Eric E Smith1, Jeffrey L Saver2, Margueritte Cox3, Li Liang3, Roland Matsouaka4, Ying Xian3, Deepak L Bhatt5, Gregg C Fonarow2, Lee H Schwamm6. 1. Calgary Stroke Program, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Canada (E.E.S.). eesmith@ucalgary.ca. 2. Department of Neurology (J.L.S.) and Division of Cardiology (G.C.F.). 3. University of California, Los Angeles. Duke Clinical Research Institute (M.C., L.L., Y.X.). 4. Department of Biostatistics and Bioinformatics (R.M.). 5. Duke University, Durham, NC. Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA (D.L.B.). 6. Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.).
Abstract
BACKGROUND: Beginning in December 2014, a series of pivotal trials showed that endovascular thrombectomy (EVT) was highly effective, prompting calls to reorganize stroke systems of care. However, there are few data on how these trials influenced the frequency of EVT in clinical practice. We used data from the Get With The Guidelines-Stroke program to determine how the frequency of EVT changed in US practice. METHODS: We analyzed prospectively collected data from a cohort of 2 437 975 patients with ischemic stroke admitted to 2222 participating hospitals between April 2003 and the third quarter of 2016. Weighted linear regression with 2 linear splines and a knot at January 2015 was used to compare the slope of the change in EVT use before and after the pivotal trials were published. Potentially eligible patients were defined as last known well to arrival time ≤4.5 hours and National Institutes of Health Stroke Scale score ≥6. RESULTS: The frequency of EVT use was slowly increasing before January 2015 but then sharply accelerated thereafter. In the third quarter 2016, EVT was provided to 3.3% of all patients with ischemic stroke at all hospitals, representing 15.1% of all patients who were potentially eligible for EVT based on stroke duration and severity. At EVT-capable hospitals, 7.5% of all patients with ischemic stroke were treated in the third quarter of 2016, including 27.3% of the potentially eligible patients. From 2013 to 2016, case volumes nearly doubled at EVT-capable hospitals. Mean case volume per EVT-capable hospital was 37.6 per year in the last 4 quarters. EVT case volumes increased in nearly all US states from 2014 to the last 4 quarters, but with persistent geographic variation unexplained by differences in potential patient eligibility. CONCLUSIONS: EVT use is increasing rapidly; however, there are still opportunities to treat more patients. Reorganizing stroke systems to route patients to adequately resourced EVT-capable hospitals might increase treatment of eligible patients, improve outcomes, and reduce disparities.
BACKGROUND: Beginning in December 2014, a series of pivotal trials showed that endovascular thrombectomy (EVT) was highly effective, prompting calls to reorganize stroke systems of care. However, there are few data on how these trials influenced the frequency of EVT in clinical practice. We used data from the Get With The Guidelines-Stroke program to determine how the frequency of EVT changed in US practice. METHODS: We analyzed prospectively collected data from a cohort of 2 437 975 patients with ischemic stroke admitted to 2222 participating hospitals between April 2003 and the third quarter of 2016. Weighted linear regression with 2 linear splines and a knot at January 2015 was used to compare the slope of the change in EVT use before and after the pivotal trials were published. Potentially eligible patients were defined as last known well to arrival time ≤4.5 hours and National Institutes of Health Stroke Scale score ≥6. RESULTS: The frequency of EVT use was slowly increasing before January 2015 but then sharply accelerated thereafter. In the third quarter 2016, EVT was provided to 3.3% of all patients with ischemic stroke at all hospitals, representing 15.1% of all patients who were potentially eligible for EVT based on stroke duration and severity. At EVT-capable hospitals, 7.5% of all patients with ischemic stroke were treated in the third quarter of 2016, including 27.3% of the potentially eligible patients. From 2013 to 2016, case volumes nearly doubled at EVT-capable hospitals. Mean case volume per EVT-capable hospital was 37.6 per year in the last 4 quarters. EVT case volumes increased in nearly all US states from 2014 to the last 4 quarters, but with persistent geographic variation unexplained by differences in potential patient eligibility. CONCLUSIONS:EVT use is increasing rapidly; however, there are still opportunities to treat more patients. Reorganizing stroke systems to route patients to adequately resourced EVT-capable hospitals might increase treatment of eligible patients, improve outcomes, and reduce disparities.
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