Joint commission primary stroke centers utilize more rt-PA in the nationwide inpatient sample

Abstract

Background: The Joint Commission began certifying primary stroke centers (PSCs) in December 2003 and provides a standardized definition of stroke center care. It is unknown if PSCs outperform noncertified hospitals. We hypothesized that PSCs would use more recombinant tissue plasminogen activator (rt-PA) for ischemic stroke than would non-PSCs.

Methods and results: Data were obtained from the Nationwide Inpatient Sample from 2004 to 2009. The analysis was limited to states that publicly reported hospital identity. All patients ≥18 years with a primary diagnosis of acute ischemic stroke were included. Subjects were excluded if the treating hospital was not identified, if it was not possible to determine the temporal relationship between certification and admission, and/or if admitted as a transfer. Rt-PA was defined by ICD9 procedure code 99.10. All eligibility criteria were met by 323 228 discharges from 26 states. There were 63 145 (19.5%) at certified PSCs. Intravenous rt-PA was administered to 3.1% overall: 2.2% at non-PSCs and 6.7% at PSCs. Between 2004 and 2009, rt-PA administration increased from 1.4% to 3.3% at non-PSCs and from 6.0% to 7.6% at PSCs. In a multivariable model incorporating year, age, sex, race, insurance, income, comorbidities, DRG-based disease severity, and hospital characteristics, evaluation at a PSC was significantly associated with rt-PA utilization (OR, 1.87; 95% CI, 1.61 to 2.16).

Conclusions: Subjects evaluated at PSCs were more likely to receive rt-PA than those evaluated at non-PSCs. This association was significant after adjustment for patient and hospital-level variables. Systems of care are necessary to ensure stroke patients have rapid access to PSCs throughout the United States.

Figure 1.

There were 48 087 002 subjects in the data set, of whom 508 716 had a primary diagnosis of acute ischemic stroke. After all exclusion criteria, the final study population was 323 228.

Figure 2.

A, The percentage of patients evaluated at a primary stroke center increased from 1.4% in 2004 to 39.5% in 2009. B, The percentage of patients treated with rt‐PA at non‐PSCs was 1.4% in 2004, increasing to 3.3% in 2009. The percentage of patients treated with rt‐PA at PSCs was 6.0% in 2004, increasing to 7.6% in 2009. PSC indicates primary stroke center; rt‐PA, recombinant tissue plasminogen activator.