Transcript Slide 1
Mark J. Alberts, MD
Northwestern University
Jean Range, MS
The Joint Commission
Ann Watt, MBA
The Joint Commission
Vicki Cantwell, MBAThe Joint Commission
Joe Troy, MS
The Joint Commission
Introduction
TJC has been certifying Primary Stroke Centers since
2003
The use of IV TPA to treat eligible patients with acute
ischemic strokes is one important aspect of care at a
PSC, but certainly not the main reason to become a
PSC
IV TPA remains one of the few FDA-approved
treatments for acute ischemic stroke
IV TPA is included in all acute stroke care guidelines
Methods
Data obtained through TJC files (site visits and disease
performance measures)
2008 data
Data also obtained from AHA Helthcare Quick-Disc 2008
edition
TPA administration defined as patient presentation within
120 minutes of time last known well
IV TPA administered within 180 minutes
Patients met inclusion/exclusion criteria used by
hospital/guidelines
Correlated TPA use with cycles of certification and type of
facility
Results
Data available from 418 PSCs
251 teaching and 154 non-teaching
200 certified within past 2 years (1st cycle)
197 in their second certification cycle
21 are in their third certification cycle
1902 of 2469 total eligible patients received
TPA 77% utilization rate
Overall Rates of TPA Utilization and Cycle
Cycle Number
TPA Use
1
72.7%
2
78.6%
3
94.4%
P = 0.03 for one to three cycle comparison
Rates of TPA Utilization
Teaching vs Non-Teaching Hospitals
TJC classifies hospitals into 3 categories
Major teaching
Minor teaching
Non-teaching
Most certified PSCs (71%) are either non-teaching
or minor teaching hospitals
Rates of TPA Utilization
Teaching vs Non-Teaching Hospitals
70% use of TPA in non-teaching hospitals
81% rate of TPA use in major or minor teaching
hospitals
11% absolute difference in rate of TPA utilization
This is only among eligible patients
P < 0.05
Number of Hospitals per Cycle
Number of Treated Patients per Cycle
Number of Patients Treated per Hospital
Rates of TPA Use, Hospital Type, and Cycles
Cycle 1
Cycle 2
Cycle 3
Teaching
78%
80%
94%
Non-Teach
67%
74%
100%
Difference
- 11%
- 6%
+ 6%
Trends Over Time in Percent Eligible
Treated
Discussion Points
Higher rates of TPA use in teaching hospitals could be
due to a number of factors:
Availability of stroke teams 24/7
Familiarity with TPA protocol
Improved guidance from fellows and attending
Better patient acceptance
Discussion Points
Increase in TPA use with increased recertification
cycles:
More experience and comfort among medical staff
More efficient care leading to fewer treatment delays
Improved marketing of stroke center and its programs
May increase the number of overall eligible patients
Discussion Points
What accounts for the narrowing of treatment rates
between teaching and non-teaching facilities?
Was due largely to gains at the non-teaching hospitals
But both groups showed improvements
Demonstrates that experience matters!!
Perhaps diversion of acute patients to specific facilities
leads to improved care efficiency, comfort levels, and
program development
Limitations
Much of the data obtained from databases
Much of the data generated by self-reporting
Few audited results
We did not analyze nor control for many confounding
factors:
Risk stratification
SES
Reasons for exclusion from treatment
Ascertainment biases
Conclusions
TPA utilization at certified PSCs is associated with the
duration of time a hospital has been a Stroke Center
While TPA utilization is higher initially at teaching
hospitals, over time the non-teaching hospitals are
able to achieve high levels of TPA use
Experienced teaching hospitals have the highest rate
of TPA utilization
Conclusions
These data further support the importance of PSCs
and how time and experience improve some aspects of
acute stroke care
The vast majority of patients at a PSC do not receive
TPA, but still benefit from other aspects of organized
care at these facilities