Varying Rates of Hospital Reperfusion Therapy for Stroke: Insights From Analysis of National Stroke Audit Data

Abstract

Background and purpose: Disparities in stroke care exist globally. While reperfusion therapy is a standard treatment for acute ischemic stroke, variations in its implementation may exist across hospitals.

Methods: We analyzed data from 75,870 patients admitted to 247 acute stroke care hospitals across South Korea, sourced from the Acute Stroke Quality Assessment Program (2013-2018) by the Health Insurance Review and Assessment Service. The primary metric of interest was the hospital reperfusion therapy rate (RTR)-the proportion of patients who received intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT) among those potentially eligible for these therapies and had onset-to-arrival times ≤6 hours and initial National Institutes of Health Stroke Scale scores ≥4. We analyzed correlations between hospital RTRs, adjusted for age, sex, onset-to-arrival time, initial stroke severity, and hospital characteristics.

Results: Of the 10,513 patients eligible for reperfusion therapy, the overall RTR was 52.9%. The average hospital RTR was 34.8% with a median (interquartile range) of 37.5% (9.8-56.2). Hospitals with a greater number of beds and higher monthly stroke volume exhibited higher hospital RTRs. Factors such as monthly stroke volume, stroke unit availability, and monthly IVT and EVT case volume independently influenced hospital RTRs. Notably, hospitals with higher RTRs demonstrated reduced 1-year mortality, irrespective of stroke volume.

Conclusion: In a large national sample of acute stroke care hospitals, there was significant variability in hospital RTRs, with those having higher stroke volumes typically showing higher hospital RTRs. Additionally, an inverse correlation between hospital RTRs and 1-year mortality highlights the clinical importance of improving RTRs.

Keywords: Cerebrovascular disease; Health services research; Infarction; Outcome research; Stroke.

Figure 1.

Distribution of (A) unadjusted hospital RTR, (B) hospital IVT rate, (C) hospital EVT rate, and (D) total stroke volume. RTR, reperfusion therapy rate; IVT, intravenous thrombolysis; EVT, endovascular thrombectomy.

Figure 2.

Hospital RTR in relation to hospital size and stroke volume. (A) Number of hospital beds (Spearman correlation coefficient=0.61, P<0.0001). (B) Average monthly stroke volume (Spearman correlation coefficient=0.64, P<0.0001). RTR, reperfusion therapy rate.

Figure 3.

Hospital RTR and 1-year mortality. (A) Unadjusted and (B) adjusted analysis. Hospital RTR was inversely correlated with 1-year mortality after stroke. (A) Pearson’s correlation coefficient=-0.26205 (P=0.0003), Spearman’s correlation coefficient=-0.23127 (P=0.0015), stroke volume-adjusted partial Pearson’s correlation coefficient=-0.21140 (P=0.0040), stroke volume-adjusted partial Spearman’s correlation coefficient=-0.21749 (P=0.0030). (B) Pearson’s correlation coefficient=-0.18319 (P=0.0126), Spearman’s correlation coefficient=-0.18151 (P=0.0134), stroke volume-adjusted partial Pearson’s correlation coefficient=-0.15391 (P=0.0370), stroke volume-adjusted partial Spearman’s correlation coefficient=-0.15376 (P=0.0372). RTR, reperfusion therapy rate.