Effect of Mobile Stroke Unit Dispatch in all Patients with Acute Stroke or <scp>TIA</scp>

Rohmann, Jessica L.; Piccininni, Marco; Ebinger, Martin; Wendt, Matthias; Weber, Joachim E.; Schwabauer, Eugen; Geisler, Frederik; Freitag, Erik; Harmel, Peter; Lorenz-Meyer, Irina; Rohrpasser-Napierkowski, Ira; Nolte, Christian H.; Nabavi, Darius G.; Schmehl, Ingo; Endres, Matthias; Audebert, Heinrich J.

doi:10.1002/ana.26541

Cited by 11 publications

(36 citation statements)

References 28 publications

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“…3 The Berlin PRehospital Or Usual Delivery of Acute Stroke Care (B_PROUD) study was a nonrandomized, controlled intervention study that enrolled patients with acute stroke events between 1 February 2017 and 8 May 2019 in Berlin, Germany, with the aim of quantifying the effect of additional MSU dispatch on patients' functional outcomes. 4,5 In the published primary analysis, the additional dispatch of MSU was found to be associated with better 3-month functional outcomes, as measured by the modified Rankin scale (mRS; ranging from 0, no symptoms to 6, death), among individuals with stroke or transient ischemic attack (TIA) and without contraindication for reperfusion treatments. 4 An extended analysis considering all stroke and TIA patients, including those with contraindications to reperfusion treatments, also found a benefit of MSU dispatch.…”

Section: Introductionmentioning

confidence: 99%

The Effect of Mobile Stroke Unit Care on Functional Outcomes: An Application of the Front-door Formula

et al. 2023

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Background: The Berlin-based B_PROUD study was designed to assess the effect of Mobile Stroke Unit (MSU) dispatch among ischemic stroke and transient ischemic attack (TIA) patients without contraindications to reperfusion treatments. However, a large proportion of patients for whom the MSU was dispatched did not ultimately receive MSU care. We estimated the causal effect of additional MSU care on 3-month functional outcomes among B_PROUD patients for whom an MSU was dispatched. Methods: We used data from the B_PROUD study (1 February 2017-8 May 2019). Given the presence of exposure–outcome unmeasured confounding, we used the front-door formula to identify the distribution of modified Rankin scale (mRS) outcomes under two hypothetical interventions: (1) receiving additional MSU care and (2) only receiving conventional care. We considered time from dispatch to thrombolysis as the full mediator, and adjusted for exposure–mediator and mediator–outcome confounding. We used a parametric estimator to estimate common odds ratio (cOR) and 95% bootstrapped confidence intervals (CI). Results: We included in total 768 ischemic stroke/TIA patients with MSU dispatch. The MSU was cancelled for 180 (23%) patients, while 588 (77%) received MSU care. The unadjusted association between care group and mRS favored conventional care (cOR=1.7, 95% CI=1.2-2.3); however, after applying the front-door formula, the mRS distribution favored MSU care (cOR=0.88, 95% CI=0.81-0.96). Conclusions: Receiving MSU care was associated with better functional outcomes than conventional care only, compatible with the hypothesized beneficial effect of MSU care on post-stroke outcomes, among stroke and TIA patients without contraindications to reperfusion treatments.

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Section: Introductionmentioning

confidence: 99%

The Effect of Mobile Stroke Unit Care on Functional Outcomes: An Application of the Front-door Formula

et al. 2023

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“…The applicability of these methods is not only restricted to observational cohort studies, but they can also be useful in non-randomized interventional studies. 39 Moreover, IPT weighting can accommodate complex, time-varying exposures and confounding structures in studies with repeated measurements and differential censoring of study participants during follow-up. 18,21 Annotated analytic code to apply IPT weighting across a diverse range of software (e.g.…”

Section: Discussionmentioning

confidence: 99%

“…In a recent real-world application, after conducting multiple imputation by chained equations, adjusted Grotta bars were presented separately for each imputed dataset. 39…”

Section: Discussionmentioning

confidence: 99%

“…In a recent real-world application, after conducting multiple imputation by chained equations, adjusted Grotta bars were presented separately for each imputed dataset. 39 Third, we cannot exclude that despite the standardized data collection in the B-SPATIAL registry some information was misclassified. Furthermore, for simplicity, in our operationalization of discharge status, we did not consider a minimum hospitalization time threshold.…”

