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Stroke thrombolysis on equal terms?: implementation and ADL outcome
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Medicine. Umeå University, Faculty of Medicine, Department of Community Medicine and Rehabilitation, Physiotherapy.
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Stroke thrombolysis is a method for restoring cerebral blood flow after ischemic stroke, with high priority in the Swedish national guidelines. implementation of stroke thrombolysis in Swedish routine stroke care has shown marked differences between demographic groups, hospital types, and regions. The general aim of this thesis were to examine the implementation of ischemic stroke thrombolysis in Swedish routine stroke care with an equity perspective; to gain more insight into the factors that influence implementation, how the treatment has reached patient groups, and differences in long-term outcomes between women and men. Analysis of data from research interviews with clinicians working within stroke care displayed that the facilitators of and barriers to the implementation of stroke thrombolysis could broadly be categorized into those related to individuals, to social interactions and context, and to organizational and resource issues. Key facilitating factors expressed in interviews were work pride and motivation, good leadership, involvement of all staff members in the implementation process, and quality assurance. Major barriers concerned lack of competence and experience, outdated attitudes regarding stroke management, counterproductive power structures, lack of continuity, and insufficient human resources. National quality register data displayed that stroke thrombolysis treatment expanded to reach more patients with mild deficits. Groups with higher education were more likely to receive treatment, compared to groups with lower educational level. These education group differences have, however, decreased over time in relative terms, but not in absolute terms. Further, there were considerable between-hospitals differences in treatment rates for patients with milder deficits, associated with hospital’s overall stroke thrombolysis rates. Moreover, larger non-university hospitals displayed treatment rate differences between educational groups that were not attributable to patient characteristics. Among thrombolysis-treated women and men, that was independent in ADL before their stroke and survived the first year post-stroke, women experienced higher probability to be dependent in ADL at both 3 and 12 months post-stroke, compared to men. This difference remained significant despite comprehensive adjustments for individual characteristics, symptom severity, and acute effects from stroke thrombolysis.

This thesis displays that clinicians face barriers and facilitators at several levels, suggesting implementation interventions could be targeted towards both the individual-, the social interactions and context-, and also the organisation and available resources level. Assurance of clinicians’ individual competence, peer support, and clinical leadership seem to be important areas to intervene. Stroke thrombolysis rates have expanded over time, and an increase in stroke thrombolysis delivery to patients with mild stroke symptoms has contributed to this increase. However, it seems considerable differences between hospitals inhibit equity of care delivery. Further, socioeconomically disadvantaged groups receive less often stroke thrombolysis. Type of hospital seems to play a role, yet the reasons for this difference are not fully understood. This thesis also display that stroke thrombolysis-treated women that survive 1 year after stroke, appears to face higher risk for dependency in ADL, compared to men.

Place, publisher, year, edition, pages
Umeå: Umeå universitet , 2017. , 66 p.
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1917
Keyword [en]
stroke, reperfusion, thrombolytic therapy, registries, multivariate analysis, healthcare disparities, female, educational status, Sweden
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:umu:diva-139953ISBN: 978-91-7601-711-1 (print)OAI: oai:DiVA.org:umu-139953DiVA: diva2:1144891
Public defence
2017-10-20, Aulan, Vårdvetarhuset, Umeå, 09:00 (Swedish)
Opponent
Supervisors
Note

Incorrect ISBN in print version 978-91-760-711-1. Correct ISBN should be 978-91-7601-711-1.

Available from: 2017-09-29 Created: 2017-09-27 Last updated: 2017-09-28Bibliographically approved
List of papers
1. Implementing thrombolytic guidelines in stroke care: perceived facilitators and barriers
Open this publication in new window or tab >>Implementing thrombolytic guidelines in stroke care: perceived facilitators and barriers
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2014 (English)In: Qualitative Health Research, ISSN 1049-7323, E-ISSN 1552-7557, Vol. 24, no 3, 412-419 p.Article in journal (Refereed) Published
Abstract [en]

We performed a qualitative study to identify facilitators of and barriers to the implementation of national guidelines on thrombolytic therapy for acute ischemic stroke. We interviewed physicians and nurses at nine Swedish hospitals using 16 explorative, semistructured interviews, and selected hospitals based on their implementation rate of new stroke care methods according to data from the Swedish Stroke Register, Riks-Stroke. Through content analysis, we identified facilitators and barriers to implementation, which we classified into three categories: (a) individuals, (b) social interactions and context, and (c) organizational and resource issues. Insights obtained from this study can be used to identify target areas for improving the implementation of thrombolytic therapy and other new methods in stroke care.

