Maximizing the population benefit from thrombolysis in acute ischemic stroke: a modeling study of in-hospital delays.
OBJECTIVE
To maximize the benefits of thrombolysis, it is necessary not only to treat more patients, but to deliver treatment as early as possible. The aims of our study were to prospectively evaluate the clinical benefit from reducing delays in the emergency stroke pathway at our district hospital and examine outcomes from scenarios that include extension of the alteplase license.


METHODS
We developed a discrete-event simulation from prospective data for patients with stroke arriving at our large district hospital. We modeled current practice and assessed the impact on stroke outcomes of measures to reduce in-hospital delays to alteplase treatment and of extensions to the European license for alteplase from 3 to 4.5 hours and to people aged >80 years.


RESULTS
Extension of the time window to 4.5 hours increases the thrombolysis rate by 4%, yielding an additional 2 patients per year with minimal or no disability at 3 months. Time window extension is most effective when combined with a system of prealerts, achieving a thrombolysis rate of 15% and an additional 8 patients per year with minimal or no disability, increasing to 13 patients per year with extension of the license to patients >80 years.


CONCLUSIONS
If implemented alone, extension of the time window for alteplase has only a modest additional population disability benefit, but this benefit can be increased 5-fold if time window extension is combined with substantial reductions to in-hospital delays.
University of Exeter Medical School, University of Exeter, Exeter, Devon, UK. thomas.monks@pcmd.ac.uk
Thomas
T
Monks
Martin
M
Pitt
Ken
K
Stein
Martin
M
James
D000369:Aged, 80 and over; D004636:Emergency Service, Hospital / Q000458:organization & administration* / Q000592:standards; D005343:Fibrinolytic Agents / Q000627:therapeutic use*; D006801:Humans; D007297:Inpatients; D017146:Models, Organizational; D017063:Outcome Assessment, Health Care; D011446:Prospective Studies; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D013997:Time Factors; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome; D014218:Triage / Q000458:organization & administration* / Q000592:standards
D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator