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Original Contribution |

Slow Progressive Acceptance of Intravenous Thrombolysis for Patients With Stroke by Rural Primary Care Physicians FREE

Enrique C. Leira, MD; Jennifer K. Pary, MD; Patricia H. Davis, MD; Karla J. Grimsman, RN; Harold P. Adams Jr, MD
[+] Author Affiliations

Author Affiliations: Division of Cerebrovascular Diseases, Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City.


Arch Neurol. 2007;64(4):518-521. doi:10.1001/archneur.64.4.518.
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Published online

Background  In the rural United States, patients with stroke are usually first evaluated locally by a nonneurologist physician (NNP) before treatment is determined.

Objective  To determine the evolution of NNPs' familiarity and attitudes about using recombinant tissue plasminogen activator (rtPA) since this therapy has been approved.

Design  Cross-sectional design using 2 similar surveys mailed in 1997 and 2003 to all primary care, family, internal, and emergency medicine physicians in the state of Iowa (1582 and 1679 physicians, respectively).

Participants  All NNPs (primary care, internal, and emergency medicine) practicing in the state of Iowa.

Main Outcome Measures  Comparison of 1997 and 2003 aggregate responses to questions about familiarity and willingness to use rtPA to treat patients who have had an acute ischemic stroke.

Results  The willingness of NNPs to use rtPA to treat acute ischemic stroke increased from 18% to 32% between 1997 and 2003. The number of NNPs who were very familiar with the National Institutes of Health Stroke Scale increased from 1% to 13%. Compared with physicians in 1997, more physicians in 2003 knew that prolonged international normalized ratios (42% vs 61%) or excessively high blood pressures (61% vs 78%) were contraindications for the use of rtPA. Still, half of the respondents perceived that they were inadequately exposed to educational material about rtPA during these years. Most expressed preference for personal methods of delivery for future educational efforts.

Conclusions  The familiarity and comfort among NNPs with the administration of rtPA is still relatively low in rural settings. The improvement observed between the years 1997 and 2003 is encouraging. The responses suggest that NNPs' acceptance of rtPA can be further improved with educational campaigns involving personal methods of delivery.

Figures in this Article

Intravenous recombinant tissue plasminogen activator (rtPA) remains the only pharmacological therapy approved for treatment of acute ischemic stroke. Still, too few patients are benefiting from this treatment.1 In the rural United States, strokes often occur in patients who are located at sites that are far from a tertiary health care center or stroke program. In smaller hospitals, a neurological consultation is only requested in one third of the suspected strokes.2 These consults may be delayed by hours or days, depending on the local availability of neurologists.3,4 As a result, often patients are first evaluated in local health facilities by nonneurologist physicians (NNPs), who sometimes have specific emergency medicine training but often have a family medicine or internal medicine background.5 These physicians may receive assistance from tertiary centers through advice over the telephone, through a telemedicine consultation,6 or by requesting an aerial transfer.7 Despite such potential aids, the time constraints for thrombolytic treatment8 often calls for a local administration. This makes NNPs ultimately responsible for obtaining consent and deciding about treatment. For that reason, their knowledge and attitudes about thrombolysis are crucial to the implementation of rtPA treatment and other future therapies for the 59 million residents in the rural United States.9 While the quality of stroke care in nonurban emergency departments has already been explored,2 little is known about NNPs' perceptions of and familiarity with rtPA in a broader sense or NNPs' evolution since rtPA was initially approved.

We used a cross-sectional design employing 2 similar independent surveys conducted in 1997 and 2003. Using a state registry, we identified all the physicians practicing family, internal, and emergency medicine in the state of Iowa. We mailed the surveys to all NNPs in the registry. Each survey covered demographic data, attitudes toward rtPA, knowledge of the current guidelines, and educational needs. A self-addressed prepaid envelope labeled with a numeric code to allow identification while maintaining anonymity was included for their response. There was no compensation for participation. Nonresponders were sent a follow-up letter (in 1997) or received a phone call (in 2003) to increase response rates. Counts and proportions were used to describe the responses of NNPs. We used χ2 statistics to compare differences in the responses between 1997 and 2003. Given the presence of multiple comparisons, we used a Bonferroni method to adjust the level of significance to 0.5%. For the statistical analysis we used SAS version 9.1 (SAS Institute Inc, Cary, NC). This study was previously approved by the institutional review board at the University of Iowa.

