Stroke Center Designations, Neurointerventionalist Demand, and the Finances of Stroke Thrombectomy in the United States

Abstract

Purpose of the ReviewThis article aims to provide an update on the designation of stroke centers, neurointerventionalist demand, and cost-effectiveness of stroke thrombectomy in the United States.Recent FindingsThere are now more than 1,660 stroke centers certified by national accrediting bodies in the United States, 306 of which are designated as thrombectomy-capable or comprehensive stroke centers. Considering the amount of nationally certified centers and the number of patients with acute stroke eligible for thrombectomy, each center would be responsible for 64 to 104 thrombectomies per year. As a result, there is a growing demand placed on neurointerventionalists, who have the ability to alter the trajectory of large vessel occlusive strokes. Numbers needed to achieve functional independence after stroke thrombectomy at 90 days range from 3.2 to 7.4 patients in the early time window and 2.8 to 3.6 patients in the extended time window in appropriately selected candidates. With the low number needed to treat, in a variety of valued-based calculations and cost-effectiveness analyses, stroke thrombectomy has proved to be both clinically effective and cost-effective.SummaryAdvancements in the early recognition and treatment of stroke have been paralleled by a remodeling of health care systems to ensure best practices in a timely manner. Stroke center–accrediting bodies provide oversight to safeguard these standards. As successful trial data from high volume centers transform into real-world experience, we must continue to re-evaluate cost-effectiveness, strike a balance between sufficient case volumes to maintain clinical excellence vs the burden and burnout associated with call responsibilities, and improve access to care for all.

Transferring neurointerventionalists saves time compared with interhospital transfer of stroke patients for endovascular thrombectomy: a collaborative pooled analysis of 1001 patients (EVEREST)

“…The triage of stroke patients with large vessel occlusion has been of increasing interest in recent years 12. It is well established that the transfer of stroke patients from primary stroke centers to a CSC is time consuming, given the required coordination of interhospital transport and patient preparation for the transfer 6 17 21 24–27.…”

“…Further concerns have been raised regarding the EXT concept 12 28. Not every primary stroke center is qualified to be a TSC.…”

“…They only lack a team of neurointerventionalists. Indeed, there is a lack of neurointerventionalists in acute stroke care, as reported by Bulwa and Chen 12…”

Workflows and Outcomes in Patients With Suspected Large Vessel Occlusion Stroke Triaged in Urban and Nonurban Areas

“…Moreover, a multifaceted quality improvement intervention for streamlining acute stroke care in undeveloped stroke systems of care is essential for undeveloped stroke systems of care to reduce disparities. 39,40 Promising strategies that could be implemented in remote areas include the deployment of an intervention team to the local stroke center to reduce the delay associated with interhospital transfers, 41,42 the implementation of mobile stroke units in remote areas densely populated, 43,44 or different protocols in local stroke centers to reduce the time from hospital arrival to intravenous thrombolysis administration and interhospital transfers. 45 The main barrier in prehospital stroke research is that interventions in a regional stroke system of care might not be generalizable to other regions.…”

Society of NeuroInterventional Surgery: position statement on pregnancy and parental leave for physicians practicing neurointerventional surgery

“…In a recent survey published in 2019, 49.9% of respondents reported call frequency to be every day or every other day 6. Although highly dependent on population density and other factors, one study estimated an average thrombectomy frequency every 4 days 7. Scheduling flexibility is recommended given the numerous prenatal appointments as well as physical demands of pregnancy and childbirth in an era of increasing volume of acute ischemic stroke cases and concomitantly increasing on-call burden of professional clinical responsibilities.…”