Time to brain imaging in acute stroke is improving: secondary analysis of the INSTINCT trial.
OBJECTIVE
Patients with acute ischemic stroke benefit from rapid evaluation and treatment, and timely brain imaging is a necessary component. We determined the effect of a targeted behavioral intervention on door-to-imaging time (DIT) among patients with ischemic stroke treated with tissue-type plasminogen activator. Second, we examined the variation in DIT accounted for by patient-level and hospital-level factors.


METHODS
The Increasing Stroke Treatment through Interventional behavioral Change Tactics (INSTINCT) trial was a cluster-randomized, controlled trial involving 24 Michigan hospitals. The intervention aimed to increase tissue-type plasminogen activator utilization. Detailed chart abstractions collected data for 557 patients with ischemic stroke. We used a series of hierarchical linear mixed-effects models to evaluate the effect of the intervention on DIT (difference-in-differences analysis) and used patient-level and hospital-level explanatory variables to decompose variation in DIT.


RESULTS
DIT improved over time, without a difference between intervention and control hospitals (intervention: 23.7-19.3 minutes, control: 28.9-19.2 minutes; P=0.56). Adjusted DIT was faster in patients who arrived by ambulance (7.2 minutes; 95% confidence interval, 4.1-10.2), had severe strokes (1.0 minute per +5-point National Institutes of Health Stroke Scale; 95% confidence interval, 0.1-2.0), and presented in the postintervention period (4.9 minutes; 95% confidence interval, 2.3-7.4). After accounting for these factors, 13.8% of variation in DIT was attributable to hospital. Neither hospital stroke volume nor stroke center status was associated with DIT.


CONCLUSIONS
Performance on DIT improved similarly in intervention and control hospitals, suggesting that nonintervention factors explain the improvement. Hospital-level factors explain a modest proportion of variation in DIT, but further research is needed to identify the hospital-level factors responsible.
From the Robert Wood Johnson Foundation Clinical Scholars Program (K.S., J.F.B.), Department of Emergency Medicine (K.S., P.A.S., W.J.M.), HSR&D Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System (K.S., J.F.B., D.A.L.), Department of Neurology (J.F.B., D.A.L., W.J.M.), and Department of Internal Medicine (D.A.L.), University of Michigan, Ann Arbor.
Kori
K
Sauser
James F
JF
Burke
Deborah A
DA
Levine
Phillip A
PA
Scott
William J
WJ
Meurer
D000368:Aged; D000552:Ambulances / Q000706:statistics & numerical data; D001921:Brain / Q000473:pathology*; D016001:Confidence Intervals; D061345:Early Medical Intervention / Q000706:statistics & numerical data* / Q000639:trends*; D004501:Education, Medical / Q000706:statistics & numerical data / Q000639:trends; D005006:Ethnicity; D005260:Female; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D016014:Linear Models; D008297:Male; D010960:Plasminogen Activators / Q000627:therapeutic use; D011859:Radiography; D020521:Stroke / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
D010960:Plasminogen Activators; D010959:Tissue Plasminogen Activator
neuroimaging; stroke