From the Division of Health and Social Care Research, King's College London, London, United Kingdom (B.D.B., C.D.A.W., A.G.R.); Royal College of Physicians, London, United Kingdom (J.C., A.H.); St George's Hospital, London, United Kingdom (C.C.G.); University of Manchester, MAHSC, Salford Royal NHS Foundation Trust, Salford, United Kingdom (P.J.T.); and National Institute for Health Research Comprehensive Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom (C.D.A.W., A.G.R.).
Stroke. 2013 Nov;44(11):3129-35. doi: 10.1161/STROKEAHA.113.001981. Epub 2013 Sep 19.
There is evidence that high-volume hospitals may produce better patient outcomes. We aimed to identify whether there were any associations between hospital thrombolysis volume and speed of thrombolysis (tissue-type plasminogen activator [tPA]) administration in patients with ischemic stroke.
Data were drawn from 2 national clinical audits in England: the Stroke Improvement National Audit Program and the 2012 Sentinel Stroke Audit. Hospitals were categorized into 3 groups based on the annualized volume of thrombolysis: 0 to 24, 25 to 49, and ≥50 cases per annum. Arrival-brain scan, onset-tPA, and arrival-tPA times were compared across groups and stratified by onset-arrival time. Multilevel logistic models were used to estimate the odds of receiving tPA within 60 minutes of arrival.
Of the 42 024 patients with acute ischemic stroke admitted to 80 hospitals, 4347 received tPA (10.3%). Patients admitted to hospitals with an annual thrombolysis volume of ≥50 cases per annum had median arrival-tPA times that were 28 and 22 minutes shorter than patients admitted to hospitals with volumes of 0 to 24 and 25 to 49, respectively. Onset-tPA times were shorter by 24 to 32 minutes across strata of onset-arrival times. In multivariable analysis, patients admitted to hospitals with a volume of ≥50 cases per annum had 4.33 (2.21-8.50; P<0.0001) the odds of receiving tPA within 60 minutes of arrival. No differences in safety outcomes were observed, with similar 30-day mortality and complication rates across the groups.
Hospitals with higher volumes of thrombolysis activity achieve statistically and clinically significant shorter delays in administering tPA to patients after arrival in hospital.
有证据表明，大容量医院可能会产生更好的患者结局。我们旨在确定缺血性脑卒中患者的医院溶栓量与溶栓（组织型纤溶酶原激活物[tPA]）给药速度之间是否存在任何关联。
数据来自英格兰的 2 项国家临床审计：Stroke Improvement National Audit Program 和 2012 年 Sentinel Stroke Audit。根据每年溶栓量，医院被分为 3 组：0 至 24、25 至 49 和≥50 例/年。比较了各组之间的到达-脑部扫描、发病- tPA 和到达-tPA 时间，并按发病-到达时间分层。使用多水平逻辑模型估计到达后 60 分钟内接受 tPA 的几率。
在 80 家医院收治的 42024 例急性缺血性脑卒中患者中，有 4347 例接受了 tPA（10.3%）。每年溶栓量≥50 例/年的患者到达-tPA 时间中位数比每年溶栓量为 0 至 24 例/年和 25 至 49 例/年的患者分别短 28 和 22 分钟。在发病-到达时间的各个分层中，发病-tPA 时间缩短了 24 至 32 分钟。在多变量分析中，每年溶栓量≥50 例/年的患者到达后 60 分钟内接受 tPA 的几率为 4.33（2.21-8.50；P<0.0001）。没有观察到安全性结果的差异，各组的 30 天死亡率和并发症发生率相似。
溶栓活动量较高的医院在患者到达医院后给予 tPA 的时间延迟方面具有统计学和临床意义上的显著缩短。
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