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Day J, Simmonds RL, Shaw L, Price CI, McClelland G, Ford GA, James M, White P, Stein K, Pope C. Healthcare professional views about a prehospital redirection pathway for stroke thrombectomy: a multiphase deductive qualitative study. Emerg Med J 2024:emermed-2023-213350. [PMID: 38729751 DOI: 10.1136/emermed-2023-213350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 04/10/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Mechanical thrombectomy for stroke is highly effective but time-critical. Delays are common because many patients require transfer between local hospitals and regional centres. A two-stage prehospital redirection pathway consisting of a simple ambulance screen followed by regional centre assessment to select patients for direct admission could optimise access. However, implementation might be challenged by the limited number of thrombectomy providers, a lack of prehospital diagnostic tests for selecting patients and whether finite resources can accommodate longer ambulance journeys plus greater central admissions. We undertook a three-phase, multiregional, qualitative study to obtain health professional views on the acceptability and feasibility of a new pathway. METHODS Online focus groups/semistructured interviews were undertaken designed to capture important contextual influences. We purposively sampled NHS staff in four regions of England. Anonymised interview transcripts underwent deductive thematic analysis guided by the NASSS (Non-adoption, Abandonment and Challenges to Scale-up, Spread and Sustainability, Implementation) Implementation Science framework. RESULTS Twenty-eight staff participated in 4 focus groups, 2 group interviews and 18 individual interviews across 4 Ambulance Trusts, 5 Hospital Trusts and 3 Integrated Stroke Delivery Networks (ISDNs). Five deductive themes were identified: (1) (suspected) stroke as a condition, (2) the pathway change, (3) the value participants placed on the proposed pathway, (4) the possible impact on NHS organisations/adopter systems and (5) the wider healthcare context. Participants perceived suspected stroke as a complex scenario. Most viewed the proposed new thrombectomy pathway as beneficial but potentially challenging to implement. Organisational concerns included staff shortages, increased workflow and bed capacity. Participants also reported wider socioeconomic issues impacting on their services contributing to concerns around the future implementation. CONCLUSIONS Positive views from health professionals were expressed about the concept of a proposed pathway while raising key content and implementation challenges and useful 'real-world' issues for consideration.
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Affiliation(s)
- Jo Day
- NIHR Applied Research Collaboration South West Peninsula, Health and Community Sciences, University of Exeter, Exeter, Devon, UK
| | | | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Graham McClelland
- North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne, UK
- Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Foundation Trust and Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Martin James
- Royal Devon University Healthcare NHS Foundation Trust and University of Exeter, University of Exeter, Exeter, Devon, UK
| | - Phil White
- Stroke Research Group, Clinical and Translational Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ken Stein
- NIHR Applied Research Collaboration South West Peninsula, University of Exeter, Exeter, Devon, UK
| | - Catherine Pope
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Alobaida M, Lip GYH, Lane DA, Sagris D, Hill A, Harrison SL. Endovascular treatment for ischemic stroke patients with and without atrial fibrillation, and the effects of adjunctive pharmacotherapy: a narrative review. Expert Opin Pharmacother 2023; 24:377-388. [PMID: 36541626 DOI: 10.1080/14656566.2022.2161362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
INTRODUCTION Endovascular thrombectomy (EVT) is associated with good clinical outcomes in patients with ischemic stroke, but the impact of EVT on clinical outcomes in patients with ischemic stroke with and without atrial fibrillation (AF), and the effect of adjunctive pharmacological therapies with EVT, remains unclear. AREAS COVERED The goal of this narrative review is to provide an overview of studies which have examined: 1) associations between EVT and outcomes for patients following ischemic stroke, 2) associations between EVT and outcomes for patients following ischemic stroke with and without AF , including function, reperfusion, hemorrhage, and mortality, 3) the effect of adjunctive pharmacological therapies peri- and post-thrombectomy, and 4) integration of prehospital care on endovascular treatment outcomes. EXPERT OPINION There is little evidence from randomized controlled trials on the effect of AF on stroke outcomes following EVT and the safety and efficacy of AF treatment in the peri-EVT such as tirofiban or Intravenous thrombolysis with Non-vitamin K Antagonist Oral Anticoagulant. The available evidence from observational studies on AF and EVT outcomes is inconsistent, but factors such as procedural EVT devices, the center volume, clinician experience, stroke recognition, and inclusion criteria of studies have all been associated with poorer clinical outcomes. Enhancing the clinical network among prehospital and hospitals will facilitate direct transfer to EVT centers, reducing stroke onset to EVT time and optimizing stroke outcomes.
