title: Emergency Care of Patients with Acute Ischemic Stroke in the Kaiser Permanente Southern California Integrated Health System.
abstract: Tissue plasminogen activator (tPA) is underutilized for treatment of acute ischemic stroke.
  
  
  
  To determine whether the probability of tPA administration for patients with ischemic stroke in an integrated health care system improved from 2009 to 2013, and to identify predictors of tPA administration.
  
  
  
  Retrospective analysis of all ischemic stroke presentations to 14 Emergency Departments between 2009 and 2013. A generalized linear mixed-effects model identified patient and hospital predictors of tPA.
  
  
  
  Primary outcome was tPA administration; secondary outcomes were door-to-imaging and door-to-needle times and tPA-related bleeding complications.
  
  
  
  Of the 11,630 patients, 3.9% received tPA. The likelihood of tPA administration increased with presentation in 2012 and 2013 (odds ratio [OR] = 1.75; 95% confidence interval [CI] = 1.26-2.43; and OR = 2.58; 95% CI = 1.90-3.51), female sex (OR = 1.27; 95% CI = 1.04-1.54), and ambulance arrival (OR = 2.17; 95% CI = 1.76-2.67), and decreased with prior stroke (OR = 0.47; 95% CI = 0.25-0.89) and increased age (OR = 0.98; 95% CI = 0.97-0.99). Likelihood varied by Medical Center (pseudo-intraclass correlation coefficient 13.5%). Among tPA-treated patients, median door-to-imaging time was 15 minutes (interquartile range, 9-23 minutes), and door-to-needle time was 73 minutes (interquartile range, 55-103 minutes). The rate of intracranial hemorrhage was 4.2% and 0.9% among tPA- and non-tPA treated patients (p < 0.001).
  
  
  
  Acute ischemic stroke care improved over time in this integrated health system. Better understanding of differences in hospital performance will have important quality-improvement and policy implications.
authors.affiliation: Assistant Professor in the Department of Emergency Medicine at Massachusetts General Hospital and Harvard Medical School in Boston. ksauser@mgh.harvard.edu.
authors.forename: Kori
authors.initials: K
authors.lastname: Sauser-Zachrison
authors.affiliation: Biostatistician in the Department of Research and Evaluation for Kaiser Permanente Southern California in Pasadena. ernest.shen@kp.org.
authors.forename: Ernest
authors.initials: E
authors.lastname: Shen
authors.affiliation: Neurologist at the Sunset Medical Center in Los Angeles, CA. zahra.a.ajani@kp.org.
authors.forename: Zahra
authors.initials: Z
authors.lastname: Ajani
authors.affiliation: Neurologist at the San Diego Medical Center in CA. william.p.neil@kp.org.
authors.forename: William P
authors.initials: WP
authors.lastname: Neil
authors.affiliation: Neurologist at the Sunset Medical Center in Los Angeles, CA. navdeep.x.sangha@kp.org.
authors.forename: Navdeep
authors.initials: N
authors.lastname: Sangha
authors.affiliation: Research Scientist in the Department of Research and Evaluation for Kaiser Permanente Southern California in Pasadena. michael.k.gould@kp.org.
authors.forename: Michael K
authors.initials: MK
authors.lastname: Gould
authors.affiliation: Research Scientist in the Department of Research and Evaluation for Kaiser Permanente Southern California in Pasadena. adam.l.sharp@kp.org.
authors.forename: Adam L
authors.initials: AL
authors.lastname: Sharp
mesh_terms: D002140:California; D003422:Critical Care; D019033:Delivery of Health Care, Integrated; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D006801:Humans; D008297:Male; D008485:Medical Audit; D017063:Outcome Assessment, Health Care; D012189:Retrospective Studies; D020521:Stroke / Q000188:drug therapy*; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator