Prehospital factors determining regional variation in thrombolytic therapy in acute ischemic stroke

Background Treatment rates with intravenous tissue plasminogen activator vary by region, which can be partially explained by organizational models of stroke care. A recent study demonstrated that prehospital factors determine a higher thrombolysis rate in a centralized vs. decentralized model in the north of the Netherlands.

Aim To investigate prehospital factors that may explain variation in thrombolytic therapy between a centralized and a decentralized model.

Methods A consecutive case observational study was conducted in the north of the Netherlands comparing patients arriving within 4.5 h in a centralized vs. decentralized stroke care model. Factors investigated were transportation mode, prehospital diagnostic accuracy, and preferential referral of thrombolysis candidates. Potential confounders were adjusted using logistic regression analysis.

Results A total of 172 and 299 arriving within 4.5 h were enrolled in centralized and decentralized settings, respectively. The rate of transportation by emergency medical services was greater in the centralized model (adjusted odds ratio 3.11; 95% confidence interval, 1.59-6.06). Also, more misdiagnoses of stroke occurred in the central model (P = 0.05). In postal code areas with and without potential preferential referral of thrombolysis candidates due to overlapping catchment areas, the odds of hospital arrival within 4.5 h in the central vs. decentral model were 2.15 (95% confidence interval, 1.39-3.32) and 1.44 (95% confidence interval, 1.04-2.00), respectively.

Conclusions These results suggest that the larger proportion of patients arriving within 4.5 h in the centralized model might be related to a lower threshold to use emergency services to transport stroke patients and partly to preferential referral of thrombolysis candidates.