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Affiliation(s)
- Muath Alobaida
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Basic Science, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Gregory Y H Lip
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Medicine and Research Laboratory, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Andrew Hill
- Department of Medicine, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - Stephanie L Harrison
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK
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Ennab Vogel N, Tatlisumak T, Wester P, Lyth J, Levin LÅ. Prediction modelling the impact of onset to treatment time on the modified Rankin Scale score at 90 days for patients with acute ischaemic stroke. BMJ Neurol Open 2022; 4:e000312. [PMID: 36072349 PMCID: PMC9386213 DOI: 10.1136/bmjno-2022-000312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Accepted: 07/20/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction Shortening the time from stroke onset to treatment increases the effectiveness of endovascular stroke therapies. Aim This study aimed to predict the modified Rankin Scale score at 90 days post-stroke (mRS-90d score) in patients with acute ischaemic stroke (AIS) with respect to four types of treatment: conservative therapy (CVT), intravenous thrombolysis only (IVT), mechanical thrombectomy only (MT) and pretreatment with IVT before MT (IVT+MT). Patients and methods This nationwide observational study included 124 484 confirmed cases of acute stroke in Sweden over 6 years (2012–2017). The associations between onset-to-treatment time (OTT), patient age and hospital admission National Institutes of Health Stroke Scale (NIHSS) score with the five-levelled mRS-90d score were retrospectively studied. A generalised linear model (GLM) was fitted to predict the mRS-90d scores for each patient group. Results The fitted GLM for CVT patients is a function of age and NIHSS score. For IVT, MT and IVT+MT patients, GLMs additionally employed OTT variables. By reducing the mean OTTs by 15 min, the number needed-to-treat (NNT) for one patient to make a favourable one-step shift in the mRS was 30 for IVT, 48 for MT and 21 for IVT+MT. Discussion and conclusion This study demonstrates linear associations of mRS-90d score with OTT for IVT, MT and IVT+MT, and shows in absolute effects measures that OTT reductions for IVT and/or MT produces substantial health gains for patients with AIS. Even moderate OTT reductions led to sharp drops in the NNT.
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Affiliation(s)
- Nicklas Ennab Vogel
- Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Turgut Tatlisumak
- Neurology, Sahlgrenska University Hospital, Göteborg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, University of Gothenburg Sahlgrenska Academy, Göteborg, Sweden
| | - Per Wester
- Department of Public Health and Clinical Science, Umeå University, Umeå, Sweden
- Department of Clinical Science, Karolinska Institute Danderyds Hospital, Stockholm, Sweden
| | - Johan Lyth
- Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Lars-Åke Levin
- Department of Health, Medicine and Caring Sciences, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
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Behrndtz A, Beare R, Iievlieva S, Andersen G, Mainz J, Gude M, Ma H, Srikanth V, Simonsen CZ, Phan T. Can Helicopters Solve the Transport Dilemma for Patients With Symptoms of Large-Vessel Occlusion Stroke in Intermediate Density Areas? A Simulation Model Based on Real Life Data. Front Neurol 2022; 13:861259. [PMID: 35547365 PMCID: PMC9082641 DOI: 10.3389/fneur.2022.861259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/21/2022] [Indexed: 11/26/2022] Open
Abstract
Background This modeling study aimed to determine if helicopters may optimize the transportation of patients with symptoms of large vessel stroke in “intermediate density” areas, such as Denmark, by bringing them directly to the comprehensive stroke center. Methods We estimated the time for the treatment of patients requiring endovascular therapy or intravenous thrombolysis under four configurations: “drip and ship” with and without helicopter and “bypass” with and without helicopter. Time delays, stroke numbers per municipality, and helicopter dispatches for four helicopter bases from 2019 were obtained from the Danish Stroke and Helicopter Registries. Discrete event simulation (DES) was used to estimate the capacity of the helicopter fleet to meet patient transport requests, given the number of stroke codes per municipality. Results The median onset-to-needle time at the comprehensive stroke center (CSC) for the bypass model with the helicopter was 115 min [interquartile range (IQR): 108, 124]; the median onset-to-groin time was 157 min (IQR: 150, 166). The median onset-to-needle time at the primary stroke center (PSC) by ground transport was 112 min (IQR: 101, 125) and the median onset-to-groin time when primary transport to the PSC was prioritized was 234 min (IQR: 209, 261). A linear correlation between travel time by ground and the number of patients transported by helicopter (rho = 0.69, p < 0.001) indicated that helicopters are being used to transport more remote patients. DES demonstrated that an increase in helicopter capture zone by 20 min increased the number of rejected patients by only 5%. Conclusions Our model calculations suggest that using helicopters to transport patients with stroke directly to the CSC in intermediate density areas markedly reduce onset-to-groin time without affecting time to thrombolysis. In this setting, helicopter capacity is not challenged by increasing the capture zone.
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Affiliation(s)
- Anne Behrndtz
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Richard Beare
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Svitlana Iievlieva
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Grethe Andersen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Jeppe Mainz
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Martin Gude
- Department of Clinical Medicine, Prehospital Department, Aarhus, Denmark
| | - Henry Ma
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Velandai Srikanth
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Than Phan
- Department of Medicine, School of Clinical Sciences at Monash Health, Stroke and Ageing Research, Monash University, Melbourne, VIC, Australia
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Price CI, White P, Balami J, Bhattarai N, Coughlan D, Exley C, Flynn D, Halvorsrud K, Lally J, McMeekin P, Shaw L, Snooks H, Vale L, Watkins A, Ford GA. Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/tzty9915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Intravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.
Objectives
The aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.
Design
A mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.
Setting
The paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.
Participants
A total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.
Interventions
The paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.
Main outcome measures
The primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.
Data sources
National registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.
Review methods
Systematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Results
The paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).
Limitations
Evidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.
Conclusions
Paramedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.
Future work
Further evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.
Trial registration
This trial is registered as ISRCTN12418919 and the systematic review protocols are registered as PROSPERO CRD42014010785 and PROSPERO CRD42015016649.
