Introduction
Stroke is the second leading cause of death in the world and the leading cause of death in China, the country alone accounting for roughly one-third of worldwide stroke mortality,1 2 with escalating cost to the healthcare system.3 Thrombolysis using intravenous tissue plasminogen activator (tPA) is one of the few evidence-based acute stroke treatments.4 5 Adherence to IV-rt PA is pivotal to the treatment for patients who had an acute ischaemic stroke (AIS): treatment with intravenous tPA within 4.5 hours of the stroke onset significantly improves clinical outcomes at 3 months.4 6
Although the overall quality of stroke care has significantly improved in China, there was no significant improvement in the adherence rate of IV-rt PA (14.1% in 2007–2008 vs 18.3% in 2012–2013), which remained significantly lower than that in the Get With The Guidelines-Stroke (GWTG-Stroke) programme (72.8% in 2007).7 8 Potential reasons for the low rate include prehospital delay, lack of regional stroke care network, high cost of tPA, low insurance coverage and concern about haemorrhagic risk.7 Significant opportunities still exist for further improvement.7
A recent meta-analysis has summarised what healthcare system factors contributed to the improvement of the thrombolysis rate,3 including travel time and location9–11 (eg, urban rather than rural location or a centralised/‘hub’ model linking outlying centres with other, generally larger, centres), training, skills and expertise11 12 (treatment by a neurologist or in a neurology department; admission to a stroke unit; treatment at a hospital with higher volume of stroke admissions or neurology beds; or accreditation as a ‘medical centre’), facilities and staffing11 13–17 (having a neurologist, stroke nurse or a stroke team; neurological or neuroimaging services; and weekend arrival) and organisational elements14 17 18 (use of stroke-specific protocols or transfer by ambulance/mobile emergency team rather than other means). However, detailed empirical data regarding the effects of such factors are not available.
Anecdotal studies mainly focused on the potential effect of individual-level socioeconomic status (SES) on the delivery of IV-rt PA, with conflicting observations. Wang et al claimed that patients with higher income were nearly twice as likely to receive IV-rt PA in China using the Chinese National Stroke Registry (CNSR) data.19 Ader et al observed that SES wasn’t associated with tPA administration among patients in the USA.20 It remains unclear how socioeconomic factors are associated with adherence rate of IV-rt PA. To the best of our knowledge, there are no published empirical studies that explore how macroeconomics and hospital-level factors associate with the adherence rate to IV-rt PA in China.
We aim to study the above research question, leveraging the natural imparity of social and economic development across China. Following previous quality improvement initiatives, such as the GWTG-Stroke programme, the Chinese Stroke Association initiated the Chinese Stroke Center Alliance (CSCA) in June 2015, as the national hospital-based stroke care quality assessment and improvement platform.21 Using data from the CSCA, we sought to identify how regional economic development and healthcare system factors were associated with adherence rate to IV-rt PA among eligible patients treated ≤4.5 hours from symptom onset.