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Ennab Vogel N, Wester P, Andersson Granberg T, Levin LÅ. Optimized density and locations of stroke centers for improved cost effectiveness of mechanical thrombectomy in patients with acute ischemic stroke. J Neurointerv Surg 2024; 16:156-162. [PMID: 37072170 PMCID: PMC10850679 DOI: 10.1136/jnis-2023-020299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/02/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND Despite the proven cost effectiveness of mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion, treatment within 6 hours from symptom onset remains inaccessible for many patients. We aimed to find the optimal number and location of treatment facilities with respect to the cost effectiveness of MT in patients with AIS, first by the most cost effective implementation of comprehensive stroke centers (CSCs), and second by the most cost effective addition of complementary thrombectomy capable stroke centers (TSCs). METHODS This study was based on nationwide observational data comprising 18 793 patients with suspected AIS potentially eligible for treatment with MT. The most cost effective solutions were attained by solving the p median facility location-allocation problem with the objective function of maximizing the incremental net monetary benefit (INMB) of MT compared with no MT in patients with AIS. Deterministic sensitivity analysis (DSA) was used as the basis of the results analysis. RESULTS The implementation strategy with seven CSCs produced the highest annual INMB per patient of all possible solutions in the base case scenario. The most cost effective implementation strategy of the extended scenario comprised seven CSCs and four TSCs. DSA revealed sensitivity to variability in MT rate and the maximum willingness to pay per quality adjusted life year gained. CONCLUSION The combination of optimization modeling and cost effectiveness analysis provides a powerful tool for configuring the extent and locations of CSCs (and TSCs). The most cost effective implementation of CSCs in Sweden entails 24/7 MT services at all seven university hospitals.
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Affiliation(s)
- Nicklas Ennab Vogel
- Department of Health, Medicine, and Caring Sciences, Linkoping University Faculty of Medicine, Linkoping, Sweden
| | - Per Wester
- Department of Public Health and Clinical Science, Umeå University, Umeå, Sweden
- Department of Clinical Science, Karolinska Institute Danderyds Hospital, Stockholm, Sweden
| | - Tobias Andersson Granberg
- Communications and Transport Systems, Linköping University Department of Science and Technology, Norrköping, Sweden
| | - Lars-Åke Levin
- Department of Health, Medicine, and Caring Sciences, Linkoping University Faculty of Medicine, Linkoping, Sweden
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Schuler FAF, Ribó M, Dequatre‐Ponchelle N, Rémi J, Dobrocky T, Goeldlin MB, Gralla J, Kaesmacher J, Meinel TR, Mordasini P, Seiffge DJ, Fischer U, Arnold M, Kägi G, Jung S. Geographical Requirements for the Applicability of the Results of the RACECAT Study to Other Stroke Networks. J Am Heart Assoc 2023; 12:e029965. [PMID: 37830330 PMCID: PMC10757535 DOI: 10.1161/jaha.123.029965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 08/11/2023] [Indexed: 10/14/2023]
Abstract
Background The RACECAT (Transfer to the Closest Local Stroke Center vs Direct Transfer to Endovascular Stroke Center of Acute Stroke Patients With Suspected Large Vessel Occlusion in the Catalan Territory) trial was the first randomized trial addressing the prehospital triage of acute stroke patients based on the distribution of thrombolysis centers and intervention centers in Catalonia, Spain. The study compared the drip-and-ship with the mothership paradigm in regions where a local thrombolysis center can be reached faster than the nearest intervention center (equipoise region). The present study aims to determine the population-based applicability of the results of the RACECAT study to 4 stroke networks with a different degree of clustering of the intervention centers (clustered, dispersed). Methods and Results Stroke networks were compared with regard to transport time saved for thrombolysis (under the drip-and-ship approach) and transport time saved for endovascular therapy (under the mothership approach). Population-based transport times were modeled with a local instance of an openrouteservice server using open data from OpenStreetMap.The fraction of the population in the equipoise region differed substantially between clustered networks (Catalonia, 63.4%; France North, 87.7%) and dispersed networks (Southwest Bavaria, 40.1%; Switzerland, 40.0%). Transport time savings for thrombolysis under the drip-and-ship approach were more marked in clustered networks (Catalonia, 29 minutes; France North, 27 minutes) than in dispersed networks (Southwest Bavaria and Switzerland, both 18 minutes). Conclusions Infrastructure differences between stroke networks may hamper the applicability of the results of the RACECAT study to other stroke networks with a different distribution of intervention centers. Stroke networks should assess the population densities and hospital type/distribution in the temporal domain before applying prehospital triage algorithms to their specific setting.
