Most U.S. hospitals did not give an approved acute stroke drug to any Medicare patients between 2005 and 2007, and a large portion of the general population does not have ready access to a hospital that provides the treatment to Medicare patients, according to research presented at the American Stroke Association’s International Stroke Conference 2009.
Tissue plasminogen activator (tPA) is a thrombolytic, or clot-busting agent. It’s the only drug approved by the U.S. Food and Drug Administration for the acute (urgent) treatment of ischemic stroke, the most common type of stroke. When given intravenously in the first three hours after the start of stroke symptoms, tPA has been shown to significantly reverse the effects of stroke and reduce permanent disability.
But researchers suspect that a small number of hospitals are responsible for administering the majority of tPA treatment.
“Previously reported national rates for tPA administration have been varied and confusing ? from 0 percent to 20 percent,” said Dawn Kleindorfer, M.D., lead author of the study and stroke neurologist and associate professor in the University of Cincinnati College of Medicine in Ohio. “These averaged national rates do not reflect the fact that some hospitals are providing this therapy to patients often; while others not at all. So, we evaluated by hospital to get a clear picture of treatment rates and access.”
The study is the first description of tPA treatment rates by U.S. hospitals using a comprehensive administrative dataset.
Kleindorfer and colleagues reviewed national Medicare claims-based database records for every fee-for-serves Medicare-eligible hospital discharge in the United States. There were 4,750 hospitals in the database, which included 495,186 ischemic stroke admission. The researchers report that, between July 1, 2005 and June 30, 2007, the tPA treatment national average was 2.4 percent of all ischemic stroke patients in the Medicare database.
“We found, unfortunately, that about 64 percent of U.S. hospitals did not give tPA to Medicare patients within the two-year study period,” Kleindorfer said.
Most hospitals that did not give the treatment were small, with an average bed size of 95, but it is unclear how hospital size was a factor. The analysis on how rural location, bed size and other factors influence hospital treatment rate is still being conducted.
Researchers also compared the hospital rates of treatment to the population density by county, and found that 40 percent of the U.S. population resides in a county without a hospital that reached at least the national average or better in tPA treatment. Kleindorfer noted that areas served by hospitals often cross county lines, but it is an overall estimate of public access to tPA- treating hospitals.
“Such nationally-based resource utilization data is important for planning at the local and national levels, especially for telemedicine efforts that can reach underserved areas,” Kleindorfer said. “We’re hoping that this information will be useful to hospital systems all over the country, as they plan to improve patient access to stroke-limiting treatments such as tPA.”
However, researchers acknowledge that the study findings are limited because only Medicare patients were included and may not reflect overall tPA use.
The findings highlight the inadequate use of an important treatment and the need for telemedicine and other approaches to ensure that patients have rapid access to acute stroke care, according to an American Stroke Association national spokesperson.
“This study sheds important light on a major disparity in acute stroke care delivery,” said spokesperson Lee Schwamm, M.D., associated professor of Neurology at Harvard. “Individuals and agencies responsible for the equitable distribution of healthcare resources need to examine these and other data to identify strategies that will provide adequate acute stroke care to all their citizens.
“With recent data suggesting that tPA can be safe and effective when given up until 4.5 hours after stroke onset, the need for broader access is even more crucial.”
Co-authors are: Yingying Xu, Ph.D.; Pooja Khatri, M.D.; Opeolu Adeoye, M.D.; and Richard Hornung, Ph.D. Individual author disclosures can be found on the abstract.
The U.S. Centers for Disease Control and Prevention funded the study.
Editor’s note: The American Heart Association/American Stroke Association strongly advocates for policies to help ensure that stroke patients across the country have access to high quality stroke care. The association supports better coordination of stroke care by working to establish Primary Stroke Centers, developing standard emergency medical service treatment and transport protocols, and removing barriers to rehabilitation to improve the treatment and recovery of stroke patients nationwide. For more information, please visit www.strokeassociation.org/yourethecure.
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