Funding
The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Phil White
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joyce Balami
- Department of Stroke Medicine, Norfolk and Norwich University Teaching Hospital NHS Trust, Norwich, UK
| | - Nawaraj Bhattarai
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Diarmuid Coughlan
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- School of Health & Life Sciences, Teesside University, Middlesbrough, UK
| | - Kristoffer Halvorsrud
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Lally
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- School of Health, Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Snooks
- Centre for Health Information Research and Evaluation, Medical School, Swansea University, Swansea, UK
| | - Luke Vale
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alan Watkins
- Centre for Health Information Research and Evaluation, Medical School, Swansea University, Swansea, UK
| | - Gary A Ford
- Oxford Academic Health Science Network, Oxford University and Oxford University Hospitals, Oxford, UK
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Allen M, Pearn K, Ford GA, White P, Rudd AG, McMeekin P, Stein K, James M. National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study. Eur Stroke J 2021; 7:28-40. [PMID: 35300255 PMCID: PMC8921787 DOI: 10.1177/23969873211063323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives To guide policy when planning thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship’ (secondary transfer) provision and the impact of bypassing local acute stroke centres. Design Outcome-based modelling study. Setting 107 acute stroke centres in England, 24 of which provide IVT and MT (IVT/MT centres) and 83 provide only IVT (IVT-only units). Participants 242,874 emergency admissions with acute stroke over 3 years (2015–2017). Intervention Reperfusion delivered by drip-and-ship, mothership or ‘hybrid’ models; impact of additional travel time to directly access an IVT/MT centre by bypassing a more local IVT-only unit; effect of pre-hospital selection for large artery occlusion (LAO). Main outcome measures Population benefit from reperfusion, time to IVT and MT, admission numbers to IVT-only units and IVT/MT centres. Results Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit, assuming unknown patient status, accrues from direct conveyance to an IVT/MT centre. However, this policy produces unsustainable admission numbers at these centres, with 78 out of 83 IVT-only units receiving fewer than 300 admissions per year (compared to 3 with drip-and-ship). Implementing a maximum permitted additional travel time to bypass an IVT-only unit, using a pre-hospital test for LAO, and selecting patients based on stroke onset time, all help to mitigate the destabilising effect but there is still some significant disruption to admission numbers, and improved selection of patients suitable for MT selectively reduces the number of patients who would receive IVT at IVT-only centres, challenging the sustainability of IVT expertise in IVT-only centres. Conclusions Implementation of reperfusion for acute stroke based solely on achieving the maximum population benefit potentially leads to destabilisation of the emergency stroke care system. Careful planning is required to create a sustainable system, and modelling may be used to help planners maximise benefit from reperfusion while creating a sustainable emergency stroke care system.
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Affiliation(s)
- Michael Allen
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Kerry Pearn
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Gary A Ford
- Radcliffe Department of Medicine, Oxford University and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil White
- Translational and Clinical Research Institute, Newcastle University and Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Anthony G Rudd
- Kings College London and 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 and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Martin James
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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7
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To support safe provision of mechanical thrombectomy services for patients with acute ischaemic stroke: 2021 consensus guidance from BASP, BSNR, ICSWP, NACCS, and UKNG. Clin Radiol 2021; 76:862.e1-862.e17. [PMID: 34482987 DOI: 10.1016/j.crad.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/05/2021] [Indexed: 01/01/2023]
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Gaude E, Nogueira B, Ladreda Mochales M, Graham S, Smith S, Shaw L, Graziadio S, Ladreda Mochales G, Sloan P, Bernstock JD, Shekhar S, Gropen TI, Price CI. A Novel Combination of Blood Biomarkers and Clinical Stroke Scales Facilitates Detection of Large Vessel Occlusion Ischemic Strokes. Diagnostics (Basel) 2021; 11:diagnostics11071137. [PMID: 34206615 PMCID: PMC8306880 DOI: 10.3390/diagnostics11071137] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 02/03/2023] Open
Abstract
Acute ischemic stroke caused by large vessel occlusions (LVOs) is a major contributor to stroke deaths and disabilities; however, identification for emergency treatment is challenging. We recruited two separate cohorts of suspected stroke patients and screened a panel of blood-derived protein biomarkers for LVO detection. Diagnostic performance was estimated by using blood biomarkers in combination with NIHSS-derived stroke severity scales. Multivariable analysis demonstrated that D-dimer (OR 16, 95% CI 5–60; p-value < 0.001) and GFAP (OR 0.002, 95% CI 0–0.68; p-value < 0.05) comprised the optimal panel for LVO detection. Combinations of D-dimer and GFAP with a number of stroke severity scales increased the number of true positives, while reducing false positives due to hemorrhage, as compared to stroke scales alone (p-value < 0.001). A combination of the biomarkers with FAST-ED resulted in the highest accuracy at 95% (95% CI: 87–99%), with sensitivity of 91% (95% CI: 72–99%), and specificity of 96% (95% CI: 90–99%). Diagnostic accuracy was confirmed in an independent cohort, in which accuracy was again shown to be 95% (95% CI: 87–99%), with a sensitivity of 82% (95% CI: 57–96%), and specificity of 98% (95% CI: 92–100%). Accordingly, the combination of D-dimer and GFAP with stroke scales may provide a simple and highly accurate tool for identifying LVO patients, with a potential impact on time to treatment.
