McDermott Mollie, Skolarus Lesli E, Burke James F
Neurology Department, University of Michigan, Cardiovascular Center, 1500 East Medical Center Drive - SPC #5855, Ann Arbor, MI, 48109-5855, USA.
BMC Neurol. 2019 May 3;19(1):86. doi: 10.1186/s12883-019-1298-2.
Although the efficacy of tissue plasminogen activator (tPA) for acute ischemic stroke is well established, rates of tPA use remain low. For clinicians, advocates, and policy-makers seeking to increase tPA treatment rates, it is important to understand what interventions exist and their relative effectiveness.
We searched PubMed and EMBASE to identify all studies published between 1995 and January 8, 2015 documenting interventions to increase the use of tPA with broadly inclusive criteria. The principal summary measure was the percentage change in rate of tPA administration. Random effects meta-analytic models were built to summarize the effect of intervention compared to control overall and for intervention characteristics.
The search yielded 1457 results of which 25 met eligibility criteria. We identified 14 pre-post studies, ten randomized controlled trials, and one quasi-experiment. Included studies targeted their interventions at emergency medical services (EMS) (n = 14), telemedicine (n = 6), and public education (n = 6). In a random effects model, tPA administration was significantly higher in the intervention arm across all studies limiting enrollment to ischemic stroke patients (n = 16) with a risk ratio (RR) of 1.80 (95% confidence interval [CI], 1.45-2.22). A trend towards increased tPA administration was observed for all intervention approaches: risk ratio of 1.73 (95% CI, 1.44-2.09) for EMS, 1.58 (95% CI, 0.72-3.47) for telemedicine, and 1.89 (95% CI, 0.77-4.65) for public education, the latter not restricted to ischemic stroke patients.
Interventions to increase tPA use appear to have considerable effectiveness. Our findings support the use of such interventions to improve stroke outcomes.
尽管组织型纤溶酶原激活剂（tPA）治疗急性缺血性卒中的疗效已得到充分证实，但tPA的使用率仍然很低。对于寻求提高tPA治疗率的临床医生、倡导者和政策制定者来说，了解现有哪些干预措施及其相对有效性很重要。
我们检索了PubMed和EMBASE，以识别1995年至2015年1月8日期间发表的所有研究，这些研究记录了采用广泛包容性标准来增加tPA使用的干预措施。主要汇总指标是tPA给药率的百分比变化。构建随机效应荟萃分析模型，以总结与对照组相比干预措施的总体效果以及干预措施的特征效果。
检索得到1457项结果，其中25项符合纳入标准。我们确定了14项前后对照研究、10项随机对照试验和1项准实验。纳入研究的干预措施针对紧急医疗服务（EMS）（n = 14）、远程医疗（n = 6）和公众教育（n = 6）。在随机效应模型中，在所有将入组限制为缺血性卒中患者的研究（n = 16）中，干预组的tPA给药率显著更高，风险比（RR）为1.80（95%置信区间[CI]，1.45 - 2.22）。在所有干预方法中均观察到tPA给药率增加的趋势：EMS的风险比为1.73（95% CI，1.44 - 2.09），远程医疗的风险比为1.58（95% CI，0.72 - 3.47），公众教育的风险比为1.89（95% CI，0.77 - 4.65），后者不限于缺血性卒中患者。
增加tPA使用的干预措施似乎具有相当大的有效性。我们的研究结果支持使用此类干预措施来改善卒中结局。
