The Influence Of Medical Insurance On The Therapeutic Effect And Hemorrhagic Complication Of Intravenous Thrombolysis In Acute Ischemic Stroke Patients

Backgrounds and purposes:Stroke is a common disease with high morbidity and mortality, which is the firstcause of death in China. The number of new cases reaches3million people each year withan annual inCreasing rate of8.7%, bringing heavy burden to the society and family.Especially the ischemic stroke, the main types of stroke, which accounts for80%of allstroke patients, needs to be paid more attention to. Up to date, intravenous thrombolysis isthe only way with sufficient evidence to treat acute ischemic stroke, and is normallyrecommended by guidelines from many countries.Many studies have found that some factors would affect the effect of intravenousthrombolysis, such as diabetes and atrial fibrillation, which can reduce the effects ofthrombolysis and inCrease the risk of hemorrhage complication. However, there are fewstudies to evaluate the influence of the medical insurance on the effect and complicationof intravenous thrombolysis. Actually, the medical insurance might affect thrombolysis.There are several reasons: non-Medicare patients might refuse thrombolysis or have delayin receiving thrombolysis because of economic constraints; in addition, non-Medicarepatients might be hard to afford the costs of treatments besides thrombolysis includingsupportive treatments and rehabilitation, which could affect neurological outcome afterthrombolysis and other treatments. In our study, we retrospectively analyzed110acuteischemic stroke patients who had received intravenous thrombolysis, to clarify theinfluence of Medicare on the effect and hemorrhage complication of intravenous thrombolysis.Methods and materials:We included110cases of ischemic stroke patients receiving intravenousthrombolysis in stroke center of Shanghai ninth people’s hospital affiliated to ShanghaiJiao Tong university school of medicine from April27th,2012to March20th,2014andanalyzed their clinical data. They were divided to Medicare groups (n=91) andnon-Medicare groups (n=19). Clinical data were analyzed, including the baseline data,onset time, concurrent disease, the main laboratory results, TOAST stroke classification,hospitalization days, the incidence of hemorrhage complications, total per capitahospitalization costs and neurological function score (modified Rankin Scale, mRS)1day,7days,1month, and3months after onset, in order to find out significant differencesbetween the two groups. Furthermore, we used multivariate linear regression to analyzethe possible predictors of hemorrhagic transformation after thrombolysis and neurologicaloutcome (mRS score)3months after onset in order to find out independent predictors ofoutcome and complications after intravenous thrombolysis, especially to determinewhether Medicare state would influence hemorrhagic complication and the neurologicaloutcome after intravenous thrombolysis in ischemic stroke patients.Results:(1) There were significant differences (P<0.05) in age, history of stroke, ratio ofpatients with softening lesion on Cranial CT before thrombolysis, glycosylated hemoglobin (HbA1c) level, and neurological outcome at3month after thrombolysis.There were moderate differences (P<0.1) in ratio of patients with history of atrialfibrillation, fasting blood sugar (FBS) level, liver function on admission, thehospitalization days. Specifically, the average age (P<0.001), the ratios of patients withhistory of stroke (P=0.008), the Ratio of patients with Cranial CT softening beforethrombolysis (P=0.032), HbA1c level (P=0.021), MRS score at3month (P=0.043) inMedicare group were significantly higher than those in non-Medicare group. The ratios ofMedicare patients with history of atrial fibrillation were moderately higher than that innon-Medicare group (P=0.06), the FBS of Medicare patients was moderately higher thanthat in non-Medicare group (P=0.097), the same as the serum Glutamate PyruvateTransaminase (GPT) level (P=0.088) and the hospitalization days (P=0.07). There wereno significant differences in hemorrhage complication and TOAST classification betweenthe two groups (P=0.13and P=0.629, respectively).(2) Multivariate linear regression analysis showed that age, the history of stroke,NIHSS score before thrombolysis and FBS level were the independent factors to predictthe higher mRS score at3months (ie, poor neurological outcome).(3) Multivariate linear regression analysis showed that FBS level, ratio of patientswith softening lesion on Cranial CT before thrombolysis and blood Creatinine level werethe independent factors to predict the hemorrhagic transformation after intravenousthrombolysis. Conclusion:This study found that the patients in non-Medicare group was younger, had lowerratio of stroke history or softing lesions on Cranial CT before thrombolysis, and had lowerHbA1c level than Medicare patients. However, the clinical outcome after thrombolysis inacute ischemic stroke patients was not associated with Medicare status but with age, thehistory of stroke, NIHSS score before thrombolysis, and FBS level. Furthermore, thehemorrhagic transformation after thrombolysis was not associated with Medicare statusbut with blood Creatinine level, FBS level, softing lesion on Cranial CT beforethrombolysis.