Recommendations for Regional Stroke Destination Plans in Rural, Suburban, and Urban Communities From the Prehospital Stroke System of Care Consensus Conference: A Consensus Statement From the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: Endorsed by the N

Jauch, Edward C.; Schwamm, Lee H.; Panagos, Peter; Barbazzeni, Jolene; Dickson, Robert; Dunne, Robert; Foