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(Stroke. 1997;28:537-542.)
© 1997 American Heart Association, Inc.
Articles |
Variables Associated With Hospital Arrival Time After Stroke
Effect of Delay on the Clinical Efficiency of Early Treatment
From the Units of Neurology (G.A., L.F., F.N., R.D'A.), Clinical Pharmacology and Therapeutics (L.B.), and Emergency Medicine (G.R.), S Orsola-Malpighi Hospital, Bologna, and Cesena Local Health Care Authority, Medical Health Care Management Unit (U.M., D.C.), Italy.
Correspondence to Dr Giuseppe Azzimondi, Servizio di Neurologia, Ospedale S Orsola-Malpighi, Via Albertoni 15, 40138 Bologna, Italy. E-mail clinphar{at}orsola.med.unibo.it.
Background and Purpose A limiting criterion for the eligibility of patients in clinical trials investigating acute stroke therapies is that time between onset of symptoms and arrival in the hospital should fall within the "therapeutic window." The aims of this study were to estimate hospital arrival time in an unselected sample of stroke patients, to assess the association with some clinical and demographic variables, and to evaluate the effects of the delay on the clinical efficiency of an effective treatment.
Methods We evaluated the delay in hospital arrival time in 189 patients (84 men, 105 women; mean age, 76.5 years) prospectively collected in the S Orsola-Malpighi Community Teaching Hospital in Bologna, Italy. Cutoffs of 2 and 5 hours were chosen to allow for hypothetical treatment within 3 and 6 hours, respectively. Exact multiple logistic regression was used to predict the delay as a function of dichotomized age, sex, symptoms on awakening, day of the week, hour of the day, area of residence, level of consciousness, and level of motor power defect. We then projected the effectiveness of tissue plasminogen activator (TPA) on disability as estimated with the aid of the odds ratio from the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stroke Trial onto our unselected sample to evaluate clinical efficiency of treatment as a function of arrival time and of hypothetical effects of educational efforts to reduce it.
Results The mean interval between onset of symptoms and
hospital arrival was 680 minutes; 59 patients (31%) arrived within 2
hours and 100 (53%) within 5 hours. Onset of symptoms when awake,
drowsiness or coma, and paralysis of at least one limb were the only
independent predictors of hospital arrival within 2 and 5 hours in both
the total sample and the subgroup of patients who were awake at stroke
onset. The effectiveness of 17%, extrapolated with the aid of the odds
ratio of 1.6 of having a favorable outcome (Barthel Index 
95 at 3
months) in treated versus untreated patients in the NINDS rt-PA Stroke
Trial, corresponded to a projected clinical efficiency of 5%. This
could be doubled by hypothesizing a 100% effect of educational efforts
in reducing the delay in hospital arrival time.
Conclusions Patients with milder symptoms, for whom treatment might be more effective, were less likely to arrive in time for therapy. The proposed model of the relationship between the delay in hospital presentation after a stroke and the clinical efficiency of a given treatment might be useful for planning future clinical trials on early stroke treatment and predicting the impact of an educational program aimed at shortening arrival time.
Key Words: disability evaluation • hospitalization • models, theoretical • stroke management
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