Does time of day or physician experience affect outcome of acute ischemic stroke patients treated with thrombolysis? A study from Finland

Authors

  • Helsinki Stroke Thrombolysis Registry Group

    1. Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
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    • The Helsinki Stroke Thrombolysis Registry Group includes also: Ville Artto, Olli Häppölä, Perttu J. Lindsberg, Katja Piironen, Janne Pitkäniemi, Kirsi Rantanen, Tiina Sairanen, Oili Salonen, Heli Silvennoinen, Lauri Soinne, Daniel Strbian.

  • Conflict of interest: Yes.
  • Sources of Funding: This study was funded by the Helsinki University Central Hospital EVO Research Fund.
  • Disclosure: Dr Atula, Dr Curtze, Dr Leppä, Mr Lindberg, Dr Mustanoja, Dr Putaala, and Dr Tiainen report no conflicts of interest. Dr Meretoja has received modest consultant fees and honoraria for speaking in educational symposia from Boehringer Ingelheim. Dr Tatlisumak has received modest research grant from Boehringer Ingelheim, has research contracts with SanofiAventis, H. Lundbeck Ab, Schering Plough, Mitsubishi Pharma Europe, BrainsGate Inc, and Concentric Medical Inc, served as a consultant to Mitsubishi Pharma Europe, Boehringer Ingelheim. Dr Kaste received honoraria from Boehringer Ingelheim, PAION AG, Forest Research Laboratories Inc, and Lundbeck AS for participating in Steering Committee meetings of all ECASS and Desmoteplase in Acute Ischemic Stroke Trial (DIAS) trials (modest), and is a consultant and on the Advisory Boards of Boehringer Ingelheim, PAION AG, Forest Research Laboratories Inc, and Lundbeck AS (modest).

Correspondence: Sami Curtze*, Department of Neurology, Helsinki University Central Hospital, PO Box 340, FI-00029 HUS, Finland.

E-mail: sami.curtze@hus.fi

Abstract

Background

Maintaining a steady thrombolysis service for treatment of acute ischemic stroke 24 h/7 days is challenging. Diurnal and seasonal variability of stroke onset affects the clinical outcome of these patients.

Hypothesis

We state that a 24 h/7 days availability of stroke-trained physicians ameliorates weekend effects and other seasonal, weekday, or non-office-hour-related influences on outcome of ischemic stroke patients treated with intravenous thrombolysis.

Methods

All consecutive ischemic stroke patients treated with thrombolysis at the Helsinki University Central Hospital were prospectively registered (n = 1581). Patients with basilar artery occlusion (n = 154) were excluded. Door-to-needle time, three-month clinical outcome as measured by the modified Rankin Scale dichotomized at 0 to 2 vs. 3 to 6, and symptomatic intracerebral hemorrhage were analyzed with logistic regression models adjusting for baseline variables. The treating physician was defined as experienced after 18 decisions made to give thrombolysis treatment.

Results

Door-to-needle time or clinical outcome did not differ with regard to time of day or season of presentation. Higher rates of symptomatic intracerebral hemorrhage occurred in spring (odds ratio 2·06, 95% confidence interval 1·03–4·11) and fall (odds ratio 2·08, 95% confidence interval 1·03–4·18). Physician experience reduced the door-to-needle time (odds ratio 0·40, 95% confidence interval 0·32–0·50) but was not associated with patient outcome (modified Rankin scale 3 to 6, odds ratio 1·22, 95% confidence interval 0·95–1·59) or symptomatic intracerebral hemorrhage (odds ratio 0·80, 95% confidence interval 0·51–1·27) rates.

Conclusions

Thrombolytic therapy can be delivered at a steady service level at all times. With proper training, less-experienced physicians can provide high quality thrombolysis, but experience translates into faster treatment.

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