Forty-nine percent of physicians returned the survey in both years (1997, N = 1582; 2003, N = 1679). The degree of completion of the questionnaire varied but was greater than 67% in both years. The demographics of the surveyed NNPs are presented in Table 1 by age, specialty, size of town, and basic resources for acute stroke care. More than 92% of the NNPs practiced in hospitals that can perform computed tomography and blood work on a continual basis, but only 56.4% of the hospitals had a neurologist available for consultations. Table 2 presents the experience with rtPA and stroke among respondents in 2003. Only 21.9% of the NNPs reported that they used rtPA more frequently in 2003 than in 1997. The Figure compares the NNPs' estimations for rtPA use in 1997 with their actual experience reported in 2003. While in 1997, 84.2% estimated that more than 3 patients would be treated with rtPA each year at their institution, only 22.7% actually reached that mark in 2003. Table 3 presents the NNPs' perceived educational exposure to rtPA and stroke, which was judged as insufficient by 45.0% of respondents. The preferred methods of further learning about stroke and rtPA were local presentations (64.5%) and conferences (49.7%). In contrast, Web site education and continuing medical education pamphlets were only favored by 13.1% and 21.4% of the physicians, respectively. Table 4 compares their knowledge about indications and contraindications of thrombolysis and attitudes toward rtPA between 1997 and 2003. The percentage of NNPs that identified anticoagulation as a contraindication of rtPA increased from 42.3% in 1997 to 62.0% in 2003. The percentage of physicians willing to give rtPA to an eligible patient rose from 18.0% in 1997 to 31.5% in 2003.

Place holder to copy figure label and caption
Figure

Comparison of the intended use of recombinant tissue plasminogen activator (rtPA) in 1997 (n = 773) with actual use in 2003 (n = 827).

Graphic Jump Location
Table Graphic Jump LocationTable 1. Baseline Characteristics of Surveyed Rural NNPs
Table Graphic Jump LocationTable 2. Experience With rtPA and Stroke Among Survey Respondents in 2003*
Table Graphic Jump LocationTable 3. Perceived Educational Support From 1997 to 2003*
Table Graphic Jump LocationTable 4. Evolution of Familiarity With Indications for rtPA Use for Stroke Treatment

Rural NNPs are a crucial but often forgotten element in the stroke chain of survival. Their perceptions about thrombolysis will not only influence their own use of rtPA but likely the acceptance of this therapy by patients, family members, and other colleagues as well. Initiatives like the promotion of primary stroke centers10 or the “drip-ship strategy”11 are unlikely to succeed in rural areas without endorsement by NNPs. In these surveys, we confirmed the crucial role that NNPs play in acute stroke care. Despite having around-the-clock computed tomography scanners and laboratory resources to treat stroke patients, consultant neurologists are not available in half of the cases.

Familiarity with the indications of rtPA has clearly grown between 1997 and 2003. This improvement is encouraging, because it translates into a more proactive attitude toward the use of rtPA in the year 2003. This relationship corroborates the notion that a lack of familiarity with rtPA is a barrier for using it and should encourage educational campaigns targeting this group of physicians. We cannot attribute this positive trend in knowledge and acceptance to any specific intervention. Instead, it may be the result of a combination of experience and exposure to rtPA, patient and relatives' increased awareness, journal articles, continuing medical education courses and pamphlets, organizational campaigns, and new trainees entering into the workforce. Similar trends of improvement are commonly seen regarding medical knowledge. For example, public awareness about acute stroke has improved in the period 1995-2000,12 and a spontaneous improvement in the number of patients treated with rtPA for stroke was noticed in the control group of a community education trial.13 A similar trend is seen for the acceptance of new therapies, which typically starts at large tertiary centers before moving to the community hospitals. This was the case for the treatment of acute myocardial infarction,14 where thrombolysis was initially restricted to use by cardiologists in tertiary centers, and rtPA was later used safely in the community hospitals when treatment regimes were strictly observed.15

Despite this improvement, the present familiarity with and acceptance among NNPs of rtPA remains relatively low. Only a small fraction of these physicians are knowledgeable about the factors that denote ineligibility for rtPA. Our results are similar to those found in other groups of physicians like US urban family medicine residents16 and practicing urban Canadian primary physicians.17 These findings clearly show that we need to increase knowledge among all NNPs about rtPA and its use in stroke care. Unfamiliarity with the therapy will signify less intended use, as only one third of the surveyed physicians are willing to use rtPA in eligible patients. While in 1997, many NNPs predicted that they would treat a significant number of patients with rtPA in their facilities, the reported experience in 2003 has been more modest. To improve the current rural use of rtPA,1 we first need to increase the comfort level of NNPs with this therapy. The slow rate of acceptance seen for rtPA in our study should be seen as a lesson for the implementation of any future acute neurological therapies with potentially serious complications in hospitals that do not have neurologists.