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Affiliation(s)
- Edoardo Gaude
- Pockit Diagnostics Ltd., Cambridge CB4 2HY, UK; (B.N.); (M.L.M.); (G.L.M.)
- Correspondence:
| | - Barbara Nogueira
- Pockit Diagnostics Ltd., Cambridge CB4 2HY, UK; (B.N.); (M.L.M.); (G.L.M.)
| | | | - Sheila Graham
- CEPA Biobank, The Newcastle NHS Foundation Trust, Newcastle upon Tyne NE3 3HD, UK; (S.G.); (P.S.)
| | - Sarah Smith
- NovoPath Biobank, Newcastle MRC Node, Newcastle NHS Foundation Trust, Newcastle upon Tyne NE1 4LP, UK;
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (L.S.); (C.I.P.)
| | - Sara Graziadio
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE2 4HH, UK;
| | | | - Philip Sloan
- CEPA Biobank, The Newcastle NHS Foundation Trust, Newcastle upon Tyne NE3 3HD, UK; (S.G.); (P.S.)
| | - Joshua D. Bernstock
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, USA;
| | - Shashank Shekhar
- University of Mississippi Medical Center, Jackson, MS 39216, USA;
| | - Toby I. Gropen
- University of Alabama at Birmingham, Birmingham, AL 35294, USA;
| | - Christopher I. Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK; (L.S.); (C.I.P.)
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Ren Y, Phan M, Luong P, Wu J, Shell D, Barras CD, Chryssidis S, Kok HK, Burney M, Tahayori B, Maingard J, Jhamb A, Thijs V, Brooks DM, Asadi H. Application of a computational model in simulating an endovascular clot retrieval service system within regional Australia. J Med Imaging Radiat Oncol 2021; 65:850-857. [PMID: 34105874 DOI: 10.1111/1754-9485.13255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Accepted: 05/13/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The global demand for endovascular clot retrieval (ECR) has grown rapidly in recent years creating challenges to healthcare system planning and resource allocation. This study aims to apply our established computational model to predict and optimise the performance and resource allocation of ECR services within regional Australia, and applying data from the state of South Australia as a modelling exercise. METHOD Local geographic information obtained using the Google Maps application program interface and real-world data was input into the discrete event simulation model we previously developed. The results were obtained after the simulation was run over 5 years. We modelled and compared a single-centre and two-centre ECR service delivery system. RESULTS Based on the input data, this model was able to simulate the ECR delivery system in the state of South Australia from the moment when emergency services were notified of a potential stroke patient to potential delivery of ECR treatment. In the model, ECR delivery improved using a two-centre system compared to a one-centre system, as the percentage of stroke patients requiring ECR was increased. When 15% of patients required ECR, the proportion of 'failure to receive ECR' cases for a single-centre system was 17.35%, compared to 3.71% for a two-centre system. CONCLUSIONS Geolocation and resource utilisation within the ECR delivery system are crucial in optimising service delivery and patient outcome. Under the model assumptions, as the number of stroke cases requiring ECR increased, a two-centre ECR system resulted in increased timely ECR delivery, compared to a single-centre system. This study demonstrated the flexibility and the potential application of our DES model in simulating the stroke service within any location worldwide.
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Affiliation(s)
- Yifan Ren
- Interventional Neuroradiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | | | - Phillip Luong
- School of Science, Computer Science and Information Technology, RMIT University, Melbourne, Victoria, Australia
| | - Jamin Wu
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Daniel Shell
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Christen D Barras
- South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, South Australia, Australia.,Department of Radiology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Steve Chryssidis
- Department of Medical Imaging, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Hong Kuan Kok
- Interventional Radiology Service - Department of Radiology, Northern Health, Melbourne, Victoria, Australia
| | - Moe Burney
- Deloitte, Sydney, New South Wales, Australia
| | - Baham Tahayori
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, Victoria, Australia
| | - Julian Maingard
- Interventional Neuroradiology Service - Department of Radiology, Monash Health, Melbourne, Victoria, Australia.,School of Medicine - Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Ashu Jhamb
- Interventional Radiology Service - Department of Radiology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Vincent Thijs
- Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - Duncan Mark Brooks
- Interventional Neuroradiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia.,Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Hamed Asadi
- Interventional Neuroradiology Service - Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia.,Interventional Neuroradiology Service - Department of Radiology, Monash Health, Melbourne, Victoria, Australia.,School of Medicine - Faculty of Health, Deakin University, Geelong, Victoria, Australia.,Interventional Radiology Service - Department of Radiology, St Vincent's Hospital, Melbourne, Victoria, Australia.,Stroke Theme, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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10
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Geographic Access to Stroke Care Services in Rural Communities in Ontario, Canada. Can J Neurol Sci 2021; 47:301-308. [PMID: 31918777 DOI: 10.1017/cjn.2020.9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada. METHODS We used the Ontario Road Network File database linked with the 2016 Ontario Acute Stroke Care Resource Inventory to estimate the proportion of people in rural communities, defined as those with a population size <10,000, who were within 30, 60, and 240 minutes of travel time by car from stroke care services, including brain imaging, thrombolysis treatment centers, stroke units, stroke prevention clinics, inpatient rehabilitation facilities, and endovascular treatment centers. RESULTS Of the 1,496,262 people residing in rural communities, the majority resided within 60 minutes of driving time to a center with computed tomography (85%), thrombolysis (81%), a stroke unit (68%), a stroke prevention clinic (74%), or inpatient rehabilitation (77.0%), but a much lower proportion (32%) were within 60 minutes of driving time to a center capable of providing endovascular thrombectomy (EVT). CONCLUSIONS Most rural Ontario residents have appropriate geographic access to stroke services, with the exception of EVT. This information may be useful for jurisdictions seeking to optimize the regional organization of stroke care services.
