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Letter by Lahr et al Regarding Article, “Promoting Thrombolysis in Acute Ischemic Stroke”

Originally published 2011;42:e411

To the Editor:

With great interest, we read the article by Dirks et al1 published in the March 2011 issue of Stroke. The authors showed that a multidimensional implementation strategy slightly increased the thrombolysis treatment rate for the intervention group (13%) compared to the control group (12%) without actually increasing clinical outcome at 3 months.

Apparently, an evaluation of a complex multifaceted intervention such as thrombolysis is considered difficult, whereas power to detect a difference in clinical outcome may have been low a priori. The fact that a multitude of interventions was applied introduces considerable potential for dilution of effect. This raises the question whether classical experimental designs are the way forward when the aim is to improve implementation of thrombolysis. Is the result obtained relevant, ie, does it help care providers or policy makers to adopt and implement a new therapy? Or might we consider the gains too limited for the time and money invested? In other words, might other research methodology be warranted?

The acute stroke pathway can be considered as a chain of linked events or actions between which complex interaction occurs. All activities along the chain should be coordinated and planned. The weakest links or bottlenecks may be identified, leading to specific solutions. Industrial engineering yielded simulation-based approaches2 that, in addition to current “trial and error” methodology, likely will contribute to improving implementation. Simulation enables assessing the entirety of the patient pathway without having to already perform a costly clinical experiment. There have been examples of successful implementation of industrial methods for health care issues. For instance, a discrete event simulation model was conducted of the process of stroke care from symptom onset through treatment with intravenous tissue plasminogen activator and it was found that a National Institutes of Neurological Disorders and Stroke-compliant treatment strategy resulted in a higher proportion of patients treated while remaining cost-effective.3 In a different study, combining an experimental design with a simulation model in infant ultrasound screening for developmental dysplasia of the hip led to selection of optimized implementation strategies.4 We advocate that implementation of thrombolytic therapy for acute ischemic stroke may benefit from such an industrial approach. First, it allows investigating the pathway as a whole, thereby offering the opportunity to study links and possible interactions in detail. Second, it could identify barriers or bottlenecks that have the greatest impact on undertreatment and patient outcomes. Third, it could directly assess the result of changes in the process in a time-saving and relatively inexpensive manner.

Applying research methodology such as simulation modeling apparently constitutes a drastic change in the way health care professionals look at a problem. It would appear, however, that such methods immensely increase the chance of efficiently finding a solution to health care problems.

Maarten M.H. Lahr, MSGert-Jan Luijckx, MD, PhDPatrick C.A.J. Vroomen, MD, PhD Department of Neurology University Medical Center Groningen University of Groningen Groningen, the NetherlandsDurk-Jouke van der Zee, MS, PhD Department of Operations Faculty of Economics & Business University of Groningen Groningen, the NetherlandsErik Buskens, MD, PhD Medical Technology Assessment Department of Epidemiology University Medical Center Groningen University of Groningen Groningen, the Netherlands

Sources of Funding

Supported by Netherlands Organization for Health Research and Development (ZonMw; reference 80-82800-98-104).




Stroke welcomes Letters to the Editor and will publish them, if suitable, as space permits. Letters must reference a Stroke published-ahead-of-print article or an article printed within the past 3 weeks. The maximum length is 750 words including no more than 5 references and 3 authors. Please submit letters typed double-spaced. Letters may be shortened or edited. Include a completed copyright transfer agreement form (available online at and


  • 1. Dirks M, Niessen LW, van Wijngaarden JD, Koudstaal PJ, Franke CL, van Oostenbrugge RJ, et al. Promoting thrombolysis in acute ischemic stroke. Stroke. 2011; 42:1325–1330.LinkGoogle Scholar
  • 2. Young T, Brailsford S, Connell C, Davies R, Harper P, Klein JH. Using industrial processes to improve patient care. BMJ. 2004; 328:162–164.CrossrefMedlineGoogle Scholar
  • 3. Stahl JE, Furie KL, Gleason S, Gazelle GS. Stroke: Effect of implementing an evaluation and treatment protocol compliant with NINDS recommendations. Radiology. 2003; 228:659–668.CrossrefMedlineGoogle Scholar
  • 4. Ramwadhdoebe S, Van Merode GG, Boere-Boonekamp MM, Sakkers RJ, Buskens E. Implementation by simulation; strategies for ultrasound screening for hip dysplasia in the Netherlands. BMC Health Serv Res. 2010; 10:75.CrossrefMedlineGoogle Scholar


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