Still, prospects are encouraging. Stroke has been identified as a top health priority among rural health leaders nationwide,18 and there are initiatives to improve the current insufficient hospital reimbursement for rtPA.19 Our results support this trend, as many NNPs are eager to learn more about rtPA. We are hopeful that future educational efforts may further improve NNPs' acceptance of rtPA. A community trial combining public and physician education in a rural community has shown an improvement in the amount of eligible patients treated with rtPA.13 While the number of treated patients is a variable that can be influenced by multiple factors, including consultant neurologists' availability,3,4 neurologists' attitudes,20 and public awareness,12 it is possible that such transient benefits may have been partially achieved by altering NNPs' perceptions.

We have also found that NNPs do not consider all methods of learning equally effective. They prefer personal methods of delivery, such as on-site educational conferences, to learn more about rtPA and stroke. This finding is consistent with previous reports that found that formal continuing medical education conferences or activities, without enabling or practice-reinforcing strategies, had relatively little impact on changing physicians' behavior.21

We recognize the limitations of our study. We used mass mailings and obtained a response from half of the physicians, but one third of the surveys were not completed. Still, we are encouraged that a large number of colleagues took the time to complete the survey, which did not offer compensation. We also recognize that this response rate could have been biased toward those NNPs with interest in or exposure to stroke, in which case, we would actually be overestimating the degree of familiarity and enthusiasm about rtPA, including the interest for further education.

The strengths of this study include the long observation time between the surveys, which enables us to determine the secular trends in NNPs' familiarity and acceptance of thrombolytic therapy. The comprehensive nature of the assessment of NNPs, which was not just limited to emergency department care, is another strength of this study. Because of the large sample size of physicians practicing in the state of Iowa, we believe our findings can be generalized to rural care in most parts of North America.

Correspondence: Enrique C. Leira, MD, Department of Neurology, University of Iowa Hospitals, 2 Roy Carver Pavilion, 200 Hawkins Dr, Iowa City, IA 52242 (enrique-leira@uiowa.edu).

Accepted for Publication: December 5, 2006.

Author Contributions:Study concept and design: Leira, Pary, and Davis. Acquisition of data: Pary, Davis, and Grimsman. Analysis and interpretation of data: Leira, Davis, and Adams. Drafting of the manuscript: Leira and Grimsman. Critical revision of the manuscript for important intellectual content: Pary, Davis, and Adams. Administrative, technical, and material support: Davis. Study supervision: Leira, Pary, Davis, and Adams.

Financial Disclosure: Dr Pary has received an educational lecture honorarium from Genentech Inc, the maker of rtPA.

Funding/Support: This study was supported in part by funds from the department of neurology at the University of Iowa, and grant 5K12RR017700-04 from the National Institutes of Health K12 Mentored Clinical Research Scholar Program at Iowa (principal investigator, Allyn Mark, MD).

Previous Presentation: This study was presented in part at the 23rd and 29th International Stroke Conferences, respectively, in 1998, in Orlando, Fla, and in 2004, San Diego, Calif.

Acknowledgment: We are thankful to Alicia Romont, BS, and Heena H. Maiseri, BS, for their assistance, and to Miriam Zimmerman, PhD, for providing the statistical review.

