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The article discusses whether intravenous tissue plasminogen activator (IV tPA) use for acute ischemic stroke increased in Massachusetts with the Primary Stroke Service program, a statewide stroke center appointment and quality improvement initiative. Data from the Massachusetts Department of Publich Health between October 2004 and June 2008 is analyzed.

In January 2005, the Massachusetts Department of Public Health announced the designation of approved hospitals as Primary Stroke Services (PSS), based on verifiable demonstration of care pathways for acute ischemic stroke. We investigated the effect of hospital characteristics on participation in the PSS program.In 2003, the Massachusetts Department of Public Health surveyed 72 Massachusetts hospitals on their readiness for PSS designation. Survey results and PSS participation rates were compared among hospitals categorized by bed size (<150 vs. > or =150 beds), rural location, and major teaching hospital status. In answer to 2003 survey questions, smaller hospitals (n = 35) were less likely than larger hospitals to have acute stroke teams (P = 0.01), 24-hour rapid computed tomography scanning and interpretation (P = 0.0006), 24-hour neurosurgery coverage (P = 0.001), and a stroke registry (P = 0.007). Smaller hospitals were less likely to be interested in PSS application in 2003 (P = 0.008), and less likely to be designated PSS when ambulance rerouting to PSS hospitals began in July 2005 (P < 0.0001). Despite this, by December 2005 the majority of Massachusetts hospitals (66/71, 92%) had achieved PSS designation. Smaller hospitals were more likely to use telemedicine to access acute stroke teams (P = 0.003).Many smaller hospitals are able to acquire the resources needed for provision of acute stroke care, despite initial limitations. Innovative strategies, such as telemedicine consultation and transfer agreements, may successfully allow smaller hospitals to satisfy Brain Attack Coalition criteria for primary stroke centers.

Objective: To determine the characteristics of patients with stroke/TIA whose admission low-density lipoprotein (LDL) levels were above goals defined by National Cholesterol Education Program Adult Treatment Panel (NCEP-ATPIII) guidelines., Methods: From January 1, 2003, to June 30, 2005, there were 1,212 discharges (1,033 stroke, 179 TIA), of whom 1,040/1,212 (86%) had lipid measurement. The preadmission individual LDL goal was determined using 2001 NCEP-ATPIII guidelines., Results: There were 284/1,040 (27%) whose measured LDL was greater than the individual preadmission LDL goal. Failure to be at goal was common even among those with previously diagnosed dyslipidemia (159/527, 30%) and those taking lipid-lowering agents (LLA) (71/370, 19%). LLA would have been indicated in 121/213 (57%) of those above LDL goal who were not already taking LLA, with optional consideration in 77/213 (36%). Lower LDL therapeutic targets were the strongest predictor, in a multivariable model, of failure to be at goal. Compared to LDL target <160 (reference), the OR for LDL target <130 was 6.4 (95% CI 3.4 to 12.0, p < 0.0001) and for LDL target <100 was 26.2 (95% CI 13.3 to 51.5, p < 0.0001). An increased likelihood of being at goal was associated with preadmission LLA (OR 4.2, 95% CI 2.9 to 6.2, p < 0.0001) and increasing calendar time (OR 1.09 per 3-month period, 95% CI 1.03 to 1.15, p = 0.004)., Conclusions: Many patients hospitalized with ischemic stroke/TIA, including those with known dyslipidemia and those taking lipid lowering agents, have measured low-density lipoprotein (LDL) that is higher than recommended by national guidelines. Patients at the greatest risk of cardiovascular events are the least likely to be at guideline-recommended LDL levels.