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tPA Door-to-Needle Time Exceeds 1 Hour for Most U.S. Stroke Patients

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Blunt Motivators May Work Best to Speed tPA Use

It’s a mistake to think that there is a one-size-fits-all intervention that will improve and speed up tPA use at all hospitals. Hospitals are heterogeneous, and every hospital has its own problems. I think the big stick approach stands a better chance of working, one that involves regulatory agencies or payers. If there was a stroke DRG (diagnosis-related group) that said stroke patients should receive tPA within 30 minutes, hospitals would figure out how to do it pretty quickly.

The 1.8% improved in-hospital mortality that Dr. Fonarow reports for patients treated with tPA within an hour of arriving at the hospital is significant. But I suspect the mortality improvement did not completely result from faster tPA treatment. Faster tPA use may be a marker for hospitals that are better organized and do a lot of things better for their stroke patients, that together maximize the stroke patients’ survival.

Dr. William J. Meurer is a neurologist and emergency medicine physician at the University of Michigan in Ann Arbor. He reported having no disclosures.


 

FROM THE ANNUAL INTERNATIONAL STROKE CONFERENCE

Some notable characteristics of these patients compared with those who received tPA after 1 hour from their arrival included a higher rate of arrival during the hours 7 a.m. to 5 p.m., Monday through Friday; more severe strokes with greater neurologic deficits; and patients who had a more prolonged time reaching the hospital after symptom onset. Patients who were older, blacks, and women were significantly less likely to get timely treatment with tPA.

Hospital factors that significantly linked with tPA treatment within an hour of arrival included sites that treated a higher volume of patients with intravenous tPA, larger hospitals, academic hospitals, and designated primary stroke centers.

Concurrent with Dr. Fonarow’s report, the results were published online (Circulation 2011 Feb. 10 [doi:10.1161/CIRCULATIONAHA.110.974675]).

Dr. Fonarow said that he has been a consultant to Pfizer, Merck, Schering Plough, Bristol Myers Squibb, and Sanofi-Aventis. He is an employee of the University of California, which holds a patent on retriever devices for treating acute stroke.

* The incorrect number of minutes was reported in an earlier version of this story. The error has been corrected.

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