Utilization of intravenous tissue-type plasminogen activator for ischemic stroke at academic medical centers - The influence of ethnicity

Background and Purpose-We sought to measure the overall rate of usage of ti ssue-type plasminogen activator (tPA) for ischemic stroke at academic medic al centers, and to determine whether ethnicity was associated with usage. Methods-Between June and December 1999, 42 academic medical centers in the United States each identified 30 consecutive ischemic stroke cases. Medical records were reviewed and information on demographics, medical history, an d treatment were abstracted, Rates of tPA use were compared for African Ame ricans and whites in univariate analysis and after adjustment for age, gend er, stroke severity, and type of medical insurance with multivariable logis tic regression, Results-Complete information was available for 1195 ischemic stroke patient s; 788 were whites and 285 were African Americans. Overall, 49 patients (4. 1%) received tPA, In the subgroup of 189 patients without a documented cont raindication to therapy, 39 (20.6%) received tPA. Ten (20%) of those receiv ing tPA had documented contraindication. African Americans were one fifth a s likely to receive tPA as whites (1.1% African Americans versus 5.3%; P=0. 001), and the difference persisted after adjustment (OR 0.21, 95% CI 0.06 t o 0.68; P=0.01), When comparison was restricted to those without a document ed contraindication to tPA, the difference remained significant (OR 0.24, 9 5% CI 0.06 to 0.93; P=0.04). Medical insurance type was independently assoc iated with tPA treatment. After adjustment for ethnicity and other demograp hic characteristics, those with Medicaid or no insurance were one ninth as likely to receive tPA as those with private medical insurance (OR 0.11, 95% CI 0.02 to 0.17; P=0.003). Conclusions-tPA is used infrequently for ischemic stroke at US academic med ical centers, even among qualifying candidates. African Americans are signi ficantly less likely to receive tPA for ischemic stroke. Contraindications to treatment do not appear to account for the difference.