A standardized, multicomponent intervention does not increase alteplase use significantly in the intention-to-treat population in community hospitals, according to research published in the December 21, 2012, online Lancet Neurology. The intervention appears to provide a significant but modest increase in alteplase use in the target population.
Phillip A. Scott, MD, Associate Professor of Emergency Medicine at the University of Michigan in Ann Arbor, and colleagues studied the barrier assessment–interactive educational intervention in a cluster-randomized controlled trial involving 12 matched pairs of acute-care community hospitals. Within the pairs, the hospitals were randomly assigned to the intervention or control group. During the course of a year, hospitals in the intervention group performed qualitative and quantitative assessments of barriers to alteplase use and developed ways to address their findings. The primary outcome was change in alteplase use in patients with ischemic stroke between the pre- and postintervention periods.
In the intention-to-treat analysis, 1.25% of patients with stroke were treated with alteplase in the intervention group before the intervention, compared with 2.79% afterward. In control hospitals, 1.25% of patients with stroke were treated with alteplase before the intervention, compared with 2.10% afterward. The difference between groups was not significant.
In the target-population analysis, alteplase use in intervention hospitals increased from 1.00% of stroke patients before the intervention to 2.62% of stroke patients after the intervention. This increase was significantly greater than that in control hospitals (ie, from 1.09% to 1.72%), but was clinically modest, according to the investigators.
“Our trial emphasizes the challenge of creation of pragmatic interventions to improve knowledge translation to safely increase rates of alteplase use in patients with stroke,” said Dr. Scott. The study “provides the first assessment of safety of stroke thrombolysis in a diverse, randomly selected cohort of hospitals with sufficient treatment numbers to ensure precise safety metrics,” he added. “Our findings also clearly establish the safety of thrombolytic delivery in a randomly selected group of emergency departments. Overall, our findings and those of previous studies support further development of educational efforts to increase alteplase use.”