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Affiliation(s)
- Florian A. F. Schuler
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Marc Ribó
- Stroke Unit, Department of NeurologyVall d’Hebron University HospitalBarcelonaSpain
| | | | - Jan Rémi
- Department of NeurologyUniversity Hospital, Ludwig‐Maximilians‐UniversityMunichGermany
| | - Tomas Dobrocky
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Martina B. Goeldlin
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
| | - Thomas R. Meinel
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University HospitalUniversity of BernSwitzerland
- Network RadiologyKantonsspital St. GallenSt. GallenSwitzerland
| | - David J. Seiffge
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Urs Fischer
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyUniversity Hospital Basel, University of BaselSwitzerland
| | - Marcel Arnold
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
| | - Georg Kägi
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
- Department of NeurologyKantonsspital St. GallenSt. GallenSwitzerland
| | - Simon Jung
- Department of NeurologyInselspital, Bern University Hospital, University of BernSwitzerland
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3
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Simister R, Black GB, Melnychuk M, Ramsay AIG, Baim-Lance A, Cohen DL, Eng J, Xanthopoulou PD, Brown MM, Rudd AG, Morris S, Fulop NJ. Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units.
Objectives
To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations.
Design
This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data.
Setting
The setting was acute stroke services in London hyperacute stroke units.
Participants
A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours).
Intervention
Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week.
Main outcome measures
Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay.
Data sources
Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period.
Results
We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions.
Limitations
We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled.
Conclusions
Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence.
Future work
Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 34. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Robert Simister
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Georgia B Black
- Department of Applied Health Research, University College London, London, UK
| | - Mariya Melnychuk
- Department of Applied Health Research, University College London, London, UK
| | - Angus IG Ramsay
- Department of Applied Health Research, University College London, London, UK
| | - Abigail Baim-Lance
- Center for Innovation in Mental Health, City University of New York, New York, NY, USA
| | - David L Cohen
- Stroke Service, Haldane and Herrick Wards, Northwick Park Hospital, London, UK
| | - Jeannie Eng
- Cancer Division, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Martin M Brown
- Queen Square Institute of Neurology, University College London, London, UK
| | - Anthony G Rudd
- King’s College London and Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Steve Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
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Allen M, Villeneuve E, Pitt M, Thornton S. How can consultant-led childbirth care at time of delivery be maximised? A modelling study. BMJ Open 2020; 10:e034830. [PMID: 32641323 PMCID: PMC7348651 DOI: 10.1136/bmjopen-2019-034830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE The Royal College of Obstetricians and Gynaecologists has advised that consolidation of birth centres, where reasonable, into birth centres of at least 6000 admissions per year should allow constant consultant presence. Currently, only 17% of mothers attend such birth centres. The objective of this work was to examine the feasibility of consolidation of birth centres, from the perspectives of birth centre size and travel times for mothers. DESIGN Computer-based optimisation. SETTING Hospital-based births. POPULATION OR SAMPLE 1.91 million admissions in 2014-2016. METHODS A multiple-objective genetic algorithm. MAIN OUTCOME MEASURES Travel time for mothers and size of birth centres. RESULTS Currently, with 161 birth centres, 17% of women attend a birth centre with at least 6000 admissions per year. We estimate that 95% of women have a travel time of 30 min or less. An example scenario, with 100 birth centres, could provide 75% of care in birth centres with at least 6000 admissions per year, with 95% of women travelling 35 min or less to their closest birth centre. Planning at local level leads to reduced ability to meet admission and travel time targets. CONCLUSIONS While it seems unrealistic to have all births in birth centres with at least 6000 admissions per year, it appears realistic to increase the percentage of mothers attending this type of birth centre from 17% to about 75% while maintaining reasonable travel times. Planning at a local level leads to suboptimal solutions.