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11
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Kamel H, Parikh NS, Chatterjee A, Kim LK, Saver JL, Schwamm LH, Zachrison KS, Nogueira RG, Adeoye O, Díaz I, Ryan AM, Pandya A, Navi BB. Access to Mechanical Thrombectomy for Ischemic Stroke in the United States. Stroke 2021; 52:2554-2561. [PMID: 33980045 DOI: 10.1161/strokeaha.120.033485] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Abhinaba Chatterjee
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
| | - Luke K Kim
- Division of Cardiology (L.K.K.), Weill Cornell Medicine, New York, NY
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
| | - Lee H Schwamm
- Department of Neurology (L.H.S.), Massachusetts General Hospital, Boston
| | - Kori S Zachrison
- Department of Emergency Medicine (K.S.Z.), Massachusetts General Hospital, Boston
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery, and Radiology, Emory University School of Medicine, Atlanta, GA (R.G.N.)
| | - Opeolu Adeoye
- Department of Emergency Medicine, University of Cincinnati, OH (O.A.)
| | - Iván Díaz
- Division of Biostatistics and Epidemiology (I.D.), Weill Cornell Medicine, New York, NY
| | - Andrew M Ryan
- Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor (A.M.R.)
| | - Ankur Pandya
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA (A.P.)
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY
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12
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Abstract
This article aims to provide a comprehensive overview of key advances on various aspects of hyper-acute management of acute ischaemic stroke. These include neuroimaging, acute stroke unit care, management of blood pressure, reperfusion therapy including intravenous thrombolysis, mechanical thrombectomy and decompressive hemicraniectomy for malignant stroke syndrome. The challenge ahead is to ensure these evidence-based treatments are now being delivered and implemented to maximise the benefits across the population.
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Affiliation(s)
| | | | - Jonathan Birns
- St Thomas' Hospital, London, UK and deputy head of School of Medicine, Health Education England, London, UK
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13
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Foo M, Maingard J, Kuan Kok H, Jhamb A, Brooks M, Barras C, Thijs V, Asadi H. Letter to the Editor: Seeking clarification regarding caseload constraints in modelling of thrombectomy service delivery. Eur Stroke J 2021; 5:449-450. [PMID: 33598564 DOI: 10.1177/2396987320925204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 04/13/2020] [Indexed: 11/17/2022] Open
Affiliation(s)
- Michelle Foo
- Radiology Department, Austin Health, Heidelberg, Australia
| | - Julian Maingard
- Interventional Neuroradiology Service, Monash Health, Clayton, Australia
| | - Hong Kuan Kok
- Interventional Radiology Service, Northern Hospital, Epping, Australia
| | - Ashu Jhamb
- Interventional Neuroradiology Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Mark Brooks
- Radiology Department, Austin Health, Heidelberg, Australia.,Interventional Neuroradiology Unit, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Christen Barras
- Interventional Neuroradiology Service, Monash Health, Clayton, Australia
| | | | - Hamed Asadi
- Radiology Department, Austin Health, Heidelberg, Australia.,Interventional Neuroradiology Service, Monash Health, Clayton, Australia
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14
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Coughlan D, McMeekin P, Flynn D, Ford GA, Lumley H, Burgess D, Balami J, Mawson A, Craig D, Rice S, White P. Secondary transfer of emergency stroke patients eligible for mechanical thrombectomy by air in rural England: economic evaluation and considerations. Emerg Med J 2020; 38:33-39. [PMID: 33172878 PMCID: PMC7788185 DOI: 10.1136/emermed-2019-209039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 08/16/2020] [Accepted: 08/27/2020] [Indexed: 11/22/2022]
Abstract
Background Mechanical thrombectomy (MT) is a time-sensitive emergency procedure for patients who had ischaemic stroke leading to improved health outcomes. Health systems need to ensure that MT is delivered to as many patients as quickly as possible. Using decision modelling, we aimed to evaluate the cost-effectiveness of secondary transfer by helicopter emergency medical services (HEMS) compared with ground emergency medical services (GEMS) of rural patients eligible for MT in England. Methods The model consisted of (1) a short-run decision tree with two branches, representing secondary transfer transportation strategies and (2) a long-run Markov model for a theoretical population of rural patients with a confirmed ischaemic stroke. Strategies were compared by lifetime costs: quality-adjusted life years (QALYs), incremental cost per QALY gained and net monetary benefit. Sensitivity and scenario analyses explored uncertainty around parameter values. Results We used the base case of early-presenting (<6 hours to arterial puncture) patient aged 75 years who had stroke to compare HEMS and GEMS. This produced an incremental cost-effectiveness ratio (ICER) of £28 027 when a 60 min reduction in travel time was assumed. Scenario analyses showed the importance of the reduction in travel time and futile transfers in lowering ICERs. For late presenting (>6 hours to arterial puncture), ground transportation is the dominant strategy. Conclusion Our model indicates that using HEMS to transfer patients who had stroke eligible for MT from remote hospitals in England may be cost-effective when: travel time is reduced by at least 60 min compared with GEMS, and a £30 000/QALY threshold is used for decision-making. However, several other logistic considerations may impact on the use of air transportation.
