Discussion
stroke, thrombolysis-eligible, Stroke, failure
STROKE, STROKE
Stroke Ready, a multilevel ED optimization and community stroke preparedness intervention, was not associated with increased use of thrombolysis. However, when analyzing the Stroke Ready intervention components separately, we found that the ED intervention was associated with increased thrombolysis, but the community intervention was not. In the last decade, Flint improved from one of the lowest-performing US communities for delivering stroke thrombolysis to a higher-performing community.Stroke Ready did not increase thrombolysis more than would be expected by the time trend in Flint alone. The failure to detect an association may be related to trends in thrombolysis that were insufficiently accounted for in our study design. There has been a consistent worldwide increase in thrombolysis. In 2009, the US thrombolysis rate was approximately 4.6%, compared with approximately 11% in 2018, and varied across communities.The Stroke Ready ED intervention was associated with a statistically significant increase in thrombolysis and decreased time from ED arrival to thrombolysis. Notably, this increase was found in hospitals that participated in Get With the Guidelines–Stroke and had achieved stroke center certification. Cluster-randomized ED thrombolysis implementation trials in the US, Australia, and the Netherlands have shown small, non–statistically significant increases in use of thrombolysis.The Stroke Ready community intervention was not associated with thrombolysis treatment rates. In addition to the power concerns, several points suggest a more cautious interpretation of the findings: (1) our study design precludes true independent evaluation of the hospital and community intervention (eg, the community intervention may have led to more thrombolysis-eligible patients with stroke presenting to the safety-net ED); (2) the community intervention and data collection were shortened by 3 months because of research restrictions necessitated by COVID-19Stroke Ready highlights some of the strengths and challenges in performing complex, multilevel interventions in the context of a community-based participatory research partnership. Strengths of the community intervention include the depth of community engagement, including community ideation, intervention development guided by health behavior theory, pilot testing with Black churches, delivery of stroke preparedness intervention by peer educators to facilitate sustainability, and co-led results dissemination.