Drip-and-ship versus mothership for endovascular treatment of acute stroke: A comparative effectiveness analysis

Abstract

Background Triage for suspected acute stroke has two main options (1) transport to the closest primary stroke center (PSC) and then to the nearest comprehensive stroke center (CSC) (Drip-and-Ship) or (2) transport the patient to the nearest CSC, bypassing a closer PSC (mothership). The purpose was to evaluate the effectiveness of drip-and-ship versus mothership models for acute stroke patients. Methods A Markov decision-analytic model was constructed. All model parameters were derived from recent medical literature. Our target population is adult patient with sudden onset of acute stroke over a one-year horizon. The primary outcome is quantified in term of quality-adjusted-life-years (QALYs). Results The base-case scenario shows the Drip-and-Ship strategy has a slightly higher expected health benefit, 0.591 QALY, as compared to 0.586 QALY in the Mothership strategy when the time to PSC is 30 minutes and to CSC is 65 minutes, although the difference in health benefit becomes minimal as the time to PSC increases towards 60 min. Multiple sensitivity analyses show that when both PSC and CSC are far from place of onset (>1.5 hours away), Drip-and-Ship becomes the better strategy. Mothership strategy is favored by smaller difference between distances to PSC and CSC, shorter transfer time from PSC to CSC, and longer delay in reperfusion in CSC for transferred patients. Drip-and-Ship is favored by the reverse. Conclusion Drip-and-ship has a slightly higher utility than mothership. This study assesses the complex issue of prehospital triage of acute stroke patients, and can provide a framework for real-world data input.

European Stroke Organisation (ESO) guidelines on mobile stroke units for prehospital stroke management

“…Despite many efforts to speed up and optimise acute stroke patient management, still only 0.8-1.3% of acute ischaemic stroke (AIS) patients receive their intravenous thrombolysis (IVT) within the so-called golden hourthe first 60 min after symptom onset, when chances of full recovery are highest. 1,2 Many reports on stroke scales, [3][4][5][6][7] emergency medical service (EMS) training and educational programmes, [8][9][10][11][12] structured EMS pre-notification to hospital stroke teams, [13][14][15] emergency department streamlining [16][17][18][19][20] and different triage pathways (mothership vs drive the doctor vs drip and ship) [21][22][23][24][25][26][27][28][29][30][31] have all demonstrated an improvement of treatment numbers and times, but timely delivery of the available and highly beneficial reperfusion therapies [IVT and mechanical thrombectomy (MT)] to AIS patients is still underachieved. Furthermore, delays in onset to treatment times correlate to longer bolus to reperfusion times in AIS patients with proximal intracranial occlusions treated with IVT.…”

Functional Outcome of Endovascular Treatment in Patients With Acute Ischemic Stroke With Large Vessel Occlusion: Mothership Versus Drip-and-Ship Model in a Portuguese Urban Region

“…There is still ongoing debate as to which model of pre-hospital care (mothership or drip-and-ship model) offers better outcomes and regional differences might play an important role in choosing either model [16][17][18][19][20][21].…”

“…Several studies have compared outcomes from the use of the drip-and-ship and mothership models, and, although most seem to favor the mothership approach (particularly, due to higher functional independence), regional differences in geography and healthcare organization make it difficult to understand the benefit for each country and region [16][17][18][19][20][21].…”

Prehospital stroke management and mobile stroke units

“…In search of the optimal referral strategy, a modelling study of 242 874 emergency admissions in England showed that most of the inhabitants of England would gain the greatest clinical benefit from direct conveyance to a stroke centre capable of administering IAT, although the study also discussed the real-life feasibility of such an approach given the potential destabilization of the EMS system [8]. Another modelling study focusing on healthcare economics concluded that the ‘drip and ship’ approach may have a slight advantage over the ‘mothership’ approach in regard to expected costs [9]. In general, the answer to ‘drip and ship’ remains unclear and more research is required to understand the preferred approach for a specific region.…”

“…Future research may clarify the role of prehospital delivery of treatments, such as new neuroprotectants and treatments to prevent haematoma enlargement. Another modelling study focusing on healthcare economics concluded that the 'drip and ship' approach may have a slight advantage over the 'mothership' approach in regard to expected costs [9]. In general, the answer to 'drip and ship' remains unclear and more research is required to understand the preferred approach for a specific region.…”