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Affiliation(s)
- Diarmuid Coughlan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Darren Flynn
- School of Health and Social Care, Teesside University, Middlesbrough, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Trust, Oxford, UK.,Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - Hannah Lumley
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
| | - David Burgess
- North East and North Cumbria Stroke Patient & Carer Panel, Newcastle upon Tyne, UK
| | - Joyce Balami
- Kellogg College, University of Oxford, Oxford, UK
| | - Andrew Mawson
- Great North Air Ambulance, Northumberland Wing, The Imperial Centre, Darlington, UK
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Rice
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Phil White
- Institute of Neuroscience (Stroke Research Group), Newcastle University, Newcastle upon Tyne, UK
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15
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White PM, Ford GA, James M, Allen M. Regarding thrombectomy centre volumes and maximising access to thrombectomy services for stroke in England: A modelling study and mechanical thrombectomy for acute ischaemic stroke: An implementation guide for the UK. Eur Stroke J 2020; 5:451-452. [PMID: 33598565 PMCID: PMC7856595 DOI: 10.1177/2396987320971126] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- P M White
- Institute of Translational and Clinical Medicine, Newcastle University, Newcastle upon-Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon-Tyne, UK
| | - G A Ford
- Radcliffe Department of Medicine, Oxford University, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - M James
- University of Exeter Medical School, Exeter, UK.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - M 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
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16
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Lahr MMH, Maas WJ, van der Zee DJ, Uyttenboogaart M, Buskens E. Rationale and design for studying organisation of care for intra-arterial thrombectomy in the Netherlands: simulation modelling study. BMJ Open 2020; 10:e032754. [PMID: 31915166 PMCID: PMC6955572 DOI: 10.1136/bmjopen-2019-032754] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The introduction of intra-arterial thrombectomy (IAT) challenges acute stroke care organisations to provide fast access to acute stroke therapies. Parameters of pathway performance include distances to primary and comprehensive stroke centres (CSCs), time to treatment and availability of ambulance services. Further expansion of IAT centres may increase treatment rates yet could affect efficient use of resources and quality of care due to lower treatment volume. The aim was to study the organisation of care and patient logistics of IAT for patients with ischaemic stroke in the Netherlands. METHODS AND ANALYSES Using a simulation modelling approach, we will quantify performance of 16 primary and CSCs offering IAT in the Netherlands. Patient data concerning both prehospital and intrahospital pathway logistics will be collected and used as input for model validation. A previously validated simulation model for intravenous thrombolysis (IVT) patients will be expanded with data of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry and trials performed in the Collaboration for New Treatments in Acute Stroke consortium to represent patient logistics, time delays and outcomes in IAT patients. Simulation experiments aim to assess effectiveness and efficiency of alternative network topologies, that is, IAT with or without IVT at the nearest primary stroke centre (PSC) versus centralised care at a CSC. Primary outcomes are IAT treatment rates and clinical outcome according to the modified Rankin Scale. Secondary outcomes include onset-to-treatment time and resource use. Mann-Whitney U and Fisher's exact tests will be used to estimate differences for continuous and categorical variables. Model and parameter uncertainty will be tested using sensitivity analyses. ETHICS AND DISSEMINATION This will be the first study to examine the organisation of acute stroke care for IAT delivery on a national scale using discrete event simulation. There are no ethics or safety concerns regarding the dissemination of information, which includes publication in peer-reviewed journals and (inter)national conference presentations. TRIAL REGISTRATION NUMBER ISRCTN99503308, ISRCTN76741621, ISRCTN19922220, ISRCTN80619088, NCT03608423; Pre-results.
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Affiliation(s)
- Maarten M H Lahr
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Willemijn J Maas
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Radiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
- Department of Operations, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
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17
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McMeekin P, Flynn D, Allen M, Coughlan D, Ford GA, Lumley H, Balami JS, James MA, Stein K, Burgess D, White P. Estimating the effectiveness and cost-effectiveness of establishing additional endovascular Thrombectomy stroke Centres in England: a discrete event simulation. BMC Health Serv Res 2019; 19:821. [PMID: 31703684 PMCID: PMC6842187 DOI: 10.1186/s12913-019-4678-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We have previously modelled that the optimal number of comprehensive stroke centres (CSC) providing endovascular thrombectomy (EVT) in England would be 30 (net 6 new centres). We now estimate the relative effectiveness and cost-effectiveness of increasing the number of centres from 24 to 30. METHODS We constructed a discrete event simulation (DES) to estimate the effectiveness and lifetime cost-effectiveness (from a payer perspective) using 1 year's incidence of stroke in England. 2000 iterations of the simulation were performed comparing baseline 24 centres to 30. RESULTS Of 80,800 patients admitted to hospital with acute stroke/year, 21,740 would be affected by the service reconfiguration. The median time to treatment for eligible early presenters (< 270 min since onset) would reduce from 195 (IQR 155-249) to 165 (IQR 105-224) minutes. Our model predicts reconfiguration would mean an additional 33 independent patients (modified Rankin scale [mRS] 0-1) and 30 fewer dependent/dead patients (mRS 3-6) per year. The net addition of 6 centres generates 190 QALYs (95%CI - 6 to 399) and results in net savings to the healthcare system of £1,864,000/year (95% CI -1,204,000 to £5,017,000). The estimated budget impact was a saving of £980,000 in year 1 and £7.07 million in years 2 to 5. CONCLUSION Changes in acute stroke service configuration will produce clinical and cost benefits when the time taken for patients to receive treatment is reduced. Benefits are highly likely to be cost saving over 5 years before any capital investment above £8 million is required.
