Few hospitals give t-PA to patients with ischemic stroke who are covered by Medicare

Two-thirds of US hospitals do not administer tissue plasminogen activator (t-PA) to patients who have a stroke and are covered by Medicare, according to the results of a national study conducted between 2005 and 2007, which were presented at the International Stroke Conference 2009.

Furthermore, many of these patients reside in counties that do not have a hospital that delivers t-PA at a rate equalling or surpassing the national average in t-PA delivery.Hospitals that did not give t-PA to patients covered by Medicare tended to be small and rural, said the study’s lead investigator, Dawn Kleindorfer, MD, stroke neurologist and associate professor, University of Cincinnati.

Dr Kleindorfer examined the MEDPAR database, a data set containing every fee-for-service Medicare-eligible hospital discharge in the United States, for rates of t-PA administration among the 4,750 hospitals included in the database. There were 495,186 admissions for ischemic stroke at these hospitals during the study period.

The national average for t-PA treatment was 2.4% of ischemic stroke admissions. Approximately 64% of the hospitals did not deliver t-PA to patients covered by Medicare during the 2 years of the study. Approximately 1% of hospitals reported treatment rates >10%.

Most of the hospitals that did not administer t-PA were small, with an average bed size of 95. Rural hospitals were also less likely to administer t-PA, and hospitals in the Northeast were more likely to treat with t-PA than hospitals in the South. The data on hospital characteristics that predict lack of t-PA use were still being collected at the time of the presentation.

Approximately 40% of the US population lives in counties without a hospital that administers t-PA at a rate equal to or greater than the 2.4% national average.

Dr Kleindorfer believes that the volume of patients admitted with ischemic stroke plays a large role in the rate at which t-PA is administered. “Small hospitals in rural Montana that see 40 stroke patients per year, and 1 patient every couple of years comes in who might be eligible for t-PA, it would be very hard to maintain a level of alertness and awareness to be able to treat someone with t-PA,” she said. “Just as we’ve shown with surgical procedures, the centers with high volume tend to be better at it.”

Measures are needed to improve access to acute stroke care, she said. “I’m hoping that my data will drive some changes in systems of care, such as more centralization,” she said. “We’re already working toward the JCAHO [Joint Commission on the Accreditation of Healthcare Organizations] stroke certification; perhaps if you identify a highly populated area that’s not giving t-PA, it might be a great hospital for telemedicine or an outreach program for a directed transfer program, or bypassing centers that aren’t designated acute stroke centers.”