Katzan  ILHammer  MDHixson  ED  et al.  Utilization of intravenous tissue plasminogen activator for acute ischemic stroke. Arch Neurol 2004;61346- 350
PubMed Link to Article
Burgin  WSStaub  LChan  W  et al.  Acute stroke care in non-urban emergency departments. Neurology 2001;572006- 2012
PubMed Link to Article
Ruland  SGorelick  PBSchneck  MKim  DMoore  CGLeurgans  S Acute stroke care in Illinois: a statewide assessment of diagnostic and treatment capabilities. Stroke 2002;331334- 1339
PubMed Link to Article
Goldstein  LBHey  LALaney  R North Carolina stroke prevention and treatment facilities survey: statewide availability of programs and services. Stroke 2000;3166- 70
PubMed Link to Article
Haskins  RJKallail  KJ Staffing in small rural hospital emergency rooms: dependence on community family physicians. Fam Pract Res J 1994;1467- 75
PubMed
Wang  SGross  HLee  SB  et al.  Remote evaluation of acute ischemic stroke in rural community hospitals in Georgia. Stroke 2004;351763- 1768
PubMed Link to Article
Silliman  SLQuinn  BHuggett  VMerino  JG Use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. Stroke 2003;34729- 733
PubMed Link to Article
Adams  HP  JrBrott  TGFurlan  AJ  et al.  Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke, a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation 1996;941167- 1174
PubMed Link to Article
United States Bureau of the Census Urban/Rural and Metropolitan/Nonmetropolitan Population: 2000.  See website. Accessed July 1, 2006
Alberts  MJHademenos  GLatchaw  RE  et al.  Recommendations for the establishment of primary stroke centers: Brain Attack Coalition. JAMA 2000;2833102- 3109
PubMed Link to Article
Silverman  IEBeland  DKChhabra  JMcCullough  LD The “drip-and-ship” approach: starting IV t-PA for acute ischemic stroke at outside hospitals prior to transfer to a regional stroke center. Conn Med 2005;69613- 620
PubMed
Schneider  ATPancioli  AMKhoury  JC  et al.  Trends in community knowledge of the warning signs and risk factors for stroke. JAMA 2003;289343- 346
PubMed Link to Article
Morgenstern  LBStaub  LChan  W  et al.  Improving delivery of acute stroke therapy: the TLL Temple Foundation Stroke Project. Stroke 2002;33160- 166
PubMed Link to Article
Hlatky  MACotugno  HEMark  DBO'Connor  CCaliff  RMPryor  DB Trends in physician management of uncomplicated acute myocardial infarction: 1970 to 1987. Am J Cardiol 1988;61515- 518
PubMed Link to Article
Chapman  GDOhman  EMTopol  EJ  et al.  Minimizing the risk of inappropriately administering thrombolytic therapy (Thrombolysis and Angioplasty in Myocardial Infarction [TAMI] study group). Am J Cardiol 1993;71783- 787
PubMed Link to Article
Wang  MYLavine  SDSoukiasian  HTabrizi  RLevy  MLGiannotta  SL Treating stroke as a medical emergency: a survey of resident physicians' attitudes toward “brain attack” and carotid endarterectomy. Neurosurgery 2001;481109- 1115
PubMed Link to Article
Merino  JGSilver  BWong  EDemaerschalk  BTamayo  AHachinski  V Physician knowledge of the benefits, risks, and contraindications of tissue plasminogen activator for acute ischemic stroke. Stroke 2001;322208- 2209
PubMed
Gamm  LHutchison  L Rural health priorities in America: where you stand depends on where you sit. J Rural Health 2003;19209- 213
PubMed Link to Article
Kleindorfer  DHill  MDWoo  D  et al.  A description of Canadian and United States physician reimbursement for thrombolytic therapy administration in acute ischemic stroke. Stroke 2005;36682- 687
PubMed Link to Article
Katzan  ILSila  CAFurlan  AJ Community use of intravenous tissue plasminogen activator for acute stroke: results of the brain matters stroke management survey. Stroke 2001;32861- 865
PubMed Link to Article
Davis  DAThomson  MAOxman  ADHaynes  RB Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274700- 705
PubMed Link to Article

Figures

Place holder to copy figure label and caption
Figure

Comparison of the intended use of recombinant tissue plasminogen activator (rtPA) in 1997 (n = 773) with actual use in 2003 (n = 827).

