Effect of Interhospital Transfer on Endovascular Treatment for Acute Ischemic Stroke

Venema, Esmée; Groot, Adrien E.; Lingsma, Hester F.; Hinsenveld, Wouter H.; Treurniet, Kilian M.; Chalos, Vicky; Zinkstok, Sanne M.; Mulder, Maxim J.H.L.; Ridder, Inger R. de; Marquering, Henk A.; Schonewille, Wouter J.; Wermer, Marieke J.H.; Majoie, Charles B. L. M.; Roos, Yvo B.W.E.M.; Dippel, Diederik W.J.; Coutinho, Jonathan M.; Roozenbeek, Bob

doi:10.1161/strokeaha.118.024091

Cited by 101 publications

(105 citation statements)

References 28 publications

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“…[29][30][31][32][33][34][35][36] Direct transportation to intervention centers may be preferable to interhospital transfers, which can be associated with delays in treatment and worse outcomes. 23,[37][38][39] The designation of additional endovascular centers in underserved areas may be part of the solution, although it may be challenging to maintain a roster of staff and neurocritical care services in such areas, and one Korean study found that outcomes were worse at small-volume compared to large-volume sites. 40 Finally, allowing patients to seek care across provincial boundaries may reduce travel time to stroke care services.…”

Section: Discussionmentioning

confidence: 99%

Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada

Kapral

Hall

Gozdyra³

et al. 2020

Can. J. Neurol. Sci.

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ABSTRACT:Background:Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada.Methods:We used the Ontario Road Network File database linked with the 2016 Ontario Acute Stroke Care Resource Inventory to estimate the proportion of people in rural communities, defined as those with a population size <10,000, who were within 30, 60, and 240 minutes of travel time by car from stroke care services, including brain imaging, thrombolysis treatment centers, stroke units, stroke prevention clinics, inpatient rehabilitation facilities, and endovascular treatment centers.Results:Of the 1,496,262 people residing in rural communities, the majority resided within 60 minutes of driving time to a center with computed tomography (85%), thrombolysis (81%), a stroke unit (68%), a stroke prevention clinic (74%), or inpatient rehabilitation (77.0%), but a much lower proportion (32%) were within 60 minutes of driving time to a center capable of providing endovascular thrombectomy (EVT).Conclusions:Most rural Ontario residents have appropriate geographic access to stroke services, with the exception of EVT. This information may be useful for jurisdictions seeking to optimize the regional organization of stroke care services.

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Section: Discussionmentioning

confidence: 99%

Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada

Kapral

Hall

Gozdyra³

et al. 2020

Can. J. Neurol. Sci.

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“…An Australian study based in Victoria found no difference in 90-day functional outcomes between transferred and direct to CSC presenters undergoing EVT9; however, international registries have demonstrated poorer outcomes in transferred patients 10–12. New South Wales and other Australian states have different geographical challenges from Victoria.…”

Section: Introductionmentioning

confidence: 99%

Impact of interhospital transfer on patients undergoing endovascular thrombectomy for acute ischaemic stroke in an Australian setting

Edwards

Blair²,

Cordato³

et al. 2020

BMJ Neurol Open

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ObjectiveTo assess the impact of interhospital transfer on the interplay between functional outcome, mortality, reperfusion rates and workflow time metrics in patients undergoing endovascular thrombectomy (EVT) for acute ischaemic stroke due to large vessel occlusion (LVO) in the anterior cerebral circulation.Design, setting and participantsThis is an analysis of a prospective database of consecutive patients undergoing EVT for LVO presenting between January 2017 and December 2018 at a single Australian comprehensive stroke centre (CSC). Patients presented directly or were transferred to the CSC from 21 sites across New South Wales and the Australian Capital Territory.Main outcome measuresThe main outcome measures were rate of good 90-day functional outcome (modified Rankin Scale 0–2), successful reperfusion (Thrombolysis in Cerebral Infarction scale grade 2b or 3), symptomatic intracerebral haemorrhage (sICH) and 90-day mortality. Key workflow time metric milestones were examined.Results154 of 213 (72%) patients were interhospital transfers. There was no significant difference in baseline characteristics including age, National Institutes of Health Stroke Scale score, intravenous thrombolysis administration or procedure time between transferred and direct presenters (all p>0.05). Transferred patients had worse 90-day functional outcome (39.6% vs 61.0%, OR 0.42, 95% CI 0.23 to 0.78), higher mortality (25.3% vs 6.8%, OR 4.66, CI 1.59 to 13.70) and longer stroke onset to treatment (groin puncture) time (298 min vs 205 min, p<0.01). Successful reperfusion rates and sICH were similar between the cohorts (96.8% vs 98.3%, and 7.8% vs 3.4%).ConclusionInterhospital transfer is associated with longer stroke onset to treatment, worse 90-day functional outcome and higher mortality compared with patients presenting directly to the CSC.

