Mark J. Alberts, MDNorthwestern University Jean Range, MSThe Joint Commission Ann Watt, MBAThe Joint Commission Vicki Cantwell, MBAThe Joint Commission Joe Troy, MSThe 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 (1 st 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 NumberTPA Use % % % 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