title: Thrombolysis and clinical outcome in patients with stroke after implementation of the Tyrol Stroke Pathway: a retrospective observational study.
abstract: BACKGROUND
  Intravenous thrombolysis for ischaemic stroke remains underused worldwide. We aimed to assess whether our statewide comprehensive stroke management programme would improve thrombolysis use and clinical outcome in patients.
  
  
  METHODS
  In 2008-09, we designed the Tyrol Stroke Pathway, which provided information campaigns for the public and standardised the entire treatment pathway from stroke onset to outpatient rehabilitation. It was commenced in Tyrol, Austria, as a long-term routine-care programme and aimed to include all patients with stroke in the survey area. We focused on thrombolysis use and outcome in the first full 4 years of implementation (2010-13).
  
  
  RESULTS
  We enrolled 4947 (99%) of 4992 patients with ischaemic stroke who were admitted to hospitals in Tyrol; 675 (14%) of the enrollees were treated with alteplase. Thrombolysis administration in Tyrol increased after programme implementation, from 160 of 1238 patients (12·9%, 95% CI 11·1-14·9) in 2010 to 213 of 1266 patients (16·8%, 14·8-19·0) in 2013 (ptrend 2010-13<0·0001). Differences in use of thrombolysis in the nine counties of Tyrol in 2010 (range, 2·2-22·6%) were reduced by 2013 (12·1-22·5%). Median statewide door-to-needle time decreased from 49 min (IQR 35-60) in 2010 to 44 min (29-60) in 2013; symptomatic post-thrombolysis intracerebral haemorrhages occurred in 28 of 675 patients (4·1%, 95% CI 2·8-5·9) during 2010-13. In four Austrian states without similar stroke programmes, thrombolysis administration remained stable or declined between 2010 and 2013 (mean reduction 14·4%, 95% CI 10·9-17·9). Although the 3-month mortality was not affected by our programme (137 [13%] of 1060 patients in 2010 vs 143 [13%] of 1069 patients in 2013), 3-month functional outcome significantly improved (modified Rankin Scale score 0-1 in 375 [40%] of 944 patients in 2010 vs 493 [53%] of 939 in 2013; score 0-2 in 531 [56%] patients in 2010 and 615 [65%] in 2013; ptrend 2010-13<0·0001).
  
  
  CONCLUSIONS
  During the period of implementation of our comprehensive stroke management programme, thrombolysis administration increased and clinical outcome significantly improved, although mortality did not change. We hope that these results will guide health authorities and stroke physicians elsewhere when implementing similar programmes for patients with stroke.
  
