Study adds to debate over organization of acute stroke care
Acute ischemic stroke patients undergoing endovascular therapy suffered worse outcomes in some respects if they had transferred from another hospital instead of being admitted directly, according to a study.
In-hospital mortality at thrombectomy centers was not significantly more common among transferred patients after adjusting for treatment delay (14.7% vs 13.4% for direct arrivals, adjusted OR 1.01, 95% CI 0.92-1.11), Get With The Guidelines-Stroke registry data showed.
But transferred patients did have:
- More symptomatic intracranial hemorrhage within 36 hours (7.0% vs 5.7%, adjusted OR 1.15, 95% CI 1.02-1.29)
- Lower odds of independent ambulation at discharge (33.1% vs 37.1%, adjusted OR 0.87, 95% CI 0.80-0.95)
- Less likelihood of being discharged home (24.3% vs 29.1%, adjusted OR 0.82, 95% CI 0.76-0.88)
Given the limited capabilities of current prehospital assessment tools and the fact that certain centers remain unable to provide mechanical thrombectomy, "it would not be feasible to eliminate interhospital transfer entirely," wrote Shreyansh Shah, MD, of Duke University Medical Center in Durham, North Carolina, and colleagues in Circulation.
Instead, they advocated the use of quality improvement programs to improve the workflow of centers not capable of endovascular therapy. Early mobilization of transport crew and the implementation of vascular imaging at the initial hospital are also important, they added.
"Overall, we need to create a system so that the correct patient goes to the correct hospital the first time around. That is the single biggest need that we have for the whole organization of acute stroke care," commented Mayank Goyal, MD, of the University of Calgary, Alberta, who was not involved in the project.
One problem is the lack of a centralized ambulance system in the U.S. that makes ambulances incapable of acting in a cohesive way -- for example, in deciding that a patient with severe stroke should be taken to the comprehensive stroke center, Goyal said in an interview.
There is no one-size-fits-all solution that would work everywhere in the U.S., however.
"You have to think at the level of geography. In New York City, if you're in a 5- or 8-mile radius of the NYU campus, there's absolutely no need for another center. Every stroke should go there," Goyal said. "If you're in Montana or upstate New York, you have to think differently."
If primary stroke centers keep creating endovascular therapy services, Goyal suggested what will happen is low volumes everywhere.
And it's too simplistic to think that a minimum volume requirement will fix the problem, he emphasized. Variables including the "number of interventionists, their experience, what is their practice like when they are not dealing with stroke, and what other options are available to the population" must be considered, he argued.
According to Shah and colleagues, transferred patients waited more than an hour longer to start thrombectomy (median time since last known well to endovascular therapy initiation 289 min vs 213 min, P<0.0001), suggestive of a delay in transit time, the authors said.
On the other hand, door-to-endovascular therapy initiation times were in the favor of this group (68.0 vs 128.0 min, P<0.0001). "This may reflect the benefit of pre-notification at the endovascular therapy center, enabling teams to prepare prior to the patient's arrival," Shah's group said.
The Get With The Guidelines-Stroke registry counted more than 1.8 million stroke patients admitted from 2012 to 2017, of whom 37,160 had endovascular therapy at 639 hospitals.
Shah and colleagues found that 42.9% of those had been transferred to the endovascular stroke center from another hospital. Interhospital transfers increased sharply starting at the end of 2014 (ultimately rising from 256 in the beginning of 2012 to 1,422 at the end of 2017).
Transferred patients were younger and more likely to be white compared to direct arrivals. They also had higher odds of treatment at teaching hospitals and Joint Commission-certified comprehensive stroke centers.
The study authors acknowledged the limited generalizability of their findings to hospitals not participating in the registry. Their risk adjustment for baseline stroke severity may also have been affected by en-route thrombolytics.
Moreover, the study did not account for late thrombectomy, which emerged in 2018's DEFUSE 3 and DAWN trials as beneficial to patients even 16-24 hours after stroke onset.
The study was funded by a grant from the American Heart Association/American Stroke Association.
Shah disclosed no conflicts of interest.
Source Reference: Shah S, et al "Use, temporal trends, and outcomes of endovascular therapy after interhospital transfer in the United States" Circulation 2019; DOI: 10.1161/CIRCULATIONAHA.118.036509.
Read the original article on Medpage Today: At Thrombectomy Centers, Worse Outcomes for Patients Transferred In