Relationship between Hospital Volume and Early Outcomes in Acute Ischemic Stroke Patients Treated with Recombinant Tissue Plasminogen Activator

Abstract

Background

There is controversy whether the annual number of acute ischemic stroke patients receiving stroke thrombolysis per hospital (hospital volume) is associated with outcomes in these patients.

Aims

The study aims to assess the relationship between hospital volume and early outcomes in acute ischemic stroke patients treated with recombinant tissue plasminogen activator.

Methods

Patients with acute ischemic stroke treated with recombinant tissue plasminogen activator from July 1, 2010 to March 31, 2012 were identified in the Japanese Diagnosis Procedure Combination database. Hospital volume was categorized into three levels (low, medium, and high volume) to obtain approximately equal numbers of patients in each group. Primary outcomes were seven-day mortality and functional independence (modified Rankin Scale score of 0 to 2) at discharge. Univariate analyses and multivariate logistic regression analyses fitted with generalized estimating equations were performed.

Results

We identified 7476 eligible patients, including 2339 (31·3%) treated in low-volume hospitals (1–7 patients annually), 2670 (35·7%) in medium-volume hospitals (8–16 patients annually), and 2467 (33·0%) in high-volume hospitals (17–48 patients annually). Seven-day mortality and functional independence at discharge were comparable among the three hospital volume groups (P = 0·17 for seven-day mortality; P = 0·22 for functional independence at discharge). The comparability between groups persisted after multivariate adjustment.

Conclusion

Hospital volume was not significantly associated with seven-day mortality or functional independence at discharge in acute ischemic stroke patients treated with recombinant tissue plasminogen activator in Japan.

Keywords

hospital volume ischemic stroke population-based study recombinant tissue plasminogen activator stroke facilities thrombolysis

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References

Lozano

Naghavi

Foreman

. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859):2095–128.

Murray

CJL

Vos

Lozano

. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012; 380(9859):2197–223.

The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333:1581–7.

Hacke

Kaste

Bluhmki

. Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke. N Engl J Med 2008; 359:1317–29.

Lees

Bluhmki

Von Kummer

. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010; 375(9727):1695–703.

Schumacher

Bateman

Boden-Albala

. Use of thrombolysis in acute ischemic stroke: analysis of the Nationwide Inpatient Sample 1999 to 2004. Ann Emerg Med 2007; 50:99–107.

Hill

Buchan

. Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study. CMAJ 2005; 172:1307–12.

Wahlgren

Ahmed

Dávalos

. Thrombolysis with alteplase for acute ischaemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet 2007; 369:275–82.

Nakagawara

Minematsu

Okada

. Thrombolysis with 0.6 mg/kg intravenous alteplase for acute ischemic stroke in routine clinical practice: the Japan post-Marketing Alteplase Registration Study (J-MARS). Stroke 2010; 41:1984–9.

10.

Halm

Lee

Chassin

. Is volume related to outcome in health care? A systematic review and methodologic critique of the literature. Ann Intern Med 2002; 137:511–20.

11.

Heuschmann

Kolominsky-Rabas

Roether

. Predictors of in-hospital mortality in patients with acute ischemic stroke treated with thrombolytic therapy. JAMA 2004; 292:1831–8.

12.

Bateman

Schumacher

Boden-Albala

. Factors associated with in-hospital mortality after administration of thrombolysis in acute ischemic stroke patients: an analysis of the nationwide inpatient sample 1999 to 2002. Stroke 2006; 37:440–6.

13.

Yamaguchi

Mori

Minematsu

. Alteplase at 0.6 mg/kg for acute ischemic stroke within 3 hours of onset: Japan Alteplase Clinical Trial (J-ACT). Stroke 2006; 37:1810–5.

14.

Ohta

Waga

Handa

Saito

Takeuchi

. New grading of level of disordered consiousness (author's transl). No Shinkei Geka 1974; 2:623–7.

15.

Shigematsu

Nakano

Watanabe

. The eye response test alone is sufficient to predict stroke outcome – reintroduction of Japan Coma Scale: a cohort study. BMJ Open 2013; 3:e002736.

16.

Ono

Wada

Takahara

Shirotani

. Indications for computed tomography in patients with mild head injury. Neurol Med Chir (Tokyo) 2007; 47:291–7, discussion 297–8.

17.

Saposnik

Webster

O'Callaghan

Hachinski

. Optimizing discharge planning: clinical predictors of longer stay after recombinant tissue plasminogen activator for acute stroke. Stroke 2005; 36:147–50.

18.

Cuzick

. A Wilcoxon-type test for trend. Stat Med 1985; 4:87–90.

19.

Adams

Del Zoppo

Alberts

. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atheros. Stroke 2007; 38:1655–711.

20.

Minematsu

Toyoda

Hirano

. Guidelines for the intravenous application of recombinant tissue-type plasminogen activator (alteplase), the second edition, October 2012: a guideline from the Japan Stroke Society. J Stroke Cerebrovasc Dis 2013; 22:571–600.

21.

Saver

Fonarow

Smith

. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. JAMA 2013; 309:2480–8.

22.

Strbian

Soinne

Sairanen

. Ultra early thrombolysis in acute ischemic stroke is associated with better outcome and lower mortality. Stroke 2010; 41:712–6.

23.

Ronning

Guldvog

. Stroke units versus general medical wards, I: twelve- and eighteen-month survival: a randomized, controlled trial. Stroke 1998; 29:58–62.

24.

Inoue

Fushimi

. Stroke care units versus general medical wards for acute management of stroke in Japan. Stroke 2014; 44:3142–7.

25.

Stroke Unit Trialists' Collaboration. Organised inpatient (stroke unit) care for stroke. Cochrane Database Syst Rev 2013; (9):CD000197.

26.

Meretoja

Strbian

Mustanoja

Tatlisumak

Lindsberg

Kaste

. Reducing in-hospital delay to 20 minutes in stroke thrombolysis. Neurology 2012; 79:306–13.

27.

Hacke

Kaste

Fieschi

. Randomised double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischaemic stroke (ECASS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 1998; 352(9136):1245–51.

28.

Ovbiagele

Saver

. Day-90 acute ischemic stroke outcomes can be derived from early functional activity level. Cerebrovasc Dis 2010; 29:50–6.