Study Suggests Few Veterans Receive Appropriate Thrombolysis Following Stroke
Within the VA healthcare system, approximately 6,000 Veterans are hospitalized with acute ischemic stroke every year. Tissue plasminogen activator (tPA) is the only medication approved by the FDA for the treatment of acute ischemic stroke, and guidelines support its use in eligible patients for the reduction of stroke symptom severity. However, past studies show that the appropriate receipt of tPA among non-stroke center designated hospitals (non-VA) is only around 14%. Using data from the VA OQP (Office of Quality and Performance) Stroke Study, this study examined the use and misuse of thrombolytic therapy with tPA in a national sample of 3,931 Veterans with acute ischemic stroke who were admitted to one of 129 VA medical centers in FY07. Veterans were considered eligible to receive tPA if they arrived at the hospital within three hours of stroke symptom onset and had no contraindications for tPA. Investigators also examined patient demographics, stroke severity, and major comorbid conditions, as well as time of stroke symptom onset, arrival at a VA emergency department (ED), and receipt of brain imaging.
Findings show that VA treatment of Veterans with acute ischemic stroke who are eligible for thrombolytic therapy is similar to that in non-stroke center hospitals in the private sector. Among the 532 Veterans with ischemic stroke presenting to VA within three hours of symptom onset, 174 (33%) were eligible for tPA, and 19 (11%) received it. Considering only the 135 Veterans who arrived within two hours of symptom onset (allowing adequate time for testing and evaluation), 19 (14%) received tPA. Among the 30 Veterans who received tPA (whether eligible to receive it or not), 5 (17%) received the wrong dose. Eligible Veterans receiving tPA were similar to eligible Veterans who did not receive tPA in terms of clinical conditions and time to brain imaging.
Authors suggest that Veterans be better educated about stroke symptoms, as the majority of patients with stroke presented to a VA hospital more than three hours after symptom onset. Toward this goal, VA is including a recommendation about patient educational efforts related to recognition and treatment-seeking for acute stroke in the Acute Stroke Directive, which is currently awaiting approval and release to the field.
Keyhani S, Arling G, Williams L, Ross J, Ordin D, Myers J, Tyndall G, Vogel B, Bravata D. The use and misuse of thrombolytic therapy within the Veterans Health Administration. Medical Care January 2012;50(1):66-73.
This study was funded by HSR&D (RRP 09-184). Dr. Keyhani is an HSR&D Career Development Awardee and is part of HSR&D’s Program to Improve Care for Veterans with Complex Comorbid Conditions, San Francisco. Dr. Bravata is part of HSR&D’s Center of Excellence on Implementing Evidence-Based Practice, Indianapolis.