Temporal trends in acute stroke management.

he benefit of intravenous recombinant tissue-type plas-minogen activator (rt-PA) for the treatment of acute ischemic stroke is well established. Unfortunately, the rates of rt-PA use among US patients with ischemic stroke remain quite low. Previously, our group published the rate of rt-PA use among ischemic stroke patients within the large Premier database, which is a 15% sampling of US hospitals that cross-references drug use with administrative data. The rate of rt-PA use was extremely low and did not increase from 2001 to 2004. 3 This was despite rt-PA being approved for use in the US since 1996. More recently, we found that the rates of rt-PA have begun to slowly increase from 1. 4 The timing of this increase seemed to coincide with primary stroke center certification by the Joint Commission in the United States in 2004, although this is only an association rather than definitive causality. Rates of rt-PA use did not seem to be affected by increased reimbursement given to hospitals for care of rt-PA–treated patients (instituted in 2006), as we had originally hypothesized. To explore the impact further of hospitals becoming certified as primary stroke centers, we used the Medicare Provider Analysis and Review (MEDPAR) database to evaluate rt-PA rates at the hospital level. This database includes all fee-for-service hospitals in the United States, and patients are included if they are Medicare-eligible (aged, >65 years or permanently disabled). Within this database, hospital characteristics associated with higher rates of rt-PA use included larger bed size, urban location, and Northeast and West geographic location within the United States in FY 2009. 5 We then compared rt-PA use between hospitals that became primary stroke centers during the study period of FY 2006–2010 to those hospitals that were not certified. As expected, hospitals that became stroke centers had higher rates of rt-PA treatment than those that did not become certified (5.0% versus 1.4%) in FY 2010. Rates of treatment increased steadily during the 3 years before and the 3 years after certification (Figure 2). 6 However, even with these substantial improvements in our systems of care, we are still not treating the vast majority of ischemic stroke patients with rt-PA. This is most certainly related to the eligibility of stroke patients for this acute reper-fusion therapy. Within the large, biracial population of 1.3 million people in the Greater Cincinnati/Northern Kentucky region, only 8% of 2308 ischemic stroke patients would have been …