NDLI: A multilevel intervention to increase community hospital use of alteplase for acute stroke (INSTINCT): a cluster-randomised controlled trial.

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A multilevel intervention to increase community hospital use of alteplase for acute stroke (INSTINCT): a cluster-randomised controlled trial.

Content Provider	World Health Organization (WHO)-Global Index Medicus
Author	Scott, Phillip A. Meurer, William J. Frederiksen, Shirley M. Kalbfleisch, John D. Xu, Zhenzhen Haan, Mary N. Silbergleit, Robert Morgenstern, Lewis B.
Spatial Coverage	Michigan
Description	Country affiliation: United States Author Affiliation: Scott PA ( Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA. phlsctt@med.umich.edu)
Abstract	BACKGROUND: Use of alteplase improves outcome in some patients with stroke. Several types of barrier frequently prevent its use. We assessed whether a standardised, barrier-assessment, multicomponent intervention could increase alteplase use in community hospitals in Michigan, USA. METHODS: In a cluster-randomised controlled trial, we selected adult, non-specialty, acute-care community hospitals in the Lower Peninsula of Michigan, USA. Eligible hospitals discharged at least 100 patients who had had a stroke per year, had less than 100â000 visits to the emergency department per year, and were not academic comprehensive stroke centres. Using a computer-generated randomisation sequence, we selected 12 matched pairs of eligible hospitals. Within pairs, the hospitals were allocated to intervention or control groups with restricted randomisation in January, 2007. Between January, 2007, and December, 2007, intervention hospitals implemented a multicomponent intervention that included qualitative and quantitative assessment of barriers to alteplase use and ways to address the findings, and provided additional support. The primary outcome was change in alteplase use in patients with stroke in emergency departments between the pre-intervention period (January, 2005, to December, 2006) and the post-intervention period (January, 2008, to January, 2010). Physicians in participating hospitals and the coordinating centre could not be masked to group assignment, but were masked to progress made in paired control hospitals. External medical reviewers who were masked to group assignment assessed outcomes. We did intention-to-treat (ITT) and target-population (without one pair that was excluded after randomisation) analyses. This trial is registered at ClinicalTrials.gov, number NCT00349479. FINDINGS: All 24 hospitals completed the study. Overall, 745 of 40â823 patients with stroke received intravenous alteplase treatment. In the ITT analysis, the proportion of patients with stroke who were admitted and treated with alteplase increased between the pre-intervention and post-intervention periods in intervention hospitals (89 [1·25%] of 7119 patients to 235 [2·79%] of 8419) to a greater extent than in control hospitals (99 [1·25%] of 7946 to 194 [2·10%] of 9222), but the difference between groups was not significant (relative risk [RR] 1·37, 95% CI 0·96-1·93; p=0·08). In the target-population analysis, the increase in alteplase use in intervention hospitals (59 [1·00%] of 5882 to 191 [2·62%] of 7288) was significantly greater than in control hospitals (65 [1·09%] of 5957 to 120 [1·72%] of 6989; RR 1·68, 95% CI 1·09-2·57; p=0·02), but was still clinically modest. INTERPRETATION: The intervention did not significantly increase alteplase use in patients with ischaemic stroke. The increase in use of alteplase in the target population was significant, but smaller than the effect to which the study was powered. Additional strategies to increase acute stroke treatment are needed. FUNDING: National Institutes of Health National Institute of Neurological Disorders and Stroke.
File Format	HTM / HTML
ISSN	14744422
e-ISSN	14744465
DOI	10.1016/S1474-4422(12)70311-3
Journal	The Lancet Neurology
Issue Number	2
Volume Number	12
Language	English
Publisher	Elsevier
Publisher Date	2013-02-01
Publisher Place	Great Britain (UK)
Access Restriction	Open
Subject Keyword	Discipline Neurology Fibrinolytic Agents Therapeutic Use Hospitals, Community Stroke Drug Therapy Tissue Plasminogen Activator Case-control Studies Michigan Outcome Assessment (health Care) Retrospective Studies Time Factors Multicenter Study Randomized Controlled Trial Research Support, N.i.h., Extramural
Content Type	Text
Resource Type	Article
Subject	Neurology (clinical)

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