Place, publisher, year, edition, pages
Sage Publications, 2014
Keyword
health care professionals, interviews semistructured, knowledge utilization, stroke
National Category
Family Medicine
Identifiers
urn:nbn:se:umu:diva-83383 (URN)10.1177/1049732313514137 (DOI)000332446400011 ()24259536 (PubMedID)
Available from: 2013-11-22 Created: 2013-11-22 Last updated: 2017-09-27Bibliographically approved
2. Thrombolytic therapy rates and stroke severity: an analysis of data from the Swedish Stroke Register (Riks-Stroke) 2007-2010
Open this publication in new window or tab >>Thrombolytic therapy rates and stroke severity: an analysis of data from the Swedish Stroke Register (Riks-Stroke) 2007-2010
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2012 (English)In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 43, no 2, 536-538 p.Article in journal (Refereed) Published
Abstract [en]

Background and Purpose: We tested the hypothesis that higher proportions of patients with minor stroke being treated with thrombolysis contribute to increasing overall rates of thrombolysis.

Methods: We included 1743 ischemic stroke patients (age 18–80 years) treated with thrombolysis, recorded in the Swedish stroke register Riks-Stroke between 2007 and 2010. Minor stroke was defined as National Institutes of Health Stroke Scale score ≤5.

Results: The proportion with minor stroke among patients treated with thrombolysis increased from 22.1% in 2007 to 28.7% in 2010 (P=0.021). The rate of increase did not differ significantly between men and women, age groups, or hospital types (university hospitals, other large hospitals, or community hospitals). Hospitals with high proportions of thrombolysis patients with minor stroke were more likely to have high thrombolysis frequencies (R=0.55; P<0.001).

Conclusions: In recent years, an increase in the proportion of patients with minor stroke treated with thrombolysis has contributed to rising overall thrombolysis rates in Sweden. At the hospital level, high rates of thrombolysis are associated with a high proportion of minor stroke being treated.

Place, publisher, year, edition, pages
New York: American Heart Association, 2012
Keyword
acute ischemic stroke, thrombolysis, rtPA, implementation, stroke severity
National Category
Family Medicine Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-48282 (URN)10.1161/STROKEAHA.111.630590 (DOI)000299798300043 ()21980204 (PubMedID)
Available from: 2011-10-14 Created: 2011-10-14 Last updated: 2017-09-28Bibliographically approved
3. Education level and inequalities in stroke reperfusion therapy: observations in the Swedish stroke register
Open this publication in new window or tab >>Education level and inequalities in stroke reperfusion therapy: observations in the Swedish stroke register
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2014 (English)In: Stroke, ISSN 0039-2499, E-ISSN 1524-4628, Vol. 45, no 9, 2762-2768 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND AND PURPOSE: Previous studies have revealed inequalities in stroke treatment based on demographics, hospital type, and region. We used the Swedish Stroke Register (Riksstroke) to test whether patient education level is associated with reperfusion (either or both of thrombolysis and thrombectomy) treatment.

METHODS: We included 85 885 patients with ischemic stroke aged 18 to 80 years registered in Riksstroke between 2003 and 2009. Education level was retrieved from Statistics Sweden, and thrombolysis, thrombectomy, patient, and hospital data were obtained from Riksstroke. We used multivariable logistic regression to analyze the association between reperfusion therapy and patient education.

RESULTS: A total of 3649 (4.2%) of the patients received reperfusion therapy. University-educated patients were more likely to be treated (5.5%) than patients with secondary (4.6%) or primary education (3.6%; P<0.001). The inequality associated with education was still present after adjustment for patient characteristics; university education odds ratio, 1.14; 95% confidence interval, 1.03 to 1.26 and secondary education odds ratio, 1.08; 95% confidence interval, 1.00 to 1.17 compared with primary education. Higher hospital specialization level was also associated with higher reperfusion levels (P<0.001). In stratified multivariable analyses by hospital type, significant treatment differences by education level existed only among large nonuniversity hospitals (university education odds ratio, 1.20; 95% confidence interval, 1.04-1.40; secondary education odds ratio, 1.14; 95% confidence interval, 1.01-1.29).

CONCLUSIONS: We demonstrated a social stratification in reperfusion, partly explained by patient characteristics and the local hospital specialization level. Further studies should address treatment delays, stroke knowledge, and means to improve reperfusion implementation in less specialized hospitals.

Place, publisher, year, edition, pages
American Heart Association, 2014
Keyword
education, reperfusion, thrombectomy, thrombolytic therapy
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:umu:diva-91520 (URN)10.1161/STROKEAHA.114.005323 (DOI)000341491500054 ()25074515 (PubMedID)
Available from: 2014-08-11 Created: 2014-08-11 Last updated: 2017-09-27Bibliographically approved
4. Sex differences in ADL among patients treated with acute intravenous thrombolysis for ischemic stroke: a 1 year prospective observational study
Open this publication in new window or tab >>Sex differences in ADL among patients treated with acute intravenous thrombolysis for ischemic stroke: a 1 year prospective observational study
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(English)Manuscript (preprint) (Other academic)
National Category
Medical and Health Sciences
Research subject
Medicine; physiotherapy
Identifiers
urn:nbn:se:umu:diva-139950 (URN)
Available from: 2017-09-27 Created: 2017-09-27 Last updated: 2017-09-28

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