PSCs treated a higher proportion of patients with rt‐PA than did non‐PSCs in this all‐payer cohort of adults (age≥18). Certification was associated with increased rt‐PA utilization in all age and hospital strata. These results add to the mounting evidence that TJC‐certified PSCs outperform noncertified hospitals with respect to rt‐PA use.18–19
Our results support the use of TJC PSCs as the building blocks of the US acute stroke care system.
In our analysis, the proportion of patients treated with rt‐PA at PSCs was relatively stable from 2004 to 2009; in comparison, the proportion of patients treated with rt‐PA at non‐PSCs more than doubled. It is not known why this occurred. Expansion of the rt‐PA treatment window to 4.5 hours after publication of ECASS‐III in 2008 may have contributed to this phenomenon.24
Hospitals without certification may be preparing for certification, participating in quality improvement initiatives, such as Get with the Guidelines, or be using telestroke programs, all of which may lead to increased rt‐PA utilization.
The association of certification with increased rt‐PA use was relatively stable across age strata and hospital variables. The association between PSC certification and rt‐PA use was stronger in rural centers than in other subgroups. However, there were a small number of hospitals and discharges in this subgroup, so these results should be interpreted with caution. Further work is needed to determine whether certification is equally effective in all hospital types and to ensure that all PSCs are functioning at a high level.
This study has several important limitations. The analysis was limited to identifiable hospitals in 24 to 26 states, depending on year. Although this diverse sample should provide excellent generalizability, the results are not truly nationally representative and should be regarded as a large convenience sample of US hospitals. TJC certification is not the only PSC certification in the United States. We were unable to account for state‐based or other certified PSCs. This misclassification may have biased the results toward the null. ICD9‐based definitions of rt‐PA are imprecise and known to underestimate rt‐PA utilization.2,25
In a prior study that compared the ICD9 procedure code of 99.10 to pharmacy billing records, ICD9 codes identified 77% of IV rt‐PA cases.2
As a result, the percentages reported in this article are likely an underestimate. Nonetheless, comparisons of relative rt‐PA utilization across hospitals are still informative. The odds ratios presented here would only be biased if there was differential misclassification of rt‐PA use between PSCs and non‐PSCS. Financial incentives for rt‐PA, which began in late 2005, apply equally to all hospitals and should reduce variability in rt‐PA coding. The use of administrative data precludes an evaluation of rt‐PA eligibility. Differences in eligibility across hospitals could have biased our findings; unfortunately, there is no way to test for this bias in the current study. Despite these limitations, our study contributes significantly to the literature. Reports from registries or quality improvement initiatives have more detailed clinical information, but data are only included from a select group of hospitals. Our study provides data on clinical practice across a wide sample of US hospitals, including those that choose not to participate in registries, thus providing important insights into the US healthcare system.
In conclusion, TJC provides a standardized, national definition of a primary stroke center. Patients treated at a TJC‐certified PSC are more likely to receive rt‐PA than those treated at noncertified hospitals. Further work is needed to determine whether certification is equally effective in all hospital types and to ensure that all PSCs are functioning at a high level. Systems of care are necessary to ensure that stroke patients have timely access to PSCs.