| Objective:This study aimed to examine the neurologists' recognition and perspective towards intravenous recombinant tissue plasminogen activator(rt-PA)thrombolysis for the treatment of acute ischemic stroke(AIS)and the influencing factors.This study also intended to explore the rate of rt-PA use in AIS patients and the reasons for not giving thrombolysis.Additionally,we specifically examined the issues of pre-hospital delay and its associated factors in AIS patients.Emergency medical services(EMS)can effectively shorten the pre-hospital delay for AIS patients,so we also investigated EMS utilization and its associated factors in patients with AIS.Finally,we summarized the problems and deficiencies for the low utilization of thrombolysis in clinical practice,summarized the corresponding strategies and suggestions,and offered scientific basis for the efficient emergency treatment of stroke and help increase intravenous rt-PA use in China.Methods:After reviewing previous references and theories,we develop a questionnaire survey to collect the data.A cross-sectional study was conducted from October 2014 to July 2015,which included 2096 patients admitted for AIS from 66 hospitals in 13 major cities across Hubei province in China.All patients were interviewed by face-to-face with trained graduate students.Moreover,we also surveyed 709 neurologists from 66 hospitals.We used Epidata 3.0 to input the data,then we used SPSS 18.0 to analyze the data.Descriptive analysis was carried out to preliminary analyze the data.Chi-square test was used to compare the cognition and behavior of different patients and neurologists.Multivariate logistic regression analysis was undertaken to explore the factors influencing neurologists'experience and attitude about rt-PA thrombolysis.Multivariate logistic regression analysis were undertaken to determine the prevalence rates and the risk factors associated with pre-hospital delays and EMS utilization in AIS patients.Decision tree analysis were undertaken to determine the risk factors associated with pre-hospital delays and EMS utilization in AIS patients.Results:1.A total of 709 neurologists were included in our analysis.Among the responding neurologists,66.0%reported using intravenous thrombolysis and 73.5%showed a better outcome after intravenous thrombolysis.Approximately 52.2%reported deficits in their knowledge of intravenous thrombolysis and 46.3%felt unconfident about their ability to employ the treatment.The main barriers to the utilization of thrombolysis for AIS patients were the delay of patient presentation(62.8%)and the fear of the risk of intracerebral haemorrhage(23.8%).Logistic regression analysis showed that neurologists who worked in level III hospital(odds ratio[OR]=1.881,95%confidence interval[CI]= 1.154-3.064),neurologists who believed the treatment was safe(OR=1.933,95%CI=1.277-2.924),neurologists who considered the treatment was beneficial(OR=2.259,95%CI=1.424-3.581),neurologists who reported deficits in their knowledge of the treatment(OR=2.991,95%CI=1.901-4.706),and neurologists who felt confident about their ability to employ the treatment(OR=2.951,95%CI=1.845-4.718)had more experiences of thrombolysis.In addition,neurologists'positive attitudes towards intravenous thrombolysis were associated with previous experiences of thrombolysis(OR=3.531,95%CI=1.881-6.631),safety awareness(OR=4.205,95%CI=2.252-7.852),and benefits or risks awareness(OR=3.461,95%CI=1.997-5.999).Finally,neurologists whose educational background was master degree or above(OR=2.165,95%CI= 1.194-3.925),neurologists whose working duration in hospital was more than 8 years(OR=2.594,95%CI=1.250-5.380),neurologists who considered the treatment was beneficial(OR=4.643,95%CI=2.704-7.970),neurologists who supported to perform thrombolysis in hospital(OR=2.248,95%CI=1.168-4.328),and neurologists who were willing to perform thrombolysis for eligible AIS patients(OR=6.320,95%CI=3.148-12.690)were more likely to choose thrombolysis as the preferred therapy for eligible AIS patients.2.A total of 2079 AIS patients were included in our analysis.Among the responding patients,only 3.8%received thrombolysis and 12.2%received thrombolysis in the time window.Among patients who used thrombolysis,67.1%were satisfied with the treatment effect.The main reasons for not using thrombolysis were late arrival of patients(37.5%),fear of the risk of complications of