title: Utilization of intravenous tissue-type plasminogen activator for ischemic stroke at academic medical centers: the influence of ethnicity.
abstract: OBJECTIVE
  We sought to measure the overall rate of usage of tissue-type plasminogen activator (tPA) for ischemic stroke at academic medical centers, and to determine whether ethnicity was associated with usage.
  
  
  METHODS
  Between June and December 1999, 42 academic medical centers in the United States each identified 30 consecutive ischemic stroke cases. Medical records were reviewed and information on demographics, medical history, and treatment were abstracted. Rates of tPA use were compared for African Americans and whites in univariate analysis and after adjustment for age, gender, stroke severity, and type of medical insurance with multivariable logistic regression.
  
  
  RESULTS
  Complete information was available for 1195 ischemic stroke patients; 788 were whites and 285 were African Americans: Overall, 49 patients (4.1%) received tPA. In the subgroup of 189 patients without a documented contraindication to therapy, 39 (20.6%) received tPA. Ten (20%) of those receiving tPA had documented contraindication. African Americans were one fifth as likely to receive tPA as whites (1.1% African Americans versus 5.3%; P=0.001), and the difference persisted after adjustment (OR 0.21, 95% CI 0.06 to 0.68; P=0.01). When comparison was restricted to those without a documented contraindication to tPA, the difference remained significant (OR 0.24, 95% CI 0.06 to 0.93; P=0.04). Medical insurance type was independently associated with tPA treatment. After adjustment for ethnicity and other demographic characteristics, those with Medicaid or no insurance were one ninth as likely to receive tPA as those with private medical insurance (OR 0.11, 95% CI 0.02 to 0.17; P=0.003).
  
  
  CONCLUSIONS
  tPA is used infrequently for ischemic stroke at US academic medical centers, even among qualifying candidates. African Americans are significantly less likely to receive tPA for ischemic stroke. Contraindications to treatment do not appear to account for the difference.
authors.affiliation: Neurovascular Service, Department of Neurology, University of California, San Francisco, CA 94143-0114, USA. clayj@itsa.ucsf.edu
authors.forename: S C
authors.initials: SC
authors.lastname: Johnston
authors.forename: L H
authors.initials: LH
authors.lastname: Fung
authors.forename: L A
authors.initials: LA
authors.lastname: Gillum
authors.forename: W S
authors.initials: WS
authors.lastname: Smith
authors.forename: L M
authors.initials: LM
authors.lastname: Brass
authors.forename: J H
authors.initials: JH
authors.lastname: Lichtman
authors.forename: A N
authors.initials: AN
authors.lastname: Brown
mesh_terms: D000046:Academic Medical Centers / Q000706:statistics & numerical data*; D001741:Black or African American / Q000706:statistics & numerical data; D000368:Aged; D002545:Brain Ischemia / Q000150:complications / Q000188:drug therapy* / Q000208:ethnology; D015331:Cohort Studies; D000075202:Contraindications; D016208:Databases, Factual; D017723:Drug Utilization Review / Q000706:statistics & numerical data*; D005260:Female; D005343:Fibrinolytic Agents / Q000627:therapeutic use; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010351:Patient Discharge / Q000706:statistics & numerical data; D020521:Stroke / Q000150:complications / Q000188:drug therapy* / Q000208:ethnology; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D014481:United States; D044465:White People / Q000706:statistics & numerical data
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator