title: Prehospital factors determining regional variation in thrombolytic therapy in acute ischemic stroke.
abstract: BACKGROUND
  Treatment rates with intravenous tissue plasminogen activator vary by region, which can be partially explained by organizational models of stroke care. A recent study demonstrated that prehospital factors determine a higher thrombolysis rate in a centralized vs. decentralized model in the north of the Netherlands.
  
  
  OBJECTIVE
  To investigate prehospital factors that may explain variation in thrombolytic therapy between a centralized and a decentralized model.
  
  
  METHODS
  A consecutive case observational study was conducted in the north of the Netherlands comparing patients arriving within 4·5 h in a centralized vs. decentralized stroke care model. Factors investigated were transportation mode, prehospital diagnostic accuracy, and preferential referral of thrombolysis candidates. Potential confounders were adjusted using logistic regression analysis.
  
  
  RESULTS
  A total of 172 and 299 arriving within 4·5 h were enrolled in centralized and decentralized settings, respectively. The rate of transportation by emergency medical services was greater in the centralized model (adjusted odds ratio 3·11; 95% confidence interval, 1·59-6·06). Also, more misdiagnoses of stroke occurred in the central model (P = 0·05). In postal code areas with and without potential preferential referral of thrombolysis candidates due to overlapping catchment areas, the odds of hospital arrival within 4·5 h in the central vs. decentral model were 2·15 (95% confidence interval, 1·39-3·32) and 1·44 (95% confidence interval, 1·04-2·00), respectively.
  
  
  CONCLUSIONS
  These results suggest that the larger proportion of patients arriving within 4·5 h in the centralized model might be related to a lower threshold to use emergency services to transport stroke patients and partly to preferential referral of thrombolysis candidates.
authors.affiliation: Department of Neurology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands.
authors.forename: Maarten M H
authors.initials: MM
authors.lastname: Lahr
authors.forename: Patrick C A J
authors.initials: PC
authors.lastname: Vroomen
authors.forename: Gert-Jan
authors.initials: GJ
authors.lastname: Luijckx
authors.forename: Durk-Jouke
authors.initials: DJ
authors.lastname: van der Zee
authors.forename: Ronald
authors.initials: R
authors.lastname: de Vos
authors.forename: Erik
authors.initials: E
authors.lastname: Buskens
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D008962:Models, Theoretical; D009426:Netherlands; D018709:Statistics, Nonparametric; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000627:therapeutic use*; D016896:Treatment Outcome; D014218:Triage / Q000379:methods*; D055815:Young Adult
chemical_list: D010959:Tissue Plasminogen Activator
keywords: acute stroke; organizational model; prehospital; regional variation; thrombolysis