thrombolysis(33.2%),and stroke symptoms were light or quickly recovered(19.2%).3.69.2%of AIS patients experienced pre-hospital delay.58.6%of patients did not recognize the initial symptoms as stroke-related.51.0%of patients contacted relative/acquaintance when symptoms first occurred,20.9%of patients did nothing,and only 15.4%of patients were transported to hospital by EMS.Among 2079 respondents,74.0%were aware of stroke,only 25.1%knew all symptoms of stroke,and only 28.3%knew all risk factors of stroke.Logistic regression analysis showed that patients with a history of stroke(OR=1.389,95%CI=1.045-1.846),the symptoms were first noticed by patients themselves(OR=1.532,95%CI=1.195-1.964)and the onset location was at home(OR=1.557,95%CI=1.161-2.089)were significantly associated with increased pre-hospital delay.In contrast,patients who considered any kind of the symptoms as severe(OR=0.480,95%CI=0.377-0.611),patients's initial reaction was called 120 or went to hospital directly(OR=0.218,95%CI=0.146-0.326),patients's initial reaction was contacted relative or acquaintance(OR=0.333,95%CI=0.228-0.486),the shorter distance from the onset place to the first hospital(OR=0.680,95%CI=0.535-0.864),and admitted to hospital by EMS(OR=0.369,95%CI=0.277-0.493)were independently associated with decreased pre-hospital delays.Decision tree analysis showed that the most important factors influenced pre-hospital delay was admission form,next were patients' care seeking behavior and whether patients considered any kind of the symptoms as severe.Other factors that influenced pre-hospital delay were who decided to see a doctor,the distance from the onset place to the first hospital,history of stroke,and onset location.Logistic regression analysis showed that EMS utilization was significantly associated with urban areas(OR=2.189,95%CI=1.538-3.115),the symptoms were first noticed by some else(OR=1.816,95%CI=1.334-2.474),considering any kind of the symptoms as severe(OR=3.722,95%CI=2.652-5.225),sudden onset of symptoms(OR=1.874,95%CI=1.014-3.466),NIHSS>4(OR=2.180,95%CI=1.617-2.939),and previous use of EMS(OR=11.518,95%CI=8.004-16.577).In contrast,patients with a history of stroke(OR=0.586,95%CI=0.397-0.864)were independently associated with decreased EMS utilization.Decision tree analysis showed that the most important factors influenced EMS utilization was previous experiences of EMS,next was whether patients considered any kind of the symptoms as severe.Other factors that influenced EMS utilization were location,NIHSS,the symptoms were first noticed by patients or other people,the onset circumstance was unconsciousness or fainting,sudden onset of symptoms,and recognition of initial symptom as stroke.Conclusions:1.The results of this survey suggested that most neurologists identified the intravenous thrombolysis for the treatment of AIS.However,neurologists' knowledge and experiences of thrombolysis,ability to employ thrombolysis,attitude and willingness towards thrombolysis had effects on neurologists' clinical decision.Compared with neurologists from level II hospitals,neurologists from level III hospitals had more thrombolysis experiences.The main barriers to the utilization of thrombolysis for AIS were the delay of patient presentation and the fear of the risk of intracerebral haemorrhage.Therefore,stepping up training and attaching importance to improvement in practical skills was important for the wide application of thrombolysis in the region.2.The rate of thrombolysis in Hubei province,China was far lower than the rates of thrombolysis in developed countries.The main reasons for not using thrombolysis were late arrival of patients and refusal of patients or their families.3.Patients' knowledge on risk factors of stroke,early symptoms of stroke,and right reaction after stroke onset was lacking.The pre-hospital delay in AIS patients was common,which was associated with patients' recognition and care seeking behavior.EMS can effectively shorten the pre-hospital delay.A very low proportion of patients with AIS used the EMS in China.Previous use of EMS,history of stroke,severe stroke,and location was significantly associated with EMS utilization.These findings highlighted the need for comprehensive education of stroke awareness and EMS utilization to further reduce the pre-hospital delays and increase the rate of thrombolysis. |
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