From the Departments of Medicine (Neurology) (L.B.G.) and Surgery
(L.A.H., R.L.), Duke Center for Cerebrovascular Disease (L.B.G.), Center for
Clinical Health Policy Research (L.B.G.), Center for Clinical Effectiveness
(L.A.H., R.L.), Duke University, Durham, NC, and the Durham VA Medical Center
(L.B.G.), Durham, NC.
Correspondence to Larry B. Goldstein, MD, Director, Duke Center for Cerebrovascular Disease, and Head, Stroke Policy Program, Center for Clinical Health Policy Research, Box 3651, Duke University Medical Center, Durham, NC 27710. E-mail golds004{at}mc.duke.edu
Methods—A single-page survey was mailed to the medical center
directors of each inpatient medical facility in North Carolina. Data
collected included questions related to the availability of selected
basic and advanced diagnostic tests and procedures, stroke
prevention and treatment programs and services (community stroke
awareness program, acute stroke identification program, acute stroke
team, stroke rtPA protocol, stroke care map, neurologist), and
facilities (Stroke Acute Care Unit or equivalent).
Results—Responses were obtained from all 125 inpatient medical
facilities in North Carolina. rtPA stroke protocols were adopted in 54
facilities located in 46 of the state's 100 counties. Seventy-four
percent of the state's population resides in counties with hospitals
providing rtPA treatment. Compared with facilities not offering rtPA,
those with rtPA protocols more commonly sponsored stroke community
awareness programs (41% versus 17%, P=0.003) and more
frequently had an organized stroke team (31% versus 8%,
P=0.001), used stroke care maps (56% versus 17%,
P<0.001), had rapid stroke identification programs
(33% versus 6%, P<0.001), or had a Stroke Acute Care
Unit or its equivalent (33% versus 7%, P<0.001).
Neurologists were available in 78% of the facilities offering rtPA
compared with 38% in facilities without rtPA protocols
(P<0.001).
Conclusions—These data show that this new therapy for
ischemic stroke is potentially available to a high proportion
of the state's citizens based on their county of residence. However,
other services that may improve outcomes and reduce stroke-related
costs (eg, stroke teams, stroke units, care maps) are not being widely
used, even in centers providing treatment with rtPA. The simple
methodology used in this study is potentially applicable in other
states and permits targeting of selected centers for development of
stroke treatment capabilities.
North Carolina lies in the country's "stroke belt," and
cerebrovascular disease is a major public health problem in the
state.10 The purpose of the present study was
to determine how widely rtPA has been adopted for the treatment of
patients with acute ischemic stroke by North Carolina hospitals
and the characteristics of the medical facilities offering this
therapy.
Several categories of data were collected relating to the availability
of basic and advanced stroke prevention and treatment facilities and
programs. These included a variety of diagnostic studies
useful in the management of patients with cerebrovascular disease and a
series of programs and services (community stroke awareness programs;
the performance of carotid endarterectomy;
the availability of an emergency department, an acute stroke team,
hospital stroke care map, an acute stroke identification program,
stroke rtPA protocol, Stroke Acute Care Unit or its equivalent; and
whether the hospital had a neurologist).
Treatment with rtPA was offered in 54 hospitals in 46 counties
(Figure
These data have several other implications for the current organization
of hospital-based stroke-related care. Although 78% of hospitals
administering rtPA for acute stroke had at least 1 neurologist on their
medical staff, 22% did not have a neurologist. Neurologists are
currently involved in the care of a minority of stroke patients in the
United States.12 13 Therefore, this relatively
high proportion may reflect caution in the use of rtPA without
neurological expertise. Only close ongoing surveillance will provide
data to determine whether rtPA-related outcomes differ according to the
specialty of the treating physician.
The International Stroke Trial found that only 4% of patients with
acute ischemic stroke presented to the hospital within
the first 3 hours after the onset of symptoms.14
Within the NINDS rt-PA trial, the most common reason that stroke
patients did not receive rtPA treatment was because they did not arrive
at the hospital in a timely fashion.1 The general
population is ordinarily not aware of stroke
symptoms,15 making the development of effective
public education programs critical.16 Although
educational campaigns may originate from a variety of sources, less
than half of the medical facilities providing rtPA had community stroke
awareness programs (less than 20% of hospitals not offering rtPA
treatment had these types of programs). Based on these data, the need
for local public education, particularly within stroke belt
communities, needs further emphasis.
Once a patient reaches the hospital, acute stroke care is expedited by
a mechanism for rapid patient identification and
treatment.17 18 However, only one third of the
hospitals with rtPA protocols also had rapid patient identification
programs. In addition, the treatment of patients with acute stroke by
an organized team19 20 and the use of stroke care
maps21 22 have been associated with shorter
hospital stays, fewer complications, and improved functional outcome.
