Duy Le, MD

Stecksén A, Glader EL, Asplund K, Norrving B, and Eriksson M. Education Level and Inequalities in Stroke Reperfusion Therapy:Observations in the Swedish Stroke Register. Stroke. 2014

An essential mantra of vascular neurology has been that time is tissue. While many studies have evaluated what systems within the hospital help to expedite thrombolytic times, this study aims to evaluate what underlying patient factors, including education level, affect thrombolytic therapy (either IV-tPA or IA). Stecksen et al conducted a retrospective study, evaluating over 85,000 patients with ischemic stroke between the ages of 18-80 years between 2003-2009 from the Swedish registry, Riksstroke. Of the 85,885 patients evaluated, only 2.3% had an unknown level of education.  3,649 (4.2%) of patients received reperfusion therapy. As a whole, university educated patients (4.6%) were more likely to be treated with thrombolysis, as opposed to secondary or primary education patients (3.6%), (p<0.001). If a hospital was deemed “specialized,” which was not clearly defined by the paper, there was more likely a higher rate or reperfusion attempted. The study also attempted to evaluate if hospital settings themselves were responsible for differing rates of thrombolytic treatment. They did not find this to be the case in both community hospitals and Academic hospitals. In stratified multivariable analyses by hospital type, significant differences by education level with regards to receiving IV-tPA existed only among large non-university hospitals (university education OR 1.20 vs. secondary education 1.14).

Weaknesses of the study, which are specified by the authors, include a lack of data for delays, distance to the hospital, and reperfusion that may have been given outside of protocol. Surely these factors would influence the timing or reperfusion therapy. Additionally, there was no evaluation and separation of IV-tPA vs. IA intervention as individual categories. Nonetheless, this study does highlight for us that as much as we can control in the hospital to streamline IV-tPA processes to increase the rate and administration time, much work remains to be done outside of the hospital, before the patient ever arrives to the ED. Targeting those and educating those in the community with secondary and primary level of education may be of great benefit.