The impact of demographic and logistic factors on effectiveness and safety of IV thrombolysis in patients with acute ischemic stroke in a rural hospital in southeastern Poland

Authors


  • Conflict of interest: None declared.

Correspondence: Piotr Sobolewski, Department of Neurology and Stroke Unit of Hospital in Sandomierz, 13 Schinzla Str. 27-600 Sandomierz, Poland.

E-mail: piotrsobolewski@poczta.onet.pl

Intravenous thrombolysis (IV thrombolysis) with recombinant tissue plasminogen activator (rt-PA) is an effective therapy for acute ischemic stroke (AIS) [1]. Only a few studies have reported on the safety and efficacy of thrombolytic therapy in patients from rural regions [2, 3]. In the region of our stroke unit (SU), air transport and telemedicine systems are not used in routine practice. Despite this, many patients reach the hospital in the critical ‘time window’, allowing the use of rt-PA. Sandomierz is a small town located in southeast Poland. Our SU cares for a population of 238 000 living in three districts: Sandomierz, Opatów, and Tarnobrzeg township. Approximately 63·4% of residents live in rural areas (RAs). We cooperate with five neighboring hospitals (NH).

Between 2006 and 2012 in our SU, 1728 patients with AIS were treated, including 280 patients (16·2%) treated with IV thrombolysis (aged 41–92, mean 70·12 ± 11·12). We treated 41·8% of patients from regions of NH, 65·8% of whom were transported through emergency departments (EDs) of NH. We studied the results of treatment of rural and urban populations and impact of the delayed transport on safety and effectiveness of IV thrombolysis. In the sub-group of patients from urban areas, there was a higher rate of good long-term functional outcome (P = 0·154). The presence of hemorrhagic transformation and symptomatic intracerebral hemorrhage was similar in both groups (P = 0·74 and P = 0·47, respectively); however, mortality was higher in patients from RAs (P = 0·06). In the group of patients who was transported through ED of NH, we found a lower incidence of good outcome at three-months (P = 0·044) and higher mortality (P = 0·029). In multivariate regression, we confirmed these correlations (Table 1).

Table 1. Multivariate logistic regression models showing factors associated with favorable outcome, deaths, HT, and SICH in patients from rural areas
VariablesFavorable outcome after three-months (mRS 0–2)Deaths within three-monthsHT*SICH*
  1. *According to the ECASS II criteria.
  2. mRS, modified Rankin scale; CI, confidence interval; HT, hemorrhagic transformation; SICH, symptomatic intracerebral hemorrhage; Significant odds ratios (ORs) are shown in bold italic.
 OR (95% CI)OR (95% CI)OR (95% CI)OR (95 CI)
Rural areas0·61 (0·35–1·06)2·21 (1·03–4·75)0·83 (0·40–1·72)0·71 (0·19–2·61)
Onset to door time1·00 (0·99–1·01)0·997 (0·99–1·01)0·995 (0·99–1·01)0·99 (0·98–1·01)
Distance from the onset to door1·01 (0·98–1·03)0·99 (0·96–1·03)1·01 (0·98–1·05)0·99 (0·94–1·06)
Patients who were transported directly from the places of the onset2·35 (1·105·01)0·37 (0·140·95)1·31 (0·47–3·68)1·43 (0·19–10·71)

Transportation of patients with AIS to a local hospital results in delay of treatment initiation [4, 5]. Delivery of patients directly to hospitals with an SU gives them a better chance for good long-term outcome and lower mortality rate.

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