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Affiliation(s)
- Peter McMeekin
- School of Health, Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK
| | - Darren Flynn
- School of Health and Social Care, Teesside University, Tees Valley, UK
| | - Mike Allen
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, Bristol, UK
| | - Diarmuid Coughlan
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Trust, Oxford, UK.,Oxford University, Oxford, UK.,Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, UK
| | - Hannah Lumley
- Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, UK
| | | | - Martin A James
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, Bristol, UK.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Ken Stein
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, Bristol, UK
| | - David Burgess
- Clinical Research Network North East and North Cumbria, North East and North Cumbria Stroke Patient & Carer Panel, Newcastle upon Tyne, UK.,North East and North Cumbria Stroke Patient & Carer Panel, Newcastle upon Tyne, UK
| | - Phil White
- Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, UK.
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18
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Black GB, Ramsay AIG, Baim-Lance A, Eng J, Melnychuk M, Xanthopoulou P, Brown MM, Morris S, Rudd AG, Simister R, Fulop NJ. What does it take to provide clinical interventions with temporal consistency? A qualitative study of London hyperacute stroke units. BMJ Open 2019; 9:e025367. [PMID: 31699711 PMCID: PMC6858131 DOI: 10.1136/bmjopen-2018-025367] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES 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 day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units (HASUs). DESIGN Interview and observation study to explain patterns of variation in delivery and outcomes of care described in a quantitative partner paper (Melnychuk et al). SETTING Eight HASUs in London. PARTICIPANTS We interviewed HASU staff (n=76), including doctors, nurses, therapists and administrators. We also conducted non-participant observations of delivery of care at different times of the day and week (n=45; ~102 hours). We analysed the data for thematic content relating to the ability of staff to provide evidence-based interventions consistently at different times of the day and week. RESULTS Staff were able to deliver 'front door' interventions consistently by taking on additional responsibilities out of hours (eg, deciding eligibility for thrombolysis); creating continuities between day and night (through, eg, governance processes and staggering rotas); building trusting relationships with, eg, Radiology and Emergency Departments and staff prioritisation of 'front door' interventions. Variations by time of day resulted from reduced staffing in HASUs and elsewhere in hospitals in the evenings and at the weekend. Variations by day of week (eg, weekend effect) resulted from lack of therapy input and difficulties repatriating patients at weekends, and associated increases in pressure on Fridays and Mondays. CONCLUSIONS Evidence-based service standards can facilitate 7-day working in acute stroke services. Standards should ensure that the capacity and capabilities required for 'front door' interventions are available 24/7, while other services, for example, therapies are available every day of the week. The impact of standards is influenced by interdependencies between HASUs, other hospital services and social services.
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Affiliation(s)
- Georgia B 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
| | | | | | - Mariya Melnychuk
- Department of Applied Health Research, Imperial College London, London, UK
| | | | - Martin M Brown
- Department of Neurology, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Anthony G Rudd
- Clinical Effectiveness and Evaluation Unit, Royal College of Physicians, London, UK
| | - Robert Simister
- Comprehensive Stroke Service, University College London Hospitals NHS Foundation Trust, London, UK
| | - Naomi J Fulop
- Department of Applied Health Research, University College London, London, UK
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19
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Peultier AC, Redekop WK, Allen M, Peters J, Eker OF, Severens JL. Exploring the Cost-Effectiveness of Mechanical Thrombectomy Beyond 6 Hours Following Advanced Imaging in the United Kingdom. Stroke 2019; 50:3220-3227. [PMID: 31637975 PMCID: PMC6824506 DOI: 10.1161/strokeaha.119.026816] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. In the United Kingdom, mechanical thrombectomy (MT) for acute ischemic stroke patients assessed beyond 6 hours from symptom onset will be commissioned up to 12 hours provided that advanced imaging (AdvImg) demonstrates salvageable brain tissue. While the accuracy of AdvImg differs across technologies, evidence is limited regarding the proportion of patients who would benefit from late MT. We compared the cost-effectiveness of 2 care pathways: (1) MT within and beyond 6 hours based on AdvImg selection versus (2) MT only within 6 hours based on conventional imaging selection. The impact of varying AdvImg accuracy and prior probability for acute ischemic stroke patients to benefit from late MT was assessed.
