title: The use and misuse of thrombolytic therapy within the Veterans Health Administration.
abstract: BACKGROUND
  Within the Veterans Health Administration (VHA), approximately 6000 veterans are hospitalized with acute ischemic stroke annually. We examined the use and misuse of thrombolytic therapy with tissue plasminogen activator (tPA) in a national sample of veterans who were admitted to a VHA Medical Center (VAMC) with acute ischemic stroke.
  
  
  METHODS
  Medical record reviews were conducted on 5000 acute stroke patients who were admitted to a VAMC in 2007. Patients were defined as eligible to receive tPA if they arrived at the hospital within 3 hours of stroke symptom onset and had no contraindications to tPA. We compared eligible patients who received tPA to those who did not and examined the distribution of eligible patients across the 129 VAMCs included in this study.
  
  
  RESULTS
  Among the 3931 ischemic stroke patients, 174 (4.4%) were eligible for tPA. Among the 135 patients who arrived within 2 hours of symptom onset which allowed adequate time for testing and evaluation, 19 (14.1%) received tPA. An additional 11 patients received tPA but did not meet eligibility criteria. Eligible patients receiving tPA were similar to eligible patients not receiving tPA in terms of clinical conditions and time to brain imaging. Among the 30 patients that received tPA, 5 (16.6%) received the wrong dose. Among the 85 VAMCs that received ≥1 eligible patient, on average 2.3 patients were eligible for tPA annually.
  
  
  CONCLUSIONS
  Relatively few eligible veterans receive thrombolysis across the VHA system. Strategies to improve thrombolysis delivery will have to account for the low annual volume of eligible stroke patients cared for at individual VAMCs.
authors.affiliation: Department of Veterans Affairs (VHA) Health Services Research & Development Service (HSR&D) Research Enhancement Award Program (REAP), University of California at San Francisco, San Francisco, CA, USA. salomeh.keyhani@va.gov
authors.forename: Salomeh
authors.initials: S
authors.lastname: Keyhani
authors.forename: Greg
authors.initials: G
authors.lastname: Arling
authors.forename: Linda S
authors.initials: LS
authors.lastname: Williams
authors.forename: Joseph S
authors.initials: JS
authors.lastname: Ross
authors.forename: Diana L
authors.initials: DL
authors.lastname: Ordin
authors.forename: Jennifer
authors.initials: J
authors.lastname: Myers
authors.forename: Gary
authors.initials: G
authors.lastname: Tyndall
authors.forename: Bruce
authors.initials: B
authors.lastname: Vogel
authors.forename: Dawn M
authors.initials: DM
authors.lastname: Bravata
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D002545:Brain Ischemia / Q000188:drug therapy*; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D006300:Health Services Misuse; D006305:Health Status Indicators; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D012959:Socioeconomic Factors; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*; D014481:United States; D014493:United States Department of Veterans Affairs
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator