Abstract
Introduction: Alteplase is the only FDA approved thrombolytic agent for acute ischemic stroke, tenecteplase is rapidly emerging as an alternative. While both agents are readily available worldwide, low to middle income countries have limited access to acute treatment. To our knowledge, there is no validated tool available to objectively measure access to thrombolytic agents or barriers to routine clinical use.
Methods: We develop the 17-item tPA Spot Check tool to assess utilization of acute stroke thrombolysis in multiple languages. This tool was used to evaluate the current state of clinical practices in the MT2020+ Caribbean Region. Data was analyzed via SPSS.
Results: The survey was validated by three international experts with an Average Content Validity Index of 1 and a Universal Agreement index of 1 across three domains: local experience, financial constraints, and barriers to utilization.Survey response rate was 64% (73/114 responses) 46 in English, 14 in Spanish and 13 in French. Fifteen out of 44 MT2020+ Caribbean countries (34%) participated: Haiti, Dominican Republic, Jamaica, Puerto Rico, St. Lucia, Bermuda, Bahamas, Cayman Islands, Trinidad and Tobago, Barbados, Dominica, Venezuela, Nicaragua, Honduras, and Guadalupe. There was limited or no access to thrombolytic agents in 40% of countries surveyed, with 13% resorting to the use of streptokinase. Among cases treated with thrombolytics, 43% of patients had to pay out of pocket before treatment provided, 36% of treatment was paid by insurance plus patients and less than 10% were covered by insurance or governmental support respectively. Among 51% of countries survey, no acute thrombolytic treatment was provided for acute stroke in 2021 calendar year. Only 1 center treated more than 100 cases per year. Majority of respondents (88%) agreed there were barriers to acute stroke thrombolysis in the region. Absence of Stroke protocol (p<0.001), upfront cost of alteplase (p= 0.003) and access to CT scan (p=0.03) were independent predictors of fewer patients treated per year.
Conclusion: This this survey brings light to an enormous disparity in care of stroke patients around the world, specifically in the MT2020+ Caribbean region. We create a valid tool can be used to assess local access to thrombolytic.