WSO - April 2023 - 470

470
International Journal of Stroke 18(4)
Keywords
tPA, stroke, thrombolysis, children, thrombectomy, acute stroke therapy
Received: 25 March 2022; accepted: 28 August 2022
Introduction
Intravenous thrombolysis (IV-tPA) and mechanical
thrombectomy (MT) are guideline-recommended recanalization
therapies for eligible adults with acute ischemic
stroke (AIS).1 Utilization of both treatment modalities have
increased significantly in adult AIS hospitalizations in the
United States over the past decade,2 but as a result of lack
of clinical trial data, use of these treatments in children has
remained controversial.3 There have been multiple published
case reports on the successful use of IV-tPA and MT
in children but clinical trials have been inconclusive and
how the utilization of these treatments has changed over
time in various age groups of children is not yet known.4,5
The primary aim of this are to (1) evaluate national trends
in the utilization of IV-tPA and MT in AIS in various age
groups of children in the United States over the past decade.
(2) Determine demographic predictors of IV-tPA and MT use
in AIS in children of the United States over the past decade.
Methods
We used data obtained from the 2009 to 2019 KIDS
Inpatient Database (KID) to perform a retrospective serial
cross-sectional study. The KID is the largest all payer pediatric
inpatient care database in the United States. It comprises
a systematic random sample of 10% of uncomplicated
in-hospital births and approximately 80% of other pediatric
cases from each participating hospital. Discharge weights
developed using the American Hospital Association universe
of community, nonrehabilitation hospitals allow for
the calculation of national estimates from the KID. Further
details on the KID are available at https://www.hcup-us.
ahrq.gov/kidoverview.jsp
Data availability
The KID is a publicly accessible datasets that can be obtained
easily from the Health Care Utilization Project (HCUP) after
completion of a mandatory data use agreement.
Study population
All pediatric hospitalizations (1- years) with a primary discharge
diagnosis of AIS were identified from the KID using
International Classification of Diseases (ICD), Ninth
Revision, Clinical Modification (ICD-9-CM) codes 433.
X1, 434.XX, and 436 before the 2016 KID and ICD, Tenth
Revision (ICD-10), Clinical Modification codes in the
range of I63.XX afterward.
International Journal of Stroke, 18(4)
Statistical analysis
We computed the national weighted proportions of IV-tPA
and MT usage in various age groups (1-4, 5-9, 10-14. and
15-17 years). We evaluated for possible linear trend in the
frequency of each outcome over time by constructing a
logistic regression model with each characteristic as the
dependent variable and year of discharge as the independent
Outcome and covariate definition
Patients administered IV-tPA were identified using ICD9-CM
procedure code 99.10 or ICD-10, Clinical
Modification code 3E03317. Patients were also classified
as receiving IV-tPA if they had ICD-9-CM codes V45.88 or
ICD-10, Clinical Modification codes Z92.82 corresponding
to IV-tPA administration within 24 h at an outside facility.
We further reviewed the Medicare Severity DiagnosisRelated
Group in effect at the time of discharge and categorized
hospitalizations under the IV-tPA group if they had
Medicare Severity Diagnosis-Related Group codes in the
range 061-063 (for ischemic stroke with thrombolytic
agents with or without comorbidity/conditions or major
complication/comorbidity). Patients with diagnostic codes
corresponding to MT hospitalizations were identified using
ICD-9-CM procedure codes 39.74 and ICD-10, Clinical
Modification codes 03CG3ZZ, 03CG3Z6, 03CG3Z7,
03CG4Z6, and 03CG4ZZ. In-hospital mortality was
defined using the Health Care Utilization Project variable
" DIED. " Children's hospitals were defined as stand-alone
Children's
General
Hospital
or
Children's
Specialty
Hospital. Hospitals with children's unit in an adult general
hospital were classified as part of nonchildren's hospitals.
These categories were defined using the HCUP variables
" NACHTYPE " = 1-2 or KID_STRATUM = 9999 as recommended
by HCUP. This classification is based on information
provided by the National Association of Children's
Hospital and Related Institutions or the American Hospital
Association Annual Survey. All other covariates were
determined using a constellation of ICD-9-CM and ICD-10
diagnosis or procedural codes highlighted in Supplemental
Table 1.
Standard protocol approvals,
registrations, and patient consents
According to HCUP, utilization of limited data sets such as
the KID in which all direct patient identifiers specified by
the Privacy Rule have been removed, does not require
review by an Institutional Review Board.
https://www.hcup-us.ahrq.gov/kidoverview.jsp https://www.hcup-us.ahrq.gov/kidoverview.jsp
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