THE CHOICE OF THROMBOLYTIC AGENTS IN THE EMERGENCY DEPARTMENT

Study objective: To assess the choice of thrombolytic agents in emerge ncy departments and whether administrators and third-party payers are influencing choices because of cost differences. Design: A telephone s urvey. Type of participants: ED medical directors, stratifying for hos pital ownership, size, and regions of the United States. Measurements and main results: One hundred twenty-three ED medical directors comple ted the interview. Findings indicate that formularies include recombin ant tissue-type plasminogen activator (rt-PA) in 94.3% of surveyed hos pitals and streptokinase in 63.4%. Public hospitals were significantly less likely to have rt-PA on the formulary (P=.0001). Based on payer type, 68.9% to 77.5% of patients requiring thrombolysis receive rt-PA, with approximately 15% of EDs using it for 1% to 25% of patients and an additional 15% using it for 26% to 50% of patients. Fourteen medica l directors (11%) reported that they delay treatment with rt-PA until authorization is provided by the health maintenance organization, and 40% indicated they would change their choice of agents if rt-PA was de nied. Cardiologists were the primary decision makers regarding thrombo lytic agents in all types of hospitals. Conclusion: Although rt-PA is the most frequently selected thrombolytic agent, significant practice variations exist among hospitals. To avoid interference from third-par ty payers and administrators, physicians may need to make decisions re garding such expensive agents in more objective forums (eg, pharmacy a nd therapeutics committees) and be better prepared to defend the resul ting practice guidelines.