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Mark J. Alberts, MD Northwestern University Jean Range, MS The Joint Commission

The Impact of Joint Commission Primary Stroke Center Certification on Administration Rate of IV TPA to Eligible Patients. Mark J. Alberts, MD Northwestern University Jean Range, MS The Joint Commission Ann Watt, MBA The Joint Commission Vicki Cantwell, MBA The Joint Commission

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Mark J. Alberts, MD Northwestern University Jean Range, MS The Joint Commission

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  1. The Impact of Joint Commission Primary Stroke Center Certification on Administration Rate of IV TPA to Eligible Patients Mark J. Alberts, MD Northwestern University Jean Range, MS The Joint Commission Ann Watt, MBA The Joint Commission Vicki Cantwell, MBA The Joint Commission Joe Troy, MS The Joint Commission

  2. Introduction • TJC has been certifying Primary Stroke Centers since 2003 • The use of IV TPA to treat eligible patients with acute ischemic strokes is one important aspect of care at a PSC, but certainly not the main reason to become a PSC • IV TPA remains one of the few FDA-approved treatments for acute ischemic stroke • IV TPA is included in all acute stroke care guidelines

  3. Methods • Data obtained through TJC files (site visits and disease performance measures) • 2008 data • Data also obtained from AHA Helthcare Quick-Disc 2008 edition • TPA administration defined as patient presentation within 120 minutes of time last known well • IV TPA administered within 180 minutes • Patients met inclusion/exclusion criteria used by hospital/guidelines • Correlated TPA use with cycles of certification and type of facility

  4. Results • Data available from 418 PSCs • 251 teaching and 154 non-teaching • 200 certified within past 2 years (1st cycle) • 197 in their second certification cycle • 21 are in their third certification cycle • 1902 of 2469 total eligible patients received TPA 77% utilization rate

  5. Overall Rates of TPA Utilization and Cycle Cycle NumberTPA Use 1 72.7% 2 78.6% 3 94.4% P = 0.03 for one to three cycle comparison

  6. Rates of TPA UtilizationTeaching vs Non-Teaching Hospitals • TJC classifies hospitals into 3 categories • Major teaching • Minor teaching • Non-teaching • Most certified PSCs (71%) are either non-teaching or minor teaching hospitals

  7. Rates of TPA UtilizationTeaching vs Non-Teaching Hospitals 70% use of TPA in non-teaching hospitals 81% rate of TPA use in major or minor teaching hospitals 11% absolute difference in rate of TPA utilization This is only among eligible patients P < 0.05

  8. Number of Hospitals per Cycle

  9. Number of Treated Patients per Cycle

  10. Number of Patients Treated per Hospital

  11. Rates of TPA Use, Hospital Type, and Cycles Cycle 1Cycle 2Cycle 3 Teaching 78% 80% 94% Non-Teach 67% 74% 100% Difference - 11% - 6% + 6%

  12. Trends Over Time in Percent Eligible Treated

  13. Discussion Points • Higher rates of TPA use in teaching hospitals could be due to a number of factors: • Availability of stroke teams 24/7 • Familiarity with TPA protocol • Improved guidance from fellows and attending • Better patient acceptance

  14. Discussion Points • Increase in TPA use with increased recertification cycles: • More experience and comfort among medical staff • More efficient care leading to fewer treatment delays • Improved marketing of stroke center and its programs • May increase the number of overall eligible patients

  15. Discussion Points • What accounts for the narrowing of treatment rates between teaching and non-teaching facilities? • Was due largely to gains at the non-teaching hospitals • But both groups showed improvements • Demonstrates that experience matters!! • Perhaps diversion of acute patients to specific facilities leads to improved care efficiency, comfort levels, and program development

  16. Limitations • Much of the data obtained from databases • Much of the data generated by self-reporting • Few audited results • We did not analyze nor control for many confounding factors: • Risk stratification • SES • Reasons for exclusion from treatment • Ascertainment biases

  17. Conclusions • TPA utilization at certified PSCs is associated with the duration of time a hospital has been a Stroke Center • While TPA utilization is higher initially at teaching hospitals, over time the non-teaching hospitals are able to achieve high levels of TPA use • Experienced teaching hospitals have the highest rate of TPA utilization

  18. Conclusions • These data further support the importance of PSCs and how time and experience improve some aspects of acute stroke care • The vast majority of patients at a PSC do not receive TPA, but still benefit from other aspects of organized care at these facilities

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