May 3, 2019BMC NeurologyOpen Access

A systematic review and meta-analysis of interventions to increase stroke thrombolysis

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Why the study?

Although tPA efficacy for acute ischemic stroke is established, use rates remain low, prompting the need to understand available interventions and their relative effectiveness to increase treatment rates.

Do interventions targeting EMS, telemedicine, or public education increase the rate of tPA administration in patients with acute ischemic stroke?

Structured PICO

Do interventions targeting EMS, telemedicine, or public education increase the rate of tPA administration in patients with acute ischemic stroke?

Population

25 studies (14 pre-post studies, 10 randomized controlled trials, and 1 quasi-experiment) evaluating interventions to increase the use of tissue plasminogen activator (tPA) for acute ischemic stroke.

Intervention

Interventions to increase tPA use, targeted at emergency medical services (EMS) (n=14), telemedicine (n=6), and public education (n=6).

Comparator

Control group without the specific intervention.

Outcome

Percentage change in rate of tPA administration.

Interventions targeting EMS, telemedicine, and public education are effective at significantly increasing the rates of tPA administration for acute ischemic stroke.

Implication

Supports implementing EMS, telemedicine, and education interventions to boost tPA rates; reinforces pooled evidence across 16 studies.

Abstract

BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: Interventions to increase tPA use appear to have considerable effectiveness. Our findings support the use of such interventions to improve stroke outcomes.