Although only high-volume centers can support a dedicated stroke
unit,19 21 22 23 24 25 26 27 the provision of organized stroke
care can be accomplished in many settings. Stroke care maps were used
in just over one half of the hospitals with rtPA protocols, and stroke
teams were organized in one third. Significantly fewer hospitals
without rtPA protocols had these programs. Given their apparent
benefit, more widespread adoption of organized care systems should be
advocated.
These data show that rtPA, a new therapy for ischemic stroke,
is potentially available to a high proportion of the North Carolina's
citizens based on their county of residence. However, other services
that may improve outcomes and reduce stroke-related costs (eg, stroke
teams, stroke units, care maps) are not being widely used, even in
centers providing treatment with rtPA. The simple methodology employed
in this study is applicable in other states and permits targeting of
selected centers for development of stroke treatment capabilities.
Received June 11, 1998;
revision received July 10, 1998;
accepted July 10, 1998.
2.
Caplan LR, Mohr JP, Kistler JP, Koroshetz W, Grotta J.
Should thrombolytic therapy be the first-line treatment
for acute ischemic stroke? N Engl J Med. 1997;337:1309–1313.
3.
Brott T. Thrombolysis for stroke.
Arch Neurol. 1996;53:1305–1306.
4.
Riggs JE. Tissue-type plasminogen
activator should not be used in acute ischemic
stroke. Arch Neurol. 1996;53:1306–1308.
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Hankey GJ. Thrombolytic therapy in acute
ischaemic stroke: the jury needs more evidence. Med J Aust. 1997;166:419–422.[Medline]
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Tanne D, Mansbach HH, Verro P, Binder JR, Karanjia PN,
Dayno J, Dulli D, Book D, Levine SR. Intravenous rt-PA
therapy for stroke in clinical practice: a multicenter evaluation of
outcome. Stroke. 1998;29:288. Abstract.
7.
Grond M, Rudolf J, Schmülling S, Stenzel C,
Neveling M, Heiss W-D. Can the NINDS results be transfered into daily
routine? Stroke. 1998;29:288. Abstract.
8.
Hanson SK, Brauer DJ, Anderson DC, Koller RL,
Davenport JG, Ramirez-Lassepas M, Klassen AC, Altafullah IM, Brown RD.
Stroke treatment in the community (STIC): intravenous rt-PA
in clinical practice. Neurology. 1998;50(suppl
4):A155–A156. Abstract.
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Anderson A, Smith DB, Hughes RL. The Colorado Acute
Stroke Network experience with intravenous r-TPA in acute
ischemic stroke. Neurology. 1998;50(suppl 4):A157.
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Howard G, Evans GW, Pearce K, Howard VJ, Bell RA, Mayer
EJ, Burke GL. Is the stroke belt disappearing? An analysis of
racial, temporal, and age effects. Stroke. 1995;26:1153–1158.
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Statistical Abstracts on North Carolina Counties.
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DeFriese GH, Oddone EZ, Paul JE, Akin DR, Samsa GP. US National survey
of physician practices for the secondary and tertiary prevention of
stroke: design, service availability, and common practices.
Stroke. 1995;26:1607–1615.
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Samsa GP, Matchar DB. What role do neurologists play in determining the
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Pancioli AM, Broderick J, Kothari R, Brott T,
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© 1998 American Heart Association, Inc.
Original Contributions
North Carolina Stroke Prevention and Treatment Facilities Survey
rtPA Therapy for Acute Stroke
Abstract
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Background and Purpose—North
Carolina is situated in the "stroke belt" region of the United
States, an area of the country with a particularly high incidence of
cerebrovascular disease. The North Carolina Stroke Prevention and
Treatment Facilities Survey was carried out to determine the
availabilities of a variety of stroke prevention and treatment services
throughout the state. The purpose of the present study was to
determine how widely recombinant tissue-type plasminogen
activator (rtPA) has been adopted for the treatment of
patients with acute ischemic stroke and to determine the
characteristics of the medical facilities in the state offering
this therapy.
