The choice of thrombolytic agents in the emergency department

Study objective: To assess the choice of thrombolytic agents in emergency departments and whether administrators and third-party payers are influencing choices because of cost differences. Design: A telephone survey. Type of participants: ED medical directors, stratifying for hospital ownership, size, and regions of the United States. Measurements and main results: One hundred twenty-three ED medical directors completed the interview. Findings indicate that formularies include recombinant tissue-type plasminogen activator (rt-PA) in 94.3% of surveyed hospitals and streptokinase in 63.4%. Public hospitals were significantly less likely to have rt-PA on the formulary ( P = .0001). Based on payer type, 68.9% to 77.5% of patients requiring thrombolysis receive rt-PA, with approximately 15% of EDs using it for 1% to 25% of patients and an additional 15% using it for 26% to 50% of patients. Fourteen medical directors (11%) reported that they delay treatment with rt-PA until authorization is provided by the health maintenance organization, and 40% indicated they would change their choice of agents if rt-PA was denied. Cardiologists were the primary decision makers regarding thrombolytic agents in all types of hospitals. Conclusion: Although rt-PA is the most frequently selected thrombolytic agent, significant practice variations exist among hospitals. To avoid interference from third-party payers and administrators, physicians may need to make decisions regarding such expensive agents in more objective forums (eg, pharmacy and therapeutics committees) and be better prepared to defend the resulting practice guidelines.