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Affiliation(s)
- Michael Allen
- Medical School, University of Exeter, Exeter, United Kingdom
| | - Emma Villeneuve
- Medical School, University of Exeter, Exeter, United Kingdom
| | - Martin Pitt
- Medical School, University of Exeter, Exeter, United Kingdom
| | - Steve Thornton
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, United Kingdom
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5
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Clare CS. Role of the nurse in acute stroke care. Nurs Stand 2020; 35:68-75. [PMID: 32227723 DOI: 10.7748/ns.2020.e11482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2020] [Indexed: 11/09/2022]
Abstract
The recognition of stroke as a medical emergency, provision of specialist services and advances in treatments have contributed to a decrease in stroke-related mortality, but the incidence and burden of stroke continue to rise. A stroke is a life-threatening and life-limiting event, but prompt identification and early treatment can reduce mortality and disability, and enhance the recovery and rehabilitation potential of survivors. Nurses working in acute stroke services have a wide-ranging role that includes assessment, identification and monitoring, as well as rehabilitation, psychological support and end of life care. This article provides an overview of the diagnosis and management of strokes and transient ischaemic attacks, and describes the role of nurses in acute stroke care.
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Melnychuk M, Morris S, Black G, Ramsay AIG, Eng J, Rudd A, Baim-Lance A, Brown MM, Fulop NJ, Simister R. Variation in quality of acute stroke care by day and time of admission: prospective cohort study of weekday and weekend centralised hyperacute stroke unit care and non-centralised services. BMJ Open 2019; 9:e025366. [PMID: 31699710 PMCID: PMC6858222 DOI: 10.1136/bmjopen-2018-025366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units compared with the rest of England. DESIGN Prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. SETTING Acute stroke services in London hyperacute stroke units and the rest of England. PARTICIPANTS 68 239 patients with a primary diagnosis of stroke admitted between January and December 2014. INTERVENTIONS Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards designed to deliver uniform access to high-quality hyperacute stroke unit care across the week. MAIN OUTCOME MEASURES 16 indicators of quality of acute stroke care, mortality at 3 days after admission to the hospital, disability at the end of the inpatient spell, length of stay. RESULTS There was no variation in quality of care by day and time of admission to the hospital across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor was there variation in 3-day mortality or disability at hospital discharge (all p values>0.05). Other quality of care measures significantly varied by day and time of admission across the week in London (all p values<0.01). In the rest of England there was variation in all measures by day and time of admission across the week (all p values<0.01), except for mortality at 3 days (p value>0.05). CONCLUSIONS The London hyperacute stroke unit model achieved performance standards for 'front door' stroke care across the week. The same benefits were not achieved by other models of care in the rest of England. There was no weekend effect for mortality in London or the rest of the England. Other aspects of care were not constant across the week in London hyperacute stroke units, indicating some performance standards were perceived to be more important than others.
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Affiliation(s)
- Mariya Melnychuk
- Department of Applied Health Research, University College London, London, UK
- Faculty of Law and Social Sciences, Universidad Rey Juan Carlos, Madrid, Spain
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Georgia Black
- Department of Applied Health Research, University College London, London, UK
| | - Angus I G Ramsay
- Department of Applied Health Research, University College London, London, UK
| | - Jeannie Eng
- Cancer Division, University College London Hospitals NHS Foundation Trust, London
| | - Anthony Rudd
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, UK
| | - Abigail Baim-Lance
- Institute for Implementation Science in Population Health, City University of New York, New York, USA
| | - Martin M Brown
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
| | - Robert Simister
- Stroke Research Centre, UCL Queen Square Institute of Neurology, London
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
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7
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Allen M, Pearn K, Villeneuve E, James M, Stein K. Planning and Providing Acute Stroke Care in England: The Effect of Planning Footprint Size. Front Neurol 2019; 10:150. [PMID: 30873107 PMCID: PMC6400850 DOI: 10.3389/fneur.2019.00150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Accepted: 02/05/2019] [Indexed: 11/15/2022] Open
Abstract
Background: Guidelines in England recommend that hyperacute stroke units (HASUs) should have a minimum of 600 confirmed stroke admissions per year in order to sustain expert consultant-led services, and that travel time for patients should ideally be 30 min or less. Currently, 61% of stroke patients attend a unit with at least 600 admissions per year and 56% attend such a unit and have a travel time of no more than 30 min. Objective: We have sought to understand how varying the planning and provision footprint in England affects access to care whilst achieving the recommended admission numbers for hyper-acute stroke care. We have compared two different planning footprints to national-level planning: planning using five NHS Regions in England, and planning using 44 Sustainability and Transformation Partnerships (STPs) in England. Methods: Computer modeling and optimization using a multi-objective genetic algorithm. Results: The number of stroke admissions between STPs varies by seven-fold, while the number of stroke admissions between NHS Regions varies by 2.5-fold. In order to meet stroke admission guidelines (600/year) for all units the maximum possible proportion of patients within 30 min would be 82, 78, and 72% with no boundaries to planning/provision, NHS Region boundaries, and STP boundaries (in these scenarios patients cannot move outside of their own STP or NHS Region). If STP or NHS Region boundaries are removed for provision of service (after planning is performed at these local levels), travel time is improved, but number of admissions to individual hospitals become significantly changed, especially at STP planning level where admission numbers per unit changed by an average of 204 (19%), and not all units maintained 600 admissions after removal of boundaries. Conclusion: Planning and providing services at STP level could lead to sub-optimal service provision compared with using larger and more consistently populated planning areas.
