title: How can we improve stroke thrombolysis rates? A review of health system factors and approaches associated with thrombolysis administration rates in acute stroke care.
abstract: BACKGROUND
  Thrombolysis using intravenous (IV) tissue plasminogen activator (tPA) is one of few evidence-based acute stroke treatments, yet achieving high rates of IV tPA delivery has been problematic. The 4.5-h treatment window, the complexity of determining eligibility criteria and the availability of expertise and required resources may impact on treatment rates, with barriers encountered at the levels of the individual clinician, the social context and the health system itself. The review aimed to describe health system factors associated with higher rates of IV tPA administration for ischemic stroke and to identify whether system-focussed interventions increased tPA rates for ischemic stroke.
  
  
  METHODS
  Published original English-language research from four electronic databases spanning 1997-2014 was examined. Observational studies of the association between health system factors and tPA rates were described separately from studies of system-focussed intervention strategies aiming to increase tPA rates. Where study outcomes were sufficiently similar, a pooled meta-analysis of outcomes was conducted.
  
  
  RESULTS
  Forty-one articles met the inclusion criteria: 7 were methodologically rigorous interventions that met the Cochrane Collaboration Evidence for Practice and Organization of Care (EPOC) study design guidelines and 34 described observed associations between health system factors and rates of IV tPA. System-related factors generally associated with higher IV tPA rates were as follows: urban location, centralised or hub and spoke models, treatment by a neurologist/stroke nurse, in a neurology department/stroke unit or teaching hospital, being admitted by ambulance or mobile team and stroke-specific protocols. Results of the intervention studies suggest that telemedicine approaches did not consistently increase IV tPA rates. Quality improvement strategies appear able to provide modest increases in stroke thrombolysis (pooled odds ratio = 2.1, p = 0.05).
  
  
  CONCLUSIONS
  In order to improve IV tPA rates in acute stroke care, specific health system factors need to be targeted. Multi-component quality improvement approaches can improve IV tPA rates for stroke, although more thoughtfully designed and well-reported trials are required to safely increase rates of IV tPA to eligible stroke patients.
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia. Chris.Paul@newcastle.edu.au.|Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia. Chris.Paul@newcastle.edu.au.
authors.forename: Christine L
authors.initials: CL
authors.lastname: Paul
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia.
authors.forename: Annika
authors.initials: A
authors.lastname: Ryan
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia.
authors.forename: Shiho
authors.initials: S
authors.lastname: Rose
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia.
authors.forename: John R
authors.initials: JR
authors.lastname: Attia
authors.affiliation: Hunter New England Health, Lookout Road, New Lambton Heights, NSW, 2305, Australia.
authors.forename: Erin
authors.initials: E
authors.lastname: Kerr
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.|Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia.
authors.forename: Claudia
authors.initials: C
authors.lastname: Koller
authors.affiliation: The University of Newcastle, University Drive, Callaghan, NSW, 2308, Australia.|Hunter New England Health, Lookout Road, New Lambton Heights, NSW, 2305, Australia.|Hunter Medical Research Institute, 1/Kookaburra Circuit, New Lambton Heights, NSW, 2305, Australia.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Levi
mesh_terms: D000208:Acute Disease; D003422:Critical Care / Q000379:methods; D003695:Delivery of Health Care / Q000379:methods*; D005343:Fibrinolytic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D006801:Humans; D020521:Stroke / Q000188:drug therapy*; D015912:Thrombolytic Therapy / Q000379:methods*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator
keywords: Health system change; Implementation; Ischemic stroke; Quality improvement; Thrombolysis; Tissue plasminogen activator