  
  BACKGROUND
  Reformpool of the Tyrolean Health Care Fund.
authors.affiliation: Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Johann
authors.initials: J
authors.lastname: Willeit
authors.affiliation: Tyrolean Health Care Fund, Innsbruck, Austria.
authors.forename: Theresa
authors.initials: T
authors.lastname: Geley
authors.affiliation: Tyrolean Health Care Fund, Innsbruck, Austria.
authors.forename: Johannes
authors.initials: J
authors.lastname: Schöch
authors.affiliation: Tyrolean Health Care Fund, Innsbruck, Austria.
authors.forename: Heinrich
authors.initials: H
authors.lastname: Rinner
authors.affiliation: Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Andreas
authors.initials: A
authors.lastname: Tür
authors.affiliation: Tyrolean Health Care Fund, Innsbruck, Austria.
authors.forename: Hans
authors.initials: H
authors.lastname: Kreuzer
authors.affiliation: Tyrolean Regional Health Insurance, Innsbruck, Austria.
authors.forename: Norbert
authors.initials: N
authors.lastname: Thiemann
authors.affiliation: Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Michael
authors.initials: M
authors.lastname: Knoflach
authors.affiliation: Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Thomas
authors.initials: T
authors.lastname: Toell
authors.affiliation: Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Raimund
authors.initials: R
authors.lastname: Pechlaner
authors.affiliation: Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Karin
authors.initials: K
authors.lastname: Willeit
authors.affiliation: Tyrolean Health Care Fund, Innsbruck, Austria.
authors.forename: Natalie
authors.initials: N
authors.lastname: Klingler
authors.affiliation: Tyrolean Health Care Fund, Innsbruck, Austria.
authors.forename: Silvia
authors.initials: S
authors.lastname: Praxmarer
authors.affiliation: Department of Anesthesia and Intensive Care Medicine, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Michael
authors.initials: M
authors.lastname: Baubin
authors.affiliation: Department of Internal Medicine, Reutte County Hospital, Reutte, Austria.
authors.forename: Gertrud
authors.initials: G
authors.lastname: Beck
authors.affiliation: Department of Neurology, Kufstein County Hospital, Kufstein, Austria.
authors.forename: Klaus
authors.initials: K
authors.lastname: Berek
authors.affiliation: Doctors in private practice, Tyrol, Austria.
authors.forename: Christian
authors.initials: C
authors.lastname: Dengg
authors.affiliation: Department of Internal Medicine, Reutte County Hospital, Reutte, Austria.
authors.forename: Klaus
authors.initials: K
authors.lastname: Engelhardt
authors.affiliation: Department of Internal Medicine, Hall State Hospital, Hall, Austria.
authors.forename: Thomas
authors.initials: T
authors.lastname: Erlacher
authors.affiliation: Emergency Medical Service, Innsbruck, Austria.
authors.forename: Thomas
authors.initials: T
authors.lastname: Fluckinger
authors.affiliation: Department of Internal Medicine, Hall State Hospital, Hall, Austria.
authors.forename: Wilhelm
authors.initials: W
authors.lastname: Grander
authors.affiliation: Department of Neurology, Lienz County Hospital, Lienz, Austria.
authors.forename: Josef
authors.initials: J
authors.lastname: Grossmann
authors.affiliation: Department of Internal Medicine, Schwaz County Hospital, Schwaz, Austria.
authors.forename: Hermann
authors.initials: H
authors.lastname: Kathrein
authors.affiliation: Department of Internal Medicine, St Johann County Hospital, St Johann, Austria.
authors.forename: Norbert
authors.initials: N
authors.lastname: Kaiser
authors.affiliation: Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Matosevic
authors.affiliation: Department of Neurology, Hochzirl State Hospital, Zirl, Austria.
authors.forename: Heinrich
authors.initials: H
authors.lastname: Matzak
authors.affiliation: Department of Neurology, Kufstein County Hospital, Kufstein, Austria.
authors.forename: Markus
authors.initials: M
authors.lastname: Mayr
authors.affiliation: Department of Neurology, Lienz County Hospital, Lienz, Austria.
authors.forename: Robert
authors.initials: R
authors.lastname: Perfler
authors.affiliation: Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Werner
authors.initials: W
authors.lastname: Poewe
authors.affiliation: Department of Internal Medicine, Schwaz County Hospital, Schwaz, Austria.
authors.forename: Alexandra
authors.initials: A
authors.lastname: Rauter
authors.affiliation: Department of Neurology, Medical University Innsbruck, Innsbruck, Austria.
authors.forename: Gudrun
authors.initials: G
authors.lastname: Schoenherr
authors.affiliation: Department of Internal Medicine, St Vinzenz Hospital Zams, Zams, Austria.
authors.forename: Hans-Robert
authors.initials: HR
authors.lastname: Schoenherr
authors.affiliation: Emergency Medical Service, Innsbruck, Austria.
authors.forename: Adolf
authors.initials: A
authors.lastname: Schinnerl
authors.affiliation: Doctors in private practice, Tyrol, Austria.
authors.forename: Heinrich
authors.initials: H
authors.lastname: Spiss
authors.affiliation: Department of Internal Medicine, St Johann County Hospital, St Johann, Austria.
authors.forename: Theresa
authors.initials: T
authors.lastname: Thurner
authors.affiliation: Emergency Dispatch Centre Tyrol, Innsbruck, Austria.
authors.forename: Gernot
authors.initials: G
authors.lastname: Vergeiner
authors.affiliation: Department of Acute Neurology and Stroke, Feldkirch Academic Teaching Hospital, Feldkirch, Austria.
authors.forename: Philipp
authors.initials: P
authors.lastname: Werner
authors.affiliation: Department of Internal Medicine, St Vinzenz Hospital Zams, Zams, Austria.
authors.forename: Ewald
authors.initials: E
authors.lastname: Wöll
authors.affiliation: Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Willeit
authors.affiliation: Department of Neurology, Medical University Innsbruck, Innsbruck, Austria. Electronic address: stefan.kiechl@i-med.ac.at.
authors.forename: Stefan
authors.initials: S
authors.lastname: Kiechl
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001317:Austria / Q000453:epidemiology; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000494:pharmacology*; D006078:Government Programs / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy* / Q000453:epidemiology / Q000401:mortality; D015912:Thrombolytic Therapy / Q000706:statistics & numerical data*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000494:pharmacology; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator