Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.
Tyrolean Health Care Fund, Innsbruck, Austria.
Lancet Neurol. 2015 Jan;14(1):48-56. doi: 10.1016/S1474-4422(14)70286-8. Epub 2014 Nov 28.
Intravenous thrombolysis for ischaemic stroke remains underused worldwide. We aimed to assess whether our statewide comprehensive stroke management programme would improve thrombolysis use and clinical outcome in patients.
In 2008-09, we designed the Tyrol Stroke Pathway, which provided information campaigns for the public and standardised the entire treatment pathway from stroke onset to outpatient rehabilitation. It was commenced in Tyrol, Austria, as a long-term routine-care programme and aimed to include all patients with stroke in the survey area. We focused on thrombolysis use and outcome in the first full 4 years of implementation (2010-13).
We enrolled 4947 (99%) of 4992 patients with ischaemic stroke who were admitted to hospitals in Tyrol; 675 (14%) of the enrollees were treated with alteplase. Thrombolysis administration in Tyrol increased after programme implementation, from 160 of 1238 patients (12·9%, 95% CI 11·1-14·9) in 2010 to 213 of 1266 patients (16·8%, 14·8-19·0) in 2013 (ptrend 2010-13<0·0001). Differences in use of thrombolysis in the nine counties of Tyrol in 2010 (range, 2·2-22·6%) were reduced by 2013 (12·1-22·5%). Median statewide door-to-needle time decreased from 49 min (IQR 35-60) in 2010 to 44 min (29-60) in 2013; symptomatic post-thrombolysis intracerebral haemorrhages occurred in 28 of 675 patients (4·1%, 95% CI 2·8-5·9) during 2010-13. In four Austrian states without similar stroke programmes, thrombolysis administration remained stable or declined between 2010 and 2013 (mean reduction 14·4%, 95% CI 10·9-17·9). Although the 3-month mortality was not affected by our programme (137 [13%] of 1060 patients in 2010 vs 143 [13%] of 1069 patients in 2013), 3-month functional outcome significantly improved (modified Rankin Scale score 0-1 in 375 [40%] of 944 patients in 2010 vs 493 [53%] of 939 in 2013; score 0-2 in 531 [56%] patients in 2010 and 615 [65%] in 2013; ptrend 2010-13<0·0001).
During the period of implementation of our comprehensive stroke management programme, thrombolysis administration increased and clinical outcome significantly improved, although mortality did not change. We hope that these results will guide health authorities and stroke physicians elsewhere when implementing similar programmes for patients with stroke.
Reformpool of the Tyrolean Health Care Fund.
静脉溶栓治疗缺血性脑卒中在全球范围内仍未得到广泛应用。我们旨在评估我们的全州综合性脑卒中管理项目是否会改善患者的溶栓使用率和临床结局。
在 2008-09 年，我们设计了蒂罗尔卒中路径，该路径为公众提供了宣传活动，并规范了从卒中发作到门诊康复的整个治疗路径。它在奥地利蒂罗尔州作为一项长期常规护理项目启动，并旨在将调查区域内的所有卒中患者纳入研究。我们重点关注实施后的头 4 年（2010-13 年）的溶栓使用率和结局。
我们纳入了 4992 名缺血性卒中住院患者中的 4947 名（99%）；675 名（14%）患者接受了阿替普酶治疗。溶栓治疗在项目实施后增加，2010 年 1238 名患者中有 160 名（12.9%，95%CI 11.1-14.9）接受治疗，而 2013 年 1266 名患者中有 213 名（16.8%，14.8-19.0）接受治疗（2010-13 年趋势检验<0.0001）。2010 年蒂罗尔州 9 个县的溶栓使用率差异（范围 2.2-22.6%）在 2013 年缩小（12.1-22.5%）。全州门到针时间中位数从 2010 年的 49 分钟（IQR 35-60）缩短至 2013 年的 44 分钟（29-60）；2010-13 年期间，675 名患者中有 28 名（4.1%，95%CI 2.8-5.9）发生症状性溶栓后颅内出血。在没有类似卒中项目的四个奥地利州，溶栓治疗的使用率在 2010 年至 2013 年间保持稳定或下降（平均下降 14.4%，95%CI 10.9-17.9%）。虽然我们的项目没有影响 3 个月死亡率（2010 年 1060 名患者中有 137 名[13%]，2013 年 1069 名患者中有 143 名[13%]），但 3 个月的功能结局显著改善（2010 年 944 名患者中有 375 名[40%]的改良 Rankin 量表评分为 0-1，2013 年 939 名患者中有 493 名[53%]；2010 年 531 名[56%]患者和 2013 年 615 名[65%]患者的评分均为 0-2；2010-13 年趋势检验<0.0001）。
在我们的综合性脑卒中管理项目实施期间，溶栓治疗的使用率增加，临床结局显著改善，尽管死亡率没有变化。我们希望这些结果将为其他地区的卫生当局和脑卒中医生在为脑卒中患者实施类似项目时提供指导。
蒂罗尔州卫生保健基金的改革池。
