Use, Temporal Trends, and Outcomes of Endovascular Therapy After Interhospital Transfer in the United States

Abstract

BACKGROUND: The use of endovascular therapy (EVT) in acute ischemic stroke patients with large vessel occlusion (LVO) has rapidly increased in the US following pivotal trials demonstrating its benefit. Information about the contribution of interhospital transfer in improving access to EVT will help organize regional systems of stroke care. METHODS: We analyzed trends of transfer-in EVT from a cohort of 1,863,693 ischemic stroke patients admitted to 2,143 Get With The Guidelines-Stroke participating hospitals between January 2012 and December 2017. We further examined the association between arrival mode and in-hospital outcomes using multivariable logistic regression models. RESULTS: Of the 37,260 patients who received EVT at 639 hospitals during the study period, 42.9% (15,975) arrived to the EVT providing hospital after interhospital transfer. Transfer-in EVT cases increased from 256 in Q1 2012 to 1,422 in Q4 2017, with sharply accelerated increases following Q4 2014 (p<0.001 for change in linear trend). Transfer-in patients were younger, more likely to be of white race, arrive during off-hours and treated at comprehensive stroke centers. Transfer-in patients had significantly longer last known well to EVT initiation time (median 289 min vs 213 min, absolute standardized difference 67.33) but were more likely to have door to EVT initiation time of ≤ 90 minutes (65.6% vs 23.6%, absolute standardized difference 93.18). Inhospital outcomes were worse for transfer-in EVT patients in unadjusted and in risk-adjusted

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

“…Transferred patients had significantly longer stroke onset to groin puncture and reperfusion times, a finding also reported by international studies 10–12 17. In the present study, interhospital transfer was associated with delays in workflow, including increased times from CT to contact of and acceptance by the CSC.…”

Safety of inter-hospital transfer of patients with acute ischemic stroke for evaluation of endovascular thrombectomy

“…Collaborative stroke and telestroke networks can increase the number of patients with LVO who are evaluated for EVT 4,5 . However, this is at the cost of significant treatment delay due to initial evaluation in a remote hospital and subsequent secondary transfer, often preventing EVT in a large proportion of patients 11,16,20,21 . Nevertheless, considering the necessary facilities, expertise and maintenance costs linked to EVT, a ubiquitous distribution of EVT capacity seems to be unrealistic especially in rural areas 5 .…”

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

“…[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.…”