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Baseline Characteristics of Surveyed Rural NNPs
Table Graphic Jump LocationTable 2. Experience With rtPA and Stroke Among Survey Respondents in 2003*
Table Graphic Jump LocationTable 3. Perceived Educational Support From 1997 to 2003*
Table Graphic Jump LocationTable 4. Evolution of Familiarity With Indications for rtPA Use for Stroke Treatment

References

Katzan  ILHammer  MDHixson  ED  et al.  Utilization of intravenous tissue plasminogen activator for acute ischemic stroke. Arch Neurol 2004;61346- 350
PubMed Link to Article
Burgin  WSStaub  LChan  W  et al.  Acute stroke care in non-urban emergency departments. Neurology 2001;572006- 2012
PubMed Link to Article
Ruland  SGorelick  PBSchneck  MKim  DMoore  CGLeurgans  S Acute stroke care in Illinois: a statewide assessment of diagnostic and treatment capabilities. Stroke 2002;331334- 1339
PubMed Link to Article
Goldstein  LBHey  LALaney  R North Carolina stroke prevention and treatment facilities survey: statewide availability of programs and services. Stroke 2000;3166- 70
PubMed Link to Article
Haskins  RJKallail  KJ Staffing in small rural hospital emergency rooms: dependence on community family physicians. Fam Pract Res J 1994;1467- 75
PubMed
Wang  SGross  HLee  SB  et al.  Remote evaluation of acute ischemic stroke in rural community hospitals in Georgia. Stroke 2004;351763- 1768
PubMed Link to Article
Silliman  SLQuinn  BHuggett  VMerino  JG Use of a field-to-stroke center helicopter transport program to extend thrombolytic therapy to rural residents. Stroke 2003;34729- 733
PubMed Link to Article
Adams  HP  JrBrott  TGFurlan  AJ  et al.  Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke, a statement for healthcare professionals from a Special Writing Group of the Stroke Council, American Heart Association. Circulation 1996;941167- 1174
PubMed Link to Article
United States Bureau of the Census Urban/Rural and Metropolitan/Nonmetropolitan Population: 2000.  See website. Accessed July 1, 2006
Alberts  MJHademenos  GLatchaw  RE  et al.  Recommendations for the establishment of primary stroke centers: Brain Attack Coalition. JAMA 2000;2833102- 3109
PubMed Link to Article
Silverman  IEBeland  DKChhabra  JMcCullough  LD The “drip-and-ship” approach: starting IV t-PA for acute ischemic stroke at outside hospitals prior to transfer to a regional stroke center. Conn Med 2005;69613- 620
PubMed
Schneider  ATPancioli  AMKhoury  JC  et al.  Trends in community knowledge of the warning signs and risk factors for stroke. JAMA 2003;289343- 346
PubMed Link to Article
Morgenstern  LBStaub  LChan  W  et al.  Improving delivery of acute stroke therapy: the TLL Temple Foundation Stroke Project. Stroke 2002;33160- 166
PubMed Link to Article
Hlatky  MACotugno  HEMark  DBO'Connor  CCaliff  RMPryor  DB Trends in physician management of uncomplicated acute myocardial infarction: 1970 to 1987. Am J Cardiol 1988;61515- 518
PubMed Link to Article
Chapman  GDOhman  EMTopol  EJ  et al.  Minimizing the risk of inappropriately administering thrombolytic therapy (Thrombolysis and Angioplasty in Myocardial Infarction [TAMI] study group). Am J Cardiol 1993;71783- 787
PubMed Link to Article
Wang  MYLavine  SDSoukiasian  HTabrizi  RLevy  MLGiannotta  SL Treating stroke as a medical emergency: a survey of resident physicians' attitudes toward “brain attack” and carotid endarterectomy. Neurosurgery 2001;481109- 1115
PubMed Link to Article
Merino  JGSilver  BWong  EDemaerschalk  BTamayo  AHachinski  V Physician knowledge of the benefits, risks, and contraindications of tissue plasminogen activator for acute ischemic stroke. Stroke 2001;322208- 2209
PubMed
Gamm  LHutchison  L Rural health priorities in America: where you stand depends on where you sit. J Rural Health 2003;19209- 213
PubMed Link to Article
Kleindorfer  DHill  MDWoo  D  et al.  A description of Canadian and United States physician reimbursement for thrombolytic therapy administration in acute ischemic stroke. Stroke 2005;36682- 687
PubMed Link to Article
Katzan  ILSila  CAFurlan  AJ Community use of intravenous tissue plasminogen activator for acute stroke: results of the brain matters stroke management survey. Stroke 2001;32861- 865
PubMed Link to Article
Davis  DAThomson  MAOxman  ADHaynes  RB Changing physician performance: a systematic review of the effect of continuing medical education strategies. JAMA 1995;274700- 705
PubMed Link to Article

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