TY - JOUR
T1 - Maximising access to thrombectomy services for stroke in England: a modelling study
AU - Allen, Michael
AU - Pearn, Kerry
AU - James, Martin
AU - Ford, Gary
AU - White, Phil
AU - Rudd, Anthony
AU - McMeekin, Peter
AU - Stein, Ken
N1 - Funding Information:
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: GAF has received personal remuneration for educational and consultancy work for Bayer, Cerevast, Medtronic, and Pfizer. GAFs institution has received a grant from Medtronic.
Funding Information:
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was jointly funded by the Stroke Association and the National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula. The views and opinions expressed in this paper are those of the authors, and not necessarily those of the Stroke Association, the NHS, the National Institute for Health Research, or the Department of Health.
Publisher Copyright:
© European Stroke Organisation 2018.
PY - 2019/3/1
Y1 - 2019/3/1
N2 - Purpose: Both intravenous thrombolysis (IVT) and intra-arterial endovascular thrombectomy (ET) improve the outcome of patients with acute ischaemic stroke, with endovascular thrombectomy being an option for those patients with large vessel occlusions. We sought to understand how organisation of services affects time to treatment for both intravenous thrombolysis and endovascular thrombectomy. Method: A multi-objective optimisation approach was used to explore the relationship between the number of intravenous thrombolysis and endovascular thrombectomy centres and times to treatment. The analysis is based on 238,887 emergency stroke admissions in England over 3 years (2013–2015). Results: Providing hyper-acute care only in comprehensive stroke centres (CSC, providing both intravenous thrombolysis and endovascular thrombectomy, and performing >150 endovascular thrombectomy per year, maximum 40 centres) in England would lead to 15% of patients being more than 45 min away from care, and would create centres with up to 4300 stroke admissions/year. Mixing hyper-acute stroke units (providing intravenous thrombolysis only) with comprehensive stroke centres speeds time to intravenous thrombolysis and mitigates admission numbers to comprehensive stroke centres, but at the expense of increasing time to endovascular thrombectomy. With 24 comprehensive stroke centres and all remaining current acute stroke units as hyper-acute stroke units, redirecting patients directly to attend a comprehensive stroke centre by accepting a small delay (15-min maximum) in intravenous thrombolysis reduces time to endovascular thrombectomy: 25% of all patients would be redirected from hyper-acute stroke units to a comprehensive stroke centre, with an average delay in intravenous thrombolysis of 8 min, and an average improvement in time to endovascular thrombectomy of 80 min. The balance of comprehensive stroke centre:hyper-acute stroke unit admissions would change from 24:76 to 49:51. Conclusion: Planning of hyper-acute stroke services is best achieved when considering all forms of acute care and ambulance protocol together. Times to treatment need to be considered alongside manageable and sustainable admission numbers.
AB - Purpose: Both intravenous thrombolysis (IVT) and intra-arterial endovascular thrombectomy (ET) improve the outcome of patients with acute ischaemic stroke, with endovascular thrombectomy being an option for those patients with large vessel occlusions. We sought to understand how organisation of services affects time to treatment for both intravenous thrombolysis and endovascular thrombectomy. Method: A multi-objective optimisation approach was used to explore the relationship between the number of intravenous thrombolysis and endovascular thrombectomy centres and times to treatment. The analysis is based on 238,887 emergency stroke admissions in England over 3 years (2013–2015). Results: Providing hyper-acute care only in comprehensive stroke centres (CSC, providing both intravenous thrombolysis and endovascular thrombectomy, and performing >150 endovascular thrombectomy per year, maximum 40 centres) in England would lead to 15% of patients being more than 45 min away from care, and would create centres with up to 4300 stroke admissions/year. Mixing hyper-acute stroke units (providing intravenous thrombolysis only) with comprehensive stroke centres speeds time to intravenous thrombolysis and mitigates admission numbers to comprehensive stroke centres, but at the expense of increasing time to endovascular thrombectomy. With 24 comprehensive stroke centres and all remaining current acute stroke units as hyper-acute stroke units, redirecting patients directly to attend a comprehensive stroke centre by accepting a small delay (15-min maximum) in intravenous thrombolysis reduces time to endovascular thrombectomy: 25% of all patients would be redirected from hyper-acute stroke units to a comprehensive stroke centre, with an average delay in intravenous thrombolysis of 8 min, and an average improvement in time to endovascular thrombectomy of 80 min. The balance of comprehensive stroke centre:hyper-acute stroke unit admissions would change from 24:76 to 49:51. Conclusion: Planning of hyper-acute stroke services is best achieved when considering all forms of acute care and ambulance protocol together. Times to treatment need to be considered alongside manageable and sustainable admission numbers.
KW - Thrombectomy
KW - health service planning
KW - health services research
KW - stroke
UR - http://www.scopus.com/inward/record.url?scp=85062745779&partnerID=8YFLogxK
U2 - 10.1177/2396987318785421
DO - 10.1177/2396987318785421
M3 - Article
C2 - 31165093
SN - 2396-9873
VL - 4
SP - 39
EP - 49
JO - European Stroke Journal
JF - European Stroke Journal
IS - 1
ER -