiative to improve the timeliness of reperfusion in acute ischemic stroke.nn# Clinical Perspective {#article-title-23}

An observational pilot study of CSF diversion in subarachnoid haemorrhage.

BACKGROUNDnA primary focus of hospital treatment following admission for subarachnoid haemorrhage (SAH) is a prevention of cerebral artery vasospasm, which may result in ischaemic stroke. Intraventricular catheter (IVC) insertion to facilitate cerebral spinal fluid (CSF) drainage and intracranial pressure (ICP) monitoring may reduce the incidence or severity of vasospasm, but insufficient evidence exists from which clinicians may determine the best practice of CSF management.nnnAIMSnThe aim of this study was to provide the pilot data to explore the impact of different methods of CSF drainage on outcomes in patients with SAH.nnnMETHODSnIn this non-randomized observational study, patients diagnosed with SAH who had ICP monitoring in situ were prospectively enrolled. Group assignment was determined by the method of external ventricular drainage (EVD) management prescribed by the attending physician prior to enrollment.nnnRESULTSnThe 37 subjects were disproportionately divided: open-EVD group (N = 24) and monitor-ICP group (N = 13). There were no statistically significant differences by group assignment with respect to vasospasm, length of stay (LOS), highest average ICP, total CSF drained and disability upon discharge between groups.nnnCONCLUSIONSnAlthough not significant, our results show that the monitor-ICP group trended towards improved clinical outcomes. These results provide sufficient equipoise to support further research in ICP management in patients with SAH using a randomized clinical trial.nnnRELEVANCE TO CLINICAL PRACTICEnThis study provides a solid foundation for the development of a randomized trial exploring two different methods of ICP monitoring and CSF diversion during the acute phase of care following aneurysm rupture.