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Affiliation(s)
- Michael Allen
- NIHR CLAHRC South West Peninsula, University of Exeter College Of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - Kerry Pearn
- NIHR CLAHRC South West Peninsula, University of Exeter College Of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - Emma Villeneuve
- NIHR CLAHRC South West Peninsula, University of Exeter College Of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - Martin James
- Royal Devon and Exeter NHS Foundation Trust and the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, Exeter, United Kingdom
| | - Ken Stein
- NIHR CLAHRC South West Peninsula, University of Exeter College Of Medicine and Health, University of Exeter, Exeter, United Kingdom
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8
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Holodinsky JK, Almekhlafi MA, Goyal M, Kamal N. Mathematical Modeling for Decision-Making in the Field for Acute Stroke Patients With Suspected Large Vessel Occlusion. Stroke 2019; 50:212-217. [PMID: 30580736 DOI: 10.1161/strokeaha.118.021381] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jessalyn K Holodinsky
- From the Department of Community Health Sciences, Cumming School of Medicine (J.K.H., M.A.A.), University of Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine (J.K.H., M.A.A., M.G.), University of Calgary, Canada
| | - Mohammed A Almekhlafi
- From the Department of Community Health Sciences, Cumming School of Medicine (J.K.H., M.A.A.), University of Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine (J.K.H., M.A.A., M.G.), University of Calgary, Canada
- Department of Radiology, Cumming School of Medicine (M.A.A., M.G.), University of Calgary, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine (M.A.A., M.G., N.K.), University of Calgary, Canada
| | - Mayank Goyal
- Hotchkiss Brain Institute, Cumming School of Medicine (J.K.H., M.A.A., M.G.), University of Calgary, Canada
- Department of Radiology, Cumming School of Medicine (M.A.A., M.G.), University of Calgary, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine (M.A.A., M.G., N.K.), University of Calgary, Canada
| | - Noreen Kamal
- Department of Clinical Neurosciences, Cumming School of Medicine (M.A.A., M.G., N.K.), University of Calgary, Canada
- Department of Electrical and Computer Engineering, Schulich School of Engineering (N.K.), University of Calgary, Canada
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9
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Allen M, Pearn K, James M, Ford GA, White P, Rudd AG, McMeekin P, Stein K. Maximising access to thrombectomy services for stroke in England: A modelling study. Eur Stroke J 2018; 4:39-49. [PMID: 31165093 DOI: 10.1177/2396987318785421] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/24/2018] [Indexed: 12/11/2022] Open
Abstract
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.
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Affiliation(s)
- Michael Allen
- University of Exeter Medical School, Exeter, UK.,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, UK
| | - Kerry Pearn
- University of Exeter Medical School, Exeter, UK.,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, UK
| | - Martin James
- University of Exeter Medical School, Exeter, UK.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Gary A Ford
- Radcliffe Department of Medicine, Oxford University, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle-upon-Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Anthony G Rudd
- Kings College London, London, UK.,Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle-upon-Tyne, UK
| | - Ken Stein
- University of Exeter Medical School, Exeter, UK.,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, UK
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