Regional Variation in Stroke Care | Journal Scan

Study Questions:

What is the regional variation in use of fibrinolytic therapy in patients presenting with stroke?


The authors performed a retrospective cross-sectional study of all fee-for-service Medicare patients with ischemic stroke admitted via the emergency department from 2007 to 2010. Patients were assigned to 3,436 hospital service areas. Multilevel logistic regression was used to estimate regional thrombolysis rates and to determine the variation in thrombolysis treatment attributable to the region.


The study population was comprised of 844,241 admissions for ischemic stroke, of which 3.7% received intravenous tissue-type plasminogen activator and 0.5% received intra-arterial stroke treatment. The unadjusted proportion of patients with ischemic stroke who received thrombolysis varied from 9.3% in the highest treatment quintile compared with 0% in the lowest treatment quintile. Patient-level factors only explained a small proportion of the variation in fibrinolysis use. The authors estimated that if all regions performed at the level of 75th percentile region, approximately 7,000 additional patients with ischemic stroke would be treated with thrombolysis.


The authors concluded that there is considerable variation in use of reperfusion therapy for stroke across the United States.


Regional differences in care processes have been previously identified for multiple cardiovascular conditions and procedures. This study highlights the variation in use of reperfusion for ischemic stroke and identifies an important quality gap that is worthy of further study. The logical next step would be to study the hospitals that are higher users of reperfusion and share their processes of care widely to bridge this gap. Recent advances in endovascular therapy for stroke have opened up new possibilities for stroke patients and it would be equally important to create systems of care that enhance access to endovascular therapy for patients with stroke.

Clinical Topics: Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Lipid Metabolism

Keywords: Cross-Sectional Studies, Emergency Service, Hospital, Fee-for-Service Plans, Fibrinolysis, Logistic Models, Medicare, Reperfusion, Retrospective Studies, Stroke, Thrombolytic Therapy, Tissue Plasminogen Activator

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