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“…Previous post hoc analyses of prospective cohort studies have shown that for patients with an LVO of the anterior circulation, in general, it is beneficial to be directly presented to a CSC, as opposed to being transferred from a PSC. Venema et al, who also used data from the MR CLEAN Registry (part I), found that patients directly presented to a CSC had a 40-min shorter OGT and a 57-min shorter FDGT than transferred patients [3]. The authors also found a negative effect of inter-hospital transfer on the likelihood of functioning independently at 90 days post-stroke (OR: 0.69, 95% CI 0.54-0.89).…”

Section: Discussionmentioning

confidence: 99%

“…Patients who are eligible for EVT are subsequently transferred to a comprehensive stroke center (CSC). Studies show that this 'dripand-ship' system delays initiation of EVT by 40-106 min and decreases the chance of a good clinical outcome by approximately 10% [3][4][5]. Despite this clear disadvantage, the 'drip-and-ship' system is currently the most feasible, because accurately diagnosing an LVO in the prehospital setting is challenging.…”

Section: Introductionmentioning

confidence: 99%

Interhospital transfer vs. direct presentation of patients with a large vessel occlusion not eligible for IV thrombolysis

et al. 2020

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Background and purpose Direct presentation of patients with acute ischemic stroke to a comprehensive stroke center (CSC) reduces time to endovascular treatment (EVT), but may increase time to treatment for intravenous thrombolysis (IVT). This dilemma, however, is not applicable to patients who have a contraindication for IVT. We examined the effect of direct presentation to a CSC on outcomes after EVT in patients not eligible for IVT. Methods We used data from the MR CLEAN Registry (2014-2017). We included patients who were not treated with IVT and compared patients directly presented to a CSC to patients transferred from a primary stroke center. Outcomes included treatment times and 90-day modified Rankin Scale scores (mRS) adjusted for potential confounders. Results Of the 3637 patients, 680 (19%) did not receive IVT and were included in the analyses. Of these, 389 (57%) were directly presented to a CSC. The most common contraindications for IVT were anticoagulation use (49%) and presentation > 4.5 h after onset (26%). Directly presented patients had lower baseline NIHSS scores (median 16 vs. 17, p = 0.015), higher onset-to-first-door times (median 105 vs. 66 min, p < 0.001), lower first-door-to-groin times (median 93 vs. 150 min; adjusted β = − 51.6, 95% CI: − 64.0 to − 39.2) and lower onset-to-groin times (median 220 vs. 230 min; adjusted β = − 44.0, 95% CI: − 65.5 to − 22.4). The 90-day mRS score did not differ between groups (adjusted OR: 1.23, 95% CI: 0.73-2.08). Conclusions In patients who were not eligible for IVT, treatment times for EVT were better for patients directly presented to a CSC, but without a statistically significant effect on clinical outcome.

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Effect of Interhospital Transfer on Endovascular Treatment for Acute Ischemic Stroke

Abstract: Supplemental Digital Content is available in the text.

Cited by 101 publications

References 28 publications

Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada

Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada

Impact of interhospital transfer on patients undergoing endovascular thrombectomy for acute ischaemic stroke in an Australian setting

Interhospital transfer vs. direct presentation of patients with a large vessel occlusion not eligible for IV thrombolysis

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