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The Use and Misuse of Thrombolytic Therapy Within the Veterans Health Administration

Keyhani, Salomeh, MD MPH*,†,‡; Arling, Greg, PhD§; Williams, Linda S., MD‡,∥,¶,#; Ross, Joseph S., MD, MHS**; Ordin, Diana L., MD, MPH‡,††; Myers, Jennifer, MSW‡,∥; Tyndall, Gary, MD‡‡; Vogel, Bruce, PhD‡,§§; Bravata, Dawn M., MD‡,∥,#,∥∥

doi: 10.1097/MLR.0b013e3182294092
Original Articles

Background: Within the Veterans Health Administration (VHA), approximately 6000 veterans are hospitalized with acute ischemic stroke annually. We examined the use and misuse of thrombolytic therapy with tissue plasminogen activator (tPA) in a national sample of veterans who were admitted to a VHA Medical Center (VAMC) with acute ischemic stroke.

Methods: Medical record reviews were conducted on 5000 acute stroke patients who were admitted to a VAMC in 2007. Patients were defined as eligible to receive tPA if they arrived at the hospital within 3 hours of stroke symptom onset and had no contraindications to tPA. We compared eligible patients who received tPA to those who did not and examined the distribution of eligible patients across the 129 VAMCs included in this study.

Results: Among the 3931 ischemic stroke patients, 174 (4.4%) were eligible for tPA. Among the 135 patients who arrived within 2 hours of symptom onset which allowed adequate time for testing and evaluation, 19 (14.1%) received tPA. An additional 11 patients received tPA but did not meet eligibility criteria. Eligible patients receiving tPA were similar to eligible patients not receiving tPA in terms of clinical conditions and time to brain imaging. Among the 30 patients that received tPA, 5 (16.6%) received the wrong dose. Among the 85 VAMCs that received ≥1 eligible patient, on average 2.3 patients were eligible for tPA annually.

Conclusions: Relatively few eligible veterans receive thrombolysis across the VHA system. Strategies to improve thrombolysis delivery will have to account for the low annual volume of eligible stroke patients cared for at individual VAMCs.

*Department of Veterans Affairs (VHA) Health Services Research & Development Service (HSR&D) Research Enhancement Award Program (REAP)

Division of General Internal Medicine, University of California at San Francisco, San Francisco, CA

VHA HSR&D Stroke Quality Enhancement Research Initiative (QUERI) Program

§Indiana University Center for Aging Research, Indiana University School of Medicine and Regenstrief Institute

VHA HSR&D Center of Excellence on Implementing Evidence-Based Practice (CIEBP), Richard L. Roudebush VA Medical Center

Department of Neurology, Indiana University School of Medicine

#Regenstrief Institute, Indianapolis, IN

**Yale University School of Medicine

††VHA Office of Quality and Performance (OQP),Washington, DC

‡‡Emergency Department, Syracuse VA Medical Center, Syracuse, NY

§§VHA Rehabilitation Outcomes Research Center (RORC), North Florida/South Georgia Veterans Health System, Gainesville, FL

∥∥Department of Internal Medicine, Indiana University School of Medicine

Financial Disclosures: None.

The authors declare no conflict of interest.

Funding/Support: The project reported here was supported by the Department of Veterans Affairs, Veterans Health Administration (VHA), Office of Quality and Performance and Health Services Research and Development Service Quality Enhancement Research Initiative (RRP 09-184). Dr. Keyhani is also supported by a VA HSR&D Career Development Award.

Role of Sponsor: The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs.

Reprints: Salomeh Keyhani, MD, MPH, San Francisco VA Medical Center 4150 Clement (111A1) San Francisco, CA 94121. Email:

© 2012 Lippincott Williams & Wilkins, Inc.