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Affiliation(s)
- Anne-Claire Peultier
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
| | - William K Redekop
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands.,Institute for Medical Technology Assessment (W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
| | - Michael Allen
- University of Exeter Medical School, United Kingdom (M.A.).,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, United Kingdom (M.A.)
| | - Jaime Peters
- Exeter Test Group, University of Exeter Medical School, United Kingdom (J.P.)
| | - Omer Faruk Eker
- Department of Neuroradiology, Lyon University Hospital, France (O.F.E.)
| | - Johan L Severens
- From Erasmus School of Health Policy and Management (A.-C.P., W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands.,Institute for Medical Technology Assessment (W.K.R., J.L.S.), Erasmus University Rotterdam, the Netherlands
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20
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Heggie R, Wu O, White P, Ford GA, Wardlaw J, Brown MM, Clifton A, Muir KW. Mechanical thrombectomy in patients with acute ischemic stroke: A cost-effectiveness and value of implementation analysis. Int J Stroke 2019; 15:881-898. [DOI: 10.1177/1747493019879656] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Recent clinical trials have demonstrated the efficacy of mechanical thrombectomy in acute ischemic stroke. Aims To determine the cost-effectiveness, value of future research, and value of implementation of mechanical thrombectomy. Methods Using UK clinical and cost data from the Pragmatic Ischemic Stroke Thrombectomy Evaluation (PISTE) trial, we estimated the cost-effectiveness of mechanical thrombectomy over time horizons of 90-days and lifetime, based on a decision-analytic model, using all existing evidence. We performed a meta-analysis of seven clinical trials to estimate treatment effects. We used sensitivity analysis to address uncertainty. Value of implementation analysis was used to estimate the potential value of additional implementation activities to support routine delivery of mechanical thrombectomy. Results Over the trial period (90 days), compared with best medical care alone, mechanical thrombectomy incurred an incremental cost of £5207 and 0.025 gain in QALY (incremental cost-effectiveness ratio (ICER) £205,279), which would not be considered cost-effective. However, mechanical thrombectomy was shown to be cost-effective over a lifetime horizon, with an ICER of £3466 per QALY gained. The expected value of perfect information per patient eligible for mechanical thrombectomy in the UK is estimated at £3178. The expected value of full implementation of mechanical thrombectomy is estimated at £1.3 billion over five years. Conclusion Mechanical thrombectomy was cost-effective compared with best medical care alone over a patient’s lifetime. On the assumption of 30% implementation being achieved throughout the UK healthcare system, we estimate that the population health benefits obtained from this treatment are greater than the cost of implementation. Trial registration NCT01745692.
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Affiliation(s)
- Robert Heggie
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Olivia Wu
- Health Economics and Health Technology Assessment (HEHTA), Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Gary A Ford
- Division of Medical Sciences, Oxford University Hospitals NHS Trust, Oxford University, Oxford, UK
| | - Joanna Wardlaw
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Martin M Brown
- Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
| | | | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
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21
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Tajaddini A, Phan TG, Beare R, Ma H, Srikanth V, Currie G, Vu HL. Application of Strategic Transport Model and Google Maps to Develop Better Clot Retrieval Stroke Service. Front Neurol 2019; 10:692. [PMID: 31316457 PMCID: PMC6611389 DOI: 10.3389/fneur.2019.00692] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/13/2019] [Indexed: 11/21/2022] Open
Abstract
Background and purpose: Two hubs are designated to provide endovascular clot retrieval (ECR) for the State of Victoria, Australia. In an earlier study, Google Maps application programming interface (API) was used to perform modeling on the combination of hospitals optimizing for catchment in terms of current traveling time and road conditions. It is not known if these findings would remain the same if the modeling was performed with a large-scale transport demand model such as Victorian Integrated Transport Model (VITM). This model is developed by the Victorian State Government Transport has the capability to forecast travel demand into the future including future road conditions which is not possible with a Google Maps based applications. The aim of this study is to compare the travel time to potential ECR hubs using both VITM and the Google Maps API and model stability in the next 5 and 10 years. Methods: The VITM was used to generate travel time from randomly generated addresses to four existing ECR capable hubs in Melbourne city, Australia (i.e., Royal Melbourne Hospital/RMH, Monash Medical Center/MMC, Alfred Hospital/ALF, and Austin Hospital/AUS) and the optimal service boundaries given a delivering time threshold are then determined. Results: The strategic transport model and Google map methods were similar with the R2 of 0.86 (peak and off peak) and the Nash-Sutcliffe model of efficiency being 0.83 (peak) and 0.76 (off-peak travel). Futures modeling using VITM found that this proportion decreases to 82% after 5 years and 80% after 10 years. The combination of RMH and ALF provides coverage for 74% of cases, 68% by 5 years, and 66% by 10 years. The combination of RMH and AUS provides coverage for 70% of cases in the base case, 65% at 5 years, and 63% by 10 years. Discussion: The results from strategic transport model are similar to those from Google Maps. In this paper we illustrate how this method can be applied in designing and forecast stroke service model in different cities in Australia and around the world.
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Affiliation(s)
- Atousa Tajaddini
- Department of Civil Engineering, Institute of Transport Studies, Monash University, Melbourne, VIC, Australia
| | - Thanh G Phan
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Richard Beare
- Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia.,Developmental Imaging, Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Henry Ma
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Velandai Srikanth
- Stroke Unit, Monash Health, Melbourne, VIC, Australia.,Stroke and Aging Research Group, Medicine, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.,Department of Medicine, Frankston Hospital, Peninsula Health, Melbourne, VIC, Australia.,Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Graham Currie
- Department of Civil Engineering, Institute of Transport Studies, Monash University, Melbourne, VIC, Australia
| | - Hai L Vu
- Department of Civil Engineering, Institute of Transport Studies, Monash University, Melbourne, VIC, Australia
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22
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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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