Section: Strengths and Limitationsmentioning

confidence: 99%

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Adjusted horizontal stacked bar graphs (“Grotta bars”) for consistent presentation of observational stroke study results

Rohmann

Huerta-Gutiérrez

Audebert

et al. 2023

European Stroke Journal

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Background: Modified Rankin Scale (mRS) scores are used to measure functional outcomes after stroke. Researchers create horizontal stacked bar graphs (nicknamed “Grotta bars”) to illustrate distributional differences in scores between groups. In well-conducted randomized controlled trials, Grotta bars have a causal interpretation. However, the common practice of exclusively presenting unadjusted Grotta bars in observational studies can be misleading in the presence of confounding. We demonstrated this problem and a possible solution using an empirical comparison of 3-month mRS scores among stroke/TIA patients discharged home versus elsewhere after hospitalization. Patients and methods: Using data from the Berlin-based B-SPATIAL registry, we estimated the probability of being discharged home conditional on prespecified measured confounding factors and generated stabilized inverse probability of treatment (IPT) weights for each patient. We visualized mRS distributions by group with Grotta bars for the IPT-weighted population in which measured confounding was removed. We then used ordinal logistic regression to quantify unadjusted and adjusted associations between being discharged home and the 3-month mRS score. Results: Of 3184 eligible patients, 2537 (79.7%) were discharged home. In the unadjusted analyses, those discharged home had considerably lower mRS compared with patients discharged elsewhere (common odds ratio, cOR = 0.13, 95% CI: 0.11–0.15). After removing measured confounding, we obtained substantially different mRS distributions, visually apparent in the adjusted Grotta bars. No statistically significant association was found after confounding adjustment (cOR = 0.82, 95% CI: 0.60–1.12). Discussion and conclusion: The practice of presenting only unadjusted stacked bar graphs for mRS scores together with adjusted effect estimates in observational studies can be misleading. IPT weighting can be implemented to create Grotta bars that account for measured confounding, which are more consistent with the presentation of adjusted results in observational studies.

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“…Ultimately, patients whose stroke treatment began in an MSU had significantly better outcomes. Further evidence is emerging that mobile stroke units may improve outcomes for all transported ischemic stroke patients, not just those eligible for thrombolytics, while maintaining a high degree of patient safety [ 36 , 37 ]. The results of these and other trials are summarized in Table 2 .…”

Section: Emergency Medical Services and The Response To Strokementioning

confidence: 99%

Evolving Stroke Systems of Care: Stroke Diagnosis and Treatment in the Post-Thrombectomy Era

Pajor

Adeoye

2023

Neurotherapeutics

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Thrombectomy became the gold-standard treatment of acute ischemic stroke caused by large-vessel occlusions (LVO) in 2015 after five clinical trials published that year demonstrated significantly improved patient outcomes. In subsequent years, advances in stroke systems of care have centered around improving access to and expanding patient eligibility for thrombectomy. The prehospital and acute stroke treatment settings have had the greatest emphasis. Numerous prehospital stroke scales now provide emergency medical services with focused physical exams to identify LVOs, and many devices to non-invasively detect LVO are undergoing clinical testing. Mobile stroke units deployed throughout Western Europe and the USA also show promising results by bringing elements of acute stroke care directly to the patient. Numerous clinical trials since 2015 have aimed to increase candidates for thrombectomy by expanding indications and the eligibility time window. Further optimizations of thrombectomy treatment have focused on the role of thrombolytics and other adjunctive therapies that may promote neuroprotection and neurorecovery. While many of these approaches require further clinical investigation, the next decade shows significant potential for further advances in stroke care. Supplementary Information The online version contains supplementary material available at 10.1007/s13311-023-01371-7.

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Effect of Mobile Stroke Unit Dispatch in all Patients with Acute Stroke or TIA

Cited by 11 publications

References 28 publications

The Effect of Mobile Stroke Unit Care on Functional Outcomes: An Application of the Front-door Formula

The Effect of Mobile Stroke Unit Care on Functional Outcomes: An Application of the Front-door Formula

Adjusted horizontal stacked bar graphs (“Grotta bars”) for consistent presentation of observational stroke study results

Evolving Stroke Systems of Care: Stroke Diagnosis and Treatment in the Post-Thrombectomy Era

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