title: Restriction of therapy mainly explains lower thrombolysis rates in reduced stroke service levels.
abstract: OBJECTIVE
  To assess the influence of preexisting disabilities, age, and stroke service level on standardized IV thrombolysis (IVT) rates in acute ischemic stroke (AIS).
  
  
  METHODS
  We investigated standardized IVT rates in a retrospective registry-based study in 36,901 patients with AIS from the federal German state Baden-Wuerttemberg over a 5-year period. Patients admitted within 4.5 hours after stroke onset were selected. Factors associated with IVT rates (patient-level factors and stroke service level) were assessed using robust Poisson regression modeling. Interactions between factors were considered to estimate risk-adjusted mortality rates and potential IVT rates by service level (with stroke centers as benchmark).
  
  
  RESULTS
  Overall, 10,499 patients (28.5%) received IVT. The IVT rate declined with service level from 44.0% (stroke center) to 13.1% (hospitals without stroke unit [SU]). Especially patients >80 years of age and with preexisting disabilities had a lower chance of being treated with IVT at lower stroke service levels. Interactions between stroke service level and age group, preexisting disabilities, and stroke severity (all p < 0.0001) were observed. High IVT rates seemed not to increase mortality. Estimated potential IVT rates ranged between 41.9% and 44.6% depending on stroke service level.
  
  
  CONCLUSIONS
  Differences in IVT rates among stroke service levels were mainly explained by differences administering IVT to older patients and patients with preexisting disabilities. This indicates considerable further potential to increase IVT rates. Our findings support guideline recommendations to admit acute stroke patients to SUs.
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany. christoph.gumbinger@med.uni-heidelberg.de.
authors.forename: Christoph
authors.initials: C
authors.lastname: Gumbinger
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Björn
authors.initials: B
authors.lastname: Reuter
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Werner
authors.initials: W
authors.lastname: Hacke
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Tamara
authors.initials: T
authors.lastname: Sauer
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Ingo
authors.initials: I
authors.lastname: Bruder
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Curt
authors.initials: C
authors.lastname: Diehm
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Horst
authors.initials: H
authors.lastname: Wiethölter
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Karin
authors.initials: K
authors.lastname: Schoser
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Daffertshofer
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Stephan
authors.initials: S
authors.lastname: Neumaier
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Elke
authors.initials: E
authors.lastname: Drewitz
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Susanne
authors.initials: S
authors.lastname: Rode
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Rolf
authors.initials: R
authors.lastname: Kern
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Michael G
authors.initials: MG
authors.lastname: Hennerici
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Stock
authors.affiliation: From the Departments of Neurology Heidelberg (C.G., W.H., P.R.) and Mannheim (T.S., R.K., M.G.H.) and Institute of Medical Biometry and Informatics (C.S.), Heidelberg University; Department of Neurology (B.R.), University Freiburg; Office for Quality Assurance in Hospitals (GeQiK®) Stuttgart at Baden-Wuerttembergische Hospital Federation (I.B., S.R.); Department of Internal Medicine (C.D.), Max-Grundig-Klinik, Bühl; Department of Neurology (H.W.), Bürgerhospital Stuttgart; Department of Internal Medicine (K.S.), Klinikum Landkreis Tuttlingen; Department of Neurology (M.D.), Klinikum Mittelbaden, Baden-Baden; Medical Services of Health Insurance Baden-Wuerttemberg (S.N.), Freiburg; and Klinikum Stuttgart (E.D.), Germany.
authors.forename: Peter
authors.initials: P
authors.lastname: Ringleb
mesh_terms: D061605:Administration, Intravenous; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D005343:Fibrinolytic Agents / Q000008:administration & dosage*; D005858:Germany; D017052:Hospital Mortality; D006761:Hospitals / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D012042:Registries; D012189:Retrospective Studies; D012720:Severity of Illness Index; D020521:Stroke / Q000188:drug therapy* / Q000453:epidemiology*; D015912:Thrombolytic Therapy / Q000379:methods* / Q000706:statistics & numerical data*; D061665:Time-to-Treatment; D010959:Tissue Plasminogen Activator / Q000008:administration & dosage*; D016896:Treatment Outcome
chemical_list: D005343:Fibrinolytic Agents; D010959:Tissue Plasminogen Activator