This current study showed that the rate of thrombolysis in Hubei province, China was 3.8%, which was far lower than the approximately 8% prevalence of thrombolysis in developed countries [6,7,9,10], but close to the approximately 2% prevalence of thrombolysis in some other early studies in China [13,15], indicating big gaps and ample opportunities in improving AIS thrombolytic treatment in central China.
In both view of neurologists and AIS patients, the main reasons for not using thrombolysis were late arrival of patients and the fear of the risk of complications. In previous studies, a substantial proportion of patients experienced admission delay [6,18,19]. A study conducted in India reported that 29% patients presented within 3 hours of onset . Other studies conducted in Korea found that between 26.0% and 43.3% of patients arrived within 3 hours of onset [26,27]. Synthesized the results of China National Stroke Registry, China Quality Evaluation of Stroke Care and Treatment project, and study of seven cities in China, we found that approximately 70%-80% of AIS patients presented hospitals after 3 hours of stroke onset [13,15]. This means that, given the annual incidence of AIS in China (approximately 4900 000), more than 3430 000 patients would be ineligible for thrombolysis because of late presentation. The probable reason may be that most stroke patients or families cannot properly recognize the stroke symptoms or ignore the severity of symptoms or lack knowledge of care seeking behavior after stroke onset, especially when patients’ symptoms were light or quickly improved, or patients waiting for the improvement of symptoms.
As expected, a risk of bleeding, particularly intracerebral haemorrhage (ICH), can be life-threatening and was the main risk for thrombolysis, which limited the application of thrombolysis to some extent. Brown et al  revealed that 65% of physicians were reported not likely to use rt-PA because of the risk of ICH. Wang et al  showed that many Chinese physicians still overemphasized the adverse effect of thrombolysis, such as risk of ICH, for the complications may aggravate stroke symptoms and cause a conflict between doctors and patients. Especially in the current complicated medical environment in China, more and more physicians prefer to adopt conservative treatment to reduce the medical conflicts caused by complications of thrombolysis. Such an attitude would have a negative impact on patients, who would probably refuse this treatment. In the present study, 80.0% of neurologists believed that the tension between doctors and patients had a negative impact on the development of thrombolysis. Possible reasons for this tension may be attributed to patients’ general skepticism of the medical establishment, the conflict of progressive and traditional medicinal approaches, or something specific about rt-PA risks. The promotion of doctor-patient communication was one of the important premises and links to guarantee medical safety. Furthermore, the presence of appropriate staff to monitor and manage suspected complications was also essential to the proper implementation of thrombolysis.
Our study showed that the percentage of patients who were treated with thrombolysis was significantly higher in grade III hospitals than in grade II hospitals, and the multivariate logistic regression analysis also showed that neurologists’ experience was associated with hospital grade. Hospital size has been indicated to be an important predictor of quality of care, such as emergency treatment and short-term mortality for many conditions, including stroke . Hospital level was also positively correlated with other characteristics of the hospital, such as teaching status, medical staffs, medical resources, and specialty services, which were important to stroke care . Higher level hospital was equipped with a more professional medical team, more standard quality-improvement infrastructure, and better multidisciplinary collaboration, thus it can provide higher quality service of diagnosis and treatment of stroke. However, due to the lack of technical equipment, medical personnel related experiences, and other related factors such as difficulty manage of complications, the application of advanced treatments were relatively weak in lower level hospital. Similar results can be seen in other studies . Therefore, stepping up training and attaching importance to improvement in practical skills was important for the wide application of thrombolysis in the region. Remote thrombolytic therapy or telemedicine, which used network audio-visual capabilities to make the superior neurologists instant communication to physicians and patients in long distance, helping making disease assessment and finally making clinical decision, has been proposed as a solution to low utilization of thrombolysis in AIS . Chalouhi et al  conducted a study in 1643 telemedicine stroke consultations and found that 82% hospitals within the telemedicine program reported a mean increase of 55% in IV-tPA use, and the proportion of patients transferred to a primary stroke center after teleconsultation decreased from 44% to 19%. The experience of the University of Pittsburgh Medical Center telestroke network showed that the overall rate of IV tPA increased from 2.8% to 6.8% after starting telemedicine . In addition, education level and working duration had an impact on neurologists’ treatment experiences. Generally speaking, higher education level and longer job experiences were associated with both higher degree of mastering the treatment knowledge and more opportunities to develop thrombolytic therapy.
In this analysis, compared to patients who had no history of stroke, patients with prior stroke experiences were less likely to use thrombolysis. A possible explanation was that patients with past experiences of stroke were associated with increased pre-hospital delays, which may result in missing the time window for thrombolytic therapy . Our study also found that patients admitted to hospital by EMS were associated with higher rate of thrombolysis. Using EMS as an admission form was recommended by many literatures and stroke guidelines, for it can not only play a role in the efficient transfer of patients, but also requiring to act as a mobile stroke unit, which will transfer patients to more suitable hospitals and improve the efficiency of hospital emergency treatment in stroke . These findings highlighted the requirements for intervention programs to further increase the public’s awareness of EMS utilization, comprehensive education of awareness of stroke, and appropriate response after stroke.
The major strength of our study is that we explore the experiences and evaluation of thrombolysis, as well as the reasons for not giving thrombolysis in both neurologists and patients, which can offer scientific basis for the efficient emergency treatment of stroke and help to increase intravenous rt-PA use in China. This study also has a few limitations. The main limitation is that as a cross-sectional design of the study, recall bias would be inherent. Additionally, emergency physicians’ attitude towards thrombolysis greatly affects the future implementation of thrombolysis, as this is a key step in the administration of first-line therapies for stroke, which we will do in the future.