Mark J. Alberts, MD Northwestern UniversityJean Range, MS The Joint CommissionAnn Watt, MBA The Joint CommissionVicki Cantwell, MBA The Joint CommissionJoe 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

MethodsData 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 wellIV TPA administered within 180 minutesPatients met inclusion/exclusion criteria used by

hospital/guidelinesCorrelated TPA use with cycles of certification and

type of facility

Results

Data available from 418 PSCs251 teaching and 154 non-teaching200 certified within past 2 years (1st

cycle)197 in their second certification cycle21 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 UtilizationTeaching vs Non-Teaching Hospitals

TJC classifies hospitals into 3 categoriesMajor teachingMinor teachingNon-teaching

Most certified PSCs (71%) are either non-teaching or minor teaching hospitals

Rates of TPA UtilizationTeaching 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 24/7Familiarity with TPA protocolImproved guidance from fellows and attendingBetter patient acceptance

Discussion Points

Increase in TPA use with increased recertification cycles:More experience and comfort among medical

staffMore efficient care leading to fewer treatment

delaysImproved 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 databasesMuch of the data generated by self-reporting

Few audited resultsWe did not analyze nor control for many

confounding factors:Risk stratificationSESReasons for exclusion from treatmentAscertainment 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