Time to brain imaging in acute stroke is improving: secondary analysis of the INSTINCT trial.
Time to brain imaging in acute stroke is improving: secondary analysis of the INSTINCT trial.
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DOI：
10.1161/strokeaha.113.003678
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发表时间：
2014-01
期刊：
影响因子：
8.3
通讯作者：
Meurer WJ
中科院分区：
文献类型：
--
作者：
Sauser K;Burke JF;Levine DA;Scott PA;Meurer WJ
急性缺血性卒中（IS）患者受益于快速评估和治疗，及时的脑成像是必要的组成部分。我们在接受组织纤溶酶原激活剂（tPA）治疗的IS患者中确定了针对性行为干预对门到成像时间（DIT）的影响。其次，我们研究了由患者和医院水平因素引起的DIT的变化。该试验是一项随机分组的对照试验，涉及24家密歇根医院。干预旨在增加tPA的利用。详细图表摘要收集了557例IS患者的数据。我们使用了一系列分层线性混合效应模型来评估干预对DIT的影响（差异分析），并使用患者和医院水平的解释变量来分解DIT的变化。DIT随时间推移而改善，干预医院和对照医院之间无差异（干预：23.7至19.3分钟，对照：28.9至19.2分钟，p=0.56）。在由救护车到达的患者（7.2分钟; 95%CI 4.1-10.2）中，重度卒中患者（1.0分钟/+5分NIHSS; 95%CI 0.1-2.0）和在干预后阶段出现的患者（4.9分钟; 95%CI 2.3-7.4）的调整后DIT更快。在考虑这些因素后，DIT的13.8%的变化可归因于医院。医院每搏输出量和卒中中心状态均与DIT无关。在干预和控制医院中，DIT的表现也得到了类似的改善，这表明非干预因素可以解释这种改善。医院层面的因素解释了一个适度的比例的变化，在DIT，但需要进一步的研究，以确定医院层面的因素负责。
Acute ischemic stroke (IS) patients benefit from rapid evaluation and treatment, and timely brain imaging is a necessary component. We determined the effect of a targeted behavioral intervention on door-to-imaging-time (DIT) among IS patients treated with tissue plasminogen activator (tPA). Secondarily, we examined the variation in DIT accounted for by patient- and hospital-level factors. The INSTINCT trial was a cluster-randomized, controlled trial involving 24 Michigan hospitals. The intervention aimed to increase tPA utilization. Detailed chart abstractions collected data for 557 IS patients. We used a series of hierarchical linear mixed-effects models to evaluate the effect of the intervention on DIT (difference-in-differences analysis) and used patient and hospital-level explanatory variables to decompose variation in DIT. DIT improved over time, without a difference between intervention and control hospitals (intervention: 23.7 to 19.3 minutes, control: 28.9 to 19.2 minutes, p=0.56). Adjusted DIT was faster in patients who arrived by ambulance (7.2 minutes; 95%CI 4.1–10.2), had severe strokes (1.0 minute per +5 point NIHSS; 95%CI 0.1–2.0), and presented in the post-intervention period (4.9 minutes; 95%CI 2.3–7.4). After accounting for these factors, 13.8% of variation in DIT was attributable to hospital. Neither hospital stroke volume nor stroke center status was associated with DIT. Performance on DIT improved similarly in intervention and control hospitals suggesting that non-intervention factors explain the improvement. Hospital-level factors explain a modest proportion of variation in DIT but further research is needed to identify the hospital-level factors responsible.