Association Between Stroke Center and County-Level Emergency Medical Services Bypass Policies and Proportion of Stroke Patients Receiving Thrombolytic Therapy
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Abstract
Objective: Over the past two decades, numerous policy efforts have been made to improve management in acute stroke, including stroke center policy and EMS bypass policy. The effect of these policies on clinical outcomes such as thrombolysis are yet not understood on a national scale. Our objective is to identify the association between thrombolysis and stroke center policy, and furthermore, the synergistic effect of stroke center policy and EMS bypass policy on thrombolysis rates.
Methods: We conducted a retrospective observational study using a 20% national sample of Medicare beneficiaries diagnosed with ischemic stroke from 2007 to 2014. We estimated the difference-in-differences (DID) to determine the stroke center policy effect on thrombolysis rates, and to determine the stroke center and EMS bypass policy effect together on thrombolysis rates.
Results: Overall, counties that implemented a stroke center policy had a significant increase in thrombolysis compared to counties who did not have a stroke center policy (RR = 1.42, 95% CI [1.12, 1.80], p = 0.004) in the pre-policy period. There was no significant association in stroke policy counties with increasing thrombolysis rate in only the post-policy period compared to no stroke center policy counties. There was an increase in thrombolysis rate overall and in the post policy period among counties that implemented both an EMS bypass and stroke center policy compared to counties that did not implement any policy (RR = 1.48, 95% CI [1.19, 1.84], p < 0.001).
Conclusions: Counties with both stroke center policy and EMS bypass policy had significantly higher thrombolysis rates after policy implementation. This is likely the first analysis of the effect of stroke policies on thrombolysis using the largest ever national stroke database.
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