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• W2313973737 abstract "Acute ischemic stroke (IS) patients benefit from rapid evaluation and treatment. Timely brain imaging is a necessary component of evaluation and focus of national guideline and quality measurement standards. This study determined the effect of a targeted behavioral intervention on door-to-imaging-time (DIT) among acute IS patients treated with tissue plasminogen activator (t-PA) and explored patient- and hospital-level predictors of DIT. Design: The INSTINCT trial was a cluster-randomized controlled trial matching 12 intervention with 12 control hospitals. The targeted educational intervention consisted of a multi-level barrier assessment and interactive educational program aiming to increase appropriate t-PA utilization. Setting and Participants: Eligible hospitals were non-specialty, acute-care community hospitals in Michigan. A computer-generated randomization sequence balanced urban-rural status, race, and age between groups. One third of hospitals in each group were designated stroke centers. Detailed chart abstractions collected data for IS patients at hospitals before and after the intervention. Analysis: A series of hierarchical linear mixed-effects models evaluated the effect of the intervention on DIT (difference-in-differences analysis) and we used patient and hospital-level explanatory variables to decompose variation in DIT. Of the 511 t-PA-treated patients in the analysis, mean age was 69.9 years, 52.5% were male, and 75.9% non-Hispanic white; mean NIHSS score was 12.2 points (standard deviation, SD, 5.9). Mean overall DIT was 20.3 minutes (SD 13.5 min). DIT improved over time, without a difference between intervention and control hospitals (intervention: 23.7 to 19.3 min, control: 28.9 to 19.2 min, p=0.56). Approximately 11.8% of the variation in DIT was explained by patient demographics, clinical factors, stroke severity, and the mode, time, and weekday of arrival. After accounting for patient factors, 13.8% of the remaining variation in DIT was attributable to hospital. After adjusting for patient and clinical characteristics, the hospital-level mean DIT varied from 10.1 to 28.3 min, (SD 4.0 min) (Figure). Independent predictors of faster DIT were post-intervention time (4.9 min, 95% CI 2.3-7.4), ambulance arrival (7.2 min, 95%CI 4.1-10.2), and stroke severity (1.0 min per 5 point NIHSS increase, 95%CI 0.1-2.0). There was a non-significant trend toward faster DIT for presentation to stroke center hospital (4.8 min, 95% CI −0.3 - 10.0). In this representative sample, performance on DIT improved similarly in intervention and control hospitals suggesting that non-intervention factors explain the improvement. After adjusting for patient and clinical characteristics, DIT varied at the hospital level. Given that annual stroke volume and stroke center status did not independently predict DIT, further research is needed to identify the important hospital-level factors causing DIT variation." @default.
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• W2313973737 date "2013-10-01" @default.
• W2313973737 modified "2023-09-27" @default.
• W2313973737 title "Improving Time to Brain Imaging in Acute Stroke: Analysis of the Increasing Stroke Treatment through Interventional Behavioral Change Tactics (INSTINCT) Trial" @default.
• W2313973737 doi "https://doi.org/10.1016/j.annemergmed.2013.07.188" @default.
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