Key Words: cerebrovascular disorders • data collection • emergency medical services • plasminogen activator, tissue type • thrombolytic therapy
Introduction
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
The prevention and treatment of stroke is undergoing a
revolution. Much of this excitement has been prompted by the advent of
recombinant tissue-type plasminogen activator
(rtPA) therapy for selected patients with acute ischemic
stroke.1 Although there has been some controversy
surrounding the use of rtPA,2 3 4 5 emerging
data6 7 8 9 suggest that judicious use of this drug
in a variety of community settings results in outcomes similar to that
found in the clinical trial that led to the approval of rtPA by the
Food and Drug Administration. In addition to rtPA, other hyperacute
therapies are currently under development. A variety of healthcare
organizations are stressing the need for public education concerning
stroke symptoms and for the development of medical systems capable of
rapidly identifying, triaging, and treating patients with acute
stroke.
Subjects and Methods
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
A list of all inpatient medical facilities in North Carolina
(n=125) was obtained from the Division of Facilities. In January 1998,
a 1-page survey (Table 1
) was mailed to
the medical directors of each facility, with a cover letter explaining
its purpose signed by the study principal investigator and the deputy
director of the state Department of Health and Human Services.
Nonresponders were sent a second mailing, again asking them to complete
the survey. The survey was then sent by fax to those not responding to
the second mailing, with telephone follow-up as necessary.
View this table:
[in a new window]
Table 1. North Carolina Stroke Prevention and Treatment
Facilities
Survey 
2 statistics were used to compare the
characteristics of facilities offering or not offering rtPA treatment.
Population data were obtained from the last available
census,11 which permitted calculation of the
proportion of the state's population residing in counties with
hospitals providing treatment with rtPA and other stroke-related
services.
Results
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
Responses were obtained from every inpatient facility in North
Carolina, providing comprehensive statewide data. These 125 facilities
were located in 84 of the state's 100 counties. ). Seventy-four percent of the state's
population resides in counties with these facilities. Table 2 compares the characteristics of medical
facilities providing rtPA treatment with those not offering this
therapy. Hospitals with stroke rtPA protocols had more inpatient beds
(mean, 301 and range, 46 to 1124 versus mean, 148 and range, 8 to 849;
P=0.0001), more commonly sponsored stroke community
awareness programs and more frequently had an organized stroke team,
employed stroke care maps, had rapid stroke identification programs,
had a Stroke Acute Care Unit or its equivalent, and had a neurologist
on the medical staff. The Figure gives the geographic distribution by
county of facilities providing rtPA treatment, having an organized
stroke team, and having a stroke unit or its equivalent.
View larger version (52K):
[in a new window]
Figure 1. Maps of North Carolina showing counties that contain medical
facilities providing treatment of stroke patients with rtPA, having
stroke teams, or having Stroke Acute Care Units or an equivalent.
View this table:
[in a new window]
Table 2. Comparison of Characteristics of Medical Facilities
Offering and Not Offering Treatment With rtPA for Ischemic
Stroke
Discussion
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
This study provides the first comprehensive data describing the
availability of treatment with rtPA for acute stroke in an entire
state. In just over 11/2 years since this novel treatment was
approved by the Peripheral and Central Nervous System Drug
Advisory Committee to the US Food and Drug Administration, this therapy
has become available to a high proportion of North Carolina's
citizens, based on their county of residence. This has likely been
prompted by intensive efforts of the National Institutes of Health, the
American Heart Association, the National Stroke Association, and a
variety of other agencies to increase the awareness of both the general
medical community and the lay population that stroke is a treatable
disease. However, despite these efforts, 25% of North Carolina's
population still resides in counties in which medical facilities
capable of administering rtPA for acute stroke are not available.
Although patients may still be transported to facilities in other
counties for stroke-related care, because of the narrow time window for
rtPA treatment local availability of facilities is critical. No
hospital in 15 of North Carolina's 50 most populous counties currently
offers rtPA treatment. Eighty-four percent of the state's population
would reside in counties providing rtPA therapy if protocols were
adopted by at least 1 facility in each of these counties. Similar
analyses could be carried out in other states to target
hospitals for development of the capability to administer rtPA for
acute stroke.
Acknowledgments
The North Carolina Stroke Prevention and Treatment Facilities
Survey was supported through a grant from the North Carolina Department
of Health and Human Services, Division of Community Health, contract
EP003. The authors wish to thank Anne Latham for her help in obtaining
responses to the survey.
References
Top
Abstract
Introduction
Subjects and Methods
Results
Discussion
References
1.
Marler JR, Brott T, Broderick J, Kothari R,
O'Donoghue M, Barsan W, Tomsick T, Spilker J, Miller R, Sauerbeck L,
Jarrell J, Kelly J, Perkins T, McDonald T, Rorick M, Hickey C, Armitage
J, Perry C, Thalinger K, Rhude R, Schill J, Becker PS, Heath RS, Adams
D. Tissue plasminogen activator for acute
ischemic stroke. N Engl J Med. 1995;333:1581–1587.
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