for acute ischemic stroke. If given within 3 h [7], and possibly up to 4.5 h [8], tPA can significantly reduce the level of disability observed in patients 90 days after treatment. Despite the promise of tPA therapy, the stroke community has found it challenging to implement this treatment effectively and equitably in many communities. The proportion of ischemic stroke patients who are actually treated with tPA has historically been low, often not reaching more than 3-4% of all ischemic stroke admissions in the USA [9], although more recent data from national quality improvement registries, such as Get With the Guidelines ® Stroke have shown great improvements in the p roportion of eligible stroke patients treated [10].The availability of tPA treatment for acute ischemic stroke has raised two important sexbased issues, one related to the potential for sex differences in the efficacy of tPA, and the other related to sex differences in the utilization of tPA. Empirical data illustrating the potential for sex differences in the efficacy of tPA was first shown by Kent and colleagues [11], who undertook a pooled ana lysis of three randomized placebo-controlled clinical trials of IV tPA [7,[12][13][14]. The analysis showed that women received a substantially greater benefit from tPA treatment compared with men. These results were interpreted as showing that tPA had the potential to eliminate the sex difference in functional outcomes poststrokeThe importance of stroke in women is gaining increasing recognition in both clinical and public health environments [1,2]. Because of the increased life expectancy of women, there are more stroke events in women than in men, even though in all but the very oldest age groups age-specific incidence and mortality rates are higher in men than women [1]. Stroke is also important in women because women appear to not fare as well after a stroke event compared with men; stroke-related outcomes, including disability, functional status and quality of life are consistently poorer in women than in men, yet the reasons for this are not well understood [3,4]. Some of the reasons for poor poststroke outcomes undoubtedly stem from the fact that women are older (by approximately an average of 4 years) than men when they have stroke, but accounting for these age differences or differences in the burden of risk factors and comorbidities prior to the stroke event does not account for all of these observed differences [1]. The impact of stroke on women is also exacerbated by the fact that elderly women, compared with their male counterparts, are much more likely to live alone and be socially isolated at the time of their stroke, and so may be less able to adapt to the changes that a stroke event imparts [5,6].A major development in the treatment of stroke over the last 15 years has been the approval of intravenous tissue thrombolysis (IV tPA) therapy ReviewThrombolysis treatment for acute stroke: issues of efficacy and utilization in women Background: Some studies report that women with ischemic stro...

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Background: Evaluation of TIA cases in the emergency department (ED) represents a clinical dilemma because no firm guidelines exist as to their disposition (hospitalization vs. out-patient care). The ABCD 2 clinical prediction rule risk stratifies patients but little is known about how Emergency Medicine physicians (EMPs) use the rule in clinical decision making. We undertook focus groups with EMPs to determine their attitudes and use of the ABCD 2 score, and to understand how information on baseline risk, costs, compliance, and feasibility affect their decision making. Methods: Physicians from 2 EM practice groups in Michigan were invited to attend a focus group meeting. Data were collected on their knowledge, attitudes, and use of the ABCD 2 clinical prediction rule in the evaluation of TIA cases. Using a case vignette of a moderate risk patient (ABCD 2 score = 4, 7-day stroke risk = 6%), physicians were asked to choose between hospitalization or discharge for out-patient care. We then changed several baseline conditions, including 7-day stroke risk, health care costs, and compliance with out-patient follow-up, to determine under what conditions they altered the initial disposition decision. Results: Twenty two EMPs participated; all worked in community-based hospitals, 91% were male, 95% were EM board certified with an average of 16.5 years of EM experience. Respondents reported seeing an average of 6.7 (SD= 4.6) TIA patients per month. Sixty four percent (14/22) were familiar with the ABCD 2 score, but only 9% (2/22) used it regularly. Almost 60% (13/22) initially chose to hospitalize the moderate risk patient. Increasing the cost of the episode of care (from $3000 to $9000) did not change the decision to hospitalize for the majority (8/13, 62%) of EMPs. Only when 7-day stroke risk was lowered from 6% to 1% did the majority of EMPs (11/13, 85%) change their decision from hospitalization to outpatient care. Forty percent (9/22) initially chose to manage the moderate risk patient as an out-patient. A small increase in the cost of care (from $3000 to $3500) resulted in 56% (5/9) EMPs switching their decision from out-patient care to hospitalization, while a modest increase in stroke risk (from 6% to 10%) resulted in 78% (7/9) switching their initial decision. The choice of out-patient care was also influenced by the likelihood that patients would complete testing in the out-patient setting; if compliance dropped from 100% to 80% then half of the EMPs switched their decision from out-patient care to hospitalization. Increasing the number of hours that a patient would need to complete testing (from 4 to 12 hours) only had a modest impact on physician decision making. Conclusions: The ABCD 2 score was rarely used in practice. The decision to hospitalize was relatively insensitive to cost of care; 7-day stroke risk only influenced the decision when reduced to virtual certainty (1%). The decision to use out-patient care was more sensitive to cost of care, increases in stroke risk, and compliance in the out-patient setting. These data suggest future studies should focus on acceptable outpatient risks and costs to increase adoption of clinical prediction rules and appropriate decision making for TIA cases.