Introduction: We aimed to describe factors associated with IV tPA use over time, including geography, hospital-related factors, and quality improvement efforts.
Methods: Acute ischemic stroke (AIS) discharges with available hospital identifiers (2005 to 2011) in the National Inpatient Sample (NIS) were identified using ICD9 codes 433.X1, 434.X1, and 436. IV tPA use was determined using procedure code 9910 and code V4588 for drip and ship patients; patient/hospital characteristics were obtained from the NIS. Stroke center designation and Get With The Guidelines (GWTG) performance award data were publicly available. Logistic regression using patient characteristics only was followed by the addition of hospital characteristics, then state characteristics (Table). Adjusted odds ratios (aOR) with 95% CI were reported.
Results: There were 563,087 AIS; median age 74 (IQR 62 – 83), 14.9% Black, and 53.3% female. Overall, 3.76% (n=21,172) received IV tPA. In the fully adjusted model (Table), patients that were Black, Hispanic, or female were less likely to receive IV tPA, while those with private insurance were more likely to receive IV tPA. Each subsequent year, patients were 11% more likely to receive IV tPA (aOR 1.11, 95%CI 1.09-1.13). Patients discharged from designated stroke centers, GWTG hospitals with silver or gold awards, or hospitals that were teaching, large, or urban were more likely to receive IV tPA compared to patients discharged from small, critical access, or rural hospitals. Patients discharged in stroke belt states were less likely to receive IV tPA.
Conclusions: Treatment of AIS with tPA is increasing over time. Discharge from GWTG hospitals with performance achievement awards, stroke centers, or teaching, large, or urban hospitals increased this likelihood. Patients who were black, Hispanic, female, or in the stroke belt were less likely to receive tPA. Further efforts are needed to address these performance gaps.