BACKGROUND AND PURPOSE: The optimal endovascular stroke therapy (EVT) care delivery structure is unknown. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards. METHODS: We identified all consecutive patients with large vessel occlusion acute ischemic stroke treated with EVT from January 2014 to February 2019 in our health care system. In October 2017, we implemented the ISS, in which 3 additional hospitals (4 total) became EVT-performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the Southeast Texas Regional Advisory Council. RESULTS: Among 513 patients with large vessel occlusion acute ischemic stroke treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the 3 new EPHs (<70 EVT/y). After ISS, the proportion of patients who underwent interhospital transfer decreased (46% versus 37%; P<0.05). In adjusted quantile regression, ISS implementation resulted in a reduction of time from stroke onset to EPH arrival by 40 minutes (P<0.01) and onset to groin puncture by 29 minutes (P<0.05). Rates of postprocedural hemorrhage, modified Thrombolysis in Cerebral Infarction (TICI) 2b/3, and 90-day modified Rankin Scale were comparable at the higher and lower volume EPHs. The improvement in onset-to-arrival time was not reflective of overall improvement in secular trends in regional prehospital care. CONCLUSIONS: In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.
BACKGROUND AND PURPOSE: The optimal endovascular stroke therapy (EVT) care delivery structure is unknown. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards. METHODS: We identified all consecutive patients with large vessel occlusion acute ischemic stroke treated with EVT from January 2014 to February 2019 in our health care system. In October 2017, we implemented the ISS, in which 3 additional hospitals (4 total) became EVT-performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the Southeast Texas Regional Advisory Council. RESULTS: Among 513 patients with large vessel occlusion acute ischemic stroke treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the 3 new EPHs (<70 EVT/y). After ISS, the proportion of patients who underwent interhospital transfer decreased (46% versus 37%; P<0.05). In adjusted quantile regression, ISS implementation resulted in a reduction of time from stroke onset to EPH arrival by 40 minutes (P<0.01) and onset to groin puncture by 29 minutes (P<0.05). Rates of postprocedural hemorrhage, modified Thrombolysis in Cerebral Infarction (TICI) 2b/3, and 90-day modified Rankin Scale were comparable at the higher and lower volume EPHs. The improvement in onset-to-arrival time was not reflective of overall improvement in secular trends in regional prehospital care. CONCLUSIONS: In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.
Entities:
Keywords:
acute ischemic stroke; endovascular techniques; health care delivery; health occupations manpower; integrated delivery systems
Authors: Paul A Harris; Robert Taylor; Robert Thielke; Jonathon Payne; Nathaniel Gonzalez; Jose G Conde Journal: J Biomed Inform Date: 2008-09-30 Impact factor: 6.317
Authors: Maxim Mokin; Rishi Gupta; Waldo R Guerrero; David Z Rose; William S Burgin; Sananthan Sivakanthan Journal: J Neurointerv Surg Date: 2016-04-22 Impact factor: 5.836
Authors: Gregory W Albers; Michael P Marks; Stephanie Kemp; Soren Christensen; Jenny P Tsai; Santiago Ortega-Gutierrez; Ryan A McTaggart; Michel T Torbey; May Kim-Tenser; Thabele Leslie-Mazwi; Amrou Sarraj; Scott E Kasner; Sameer A Ansari; Sharon D Yeatts; Scott Hamilton; Michael Mlynash; Jeremy J Heit; Greg Zaharchuk; Sun Kim; Janice Carrozzella; Yuko Y Palesch; Andrew M Demchuk; Roland Bammer; Philip W Lavori; Joseph P Broderick; Maarten G Lansberg Journal: N Engl J Med Date: 2018-01-24 Impact factor: 91.245
Authors: Raul G Nogueira; Ashutosh P Jadhav; Diogo C Haussen; Alain Bonafe; Ronald F Budzik; Parita Bhuva; Dileep R Yavagal; Marc Ribo; Christophe Cognard; Ricardo A Hanel; Cathy A Sila; Ameer E Hassan; Monica Millan; Elad I Levy; Peter Mitchell; Michael Chen; Joey D English; Qaisar A Shah; Frank L Silver; Vitor M Pereira; Brijesh P Mehta; Blaise W Baxter; Michael G Abraham; Pedro Cardona; Erol Veznedaroglu; Frank R Hellinger; Lei Feng; Jawad F Kirmani; Demetrius K Lopes; Brian T Jankowitz; Michael R Frankel; Vincent Costalat; Nirav A Vora; Albert J Yoo; Amer M Malik; Anthony J Furlan; Marta Rubiera; Amin Aghaebrahim; Jean-Marc Olivot; Wondwossen G Tekle; Ryan Shields; Todd Graves; Roger J Lewis; Wade S Smith; David S Liebeskind; Jeffrey L Saver; Tudor G Jovin Journal: N Engl J Med Date: 2017-11-11 Impact factor: 91.245
Authors: Arthur L Day; Adnan H Siddiqui; Philip M Meyers; Tudor G Jovin; Colin P Derdeyn; Brian L Hoh; Howard Riina; Italo Linfante; Osama Zaidat; Aquilla Turk; Jay U Howington; J Mocco; Andrew J Ringer; Erol Veznedaroglu; Alexander A Khalessi; Elad I Levy; Henry Woo; Robert Harbaugh; Steven Giannotta Journal: Stroke Date: 2017-07-13 Impact factor: 7.914
Authors: Paul A Harris; Robert Taylor; Brenda L Minor; Veida Elliott; Michelle Fernandez; Lindsay O'Neal; Laura McLeod; Giovanni Delacqua; Francesco Delacqua; Jacqueline Kirby; Stephany N Duda Journal: J Biomed Inform Date: 2019-05-09 Impact factor: 6.317
Authors: Tudor G Jovin; Angel Chamorro; Erik Cobo; María A de Miquel; Carlos A Molina; Alex Rovira; Luis San Román; Joaquín Serena; Sonia Abilleira; Marc Ribó; Mònica Millán; Xabier Urra; Pere Cardona; Elena López-Cancio; Alejandro Tomasello; Carlos Castaño; Jordi Blasco; Lucía Aja; Laura Dorado; Helena Quesada; Marta Rubiera; María Hernandez-Pérez; Mayank Goyal; Andrew M Demchuk; Rüdiger von Kummer; Miquel Gallofré; Antoni Dávalos Journal: N Engl J Med Date: 2015-04-17 Impact factor: 91.245
Authors: Hamidreza Saber; Babak B Navi; James C Grotta; Hooman Kamel; Arvind Bambhroliya; Farhaan S Vahidy; Peng Roc Chen; Spiros Blackburn; Sean I Savitz; Louise McCullough; Sunil A Sheth Journal: Stroke Date: 2019-03 Impact factor: 7.914
Authors: Bruce C V Campbell; Michael D Hill; Marta Rubiera; Bijoy K Menon; Andrew Demchuk; Geoffrey A Donnan; Daniel Roy; John Thornton; Laura Dorado; Alain Bonafe; Elad I Levy; Hans-Christoph Diener; María Hernández-Pérez; Vitor Mendes Pereira; Jordi Blasco; Helena Quesada; Jeremy Rempel; Reza Jahan; Stephen M Davis; Bruce C Stouch; Peter J Mitchell; Tudor G Jovin; Jeffrey L Saver; Mayank Goyal Journal: Stroke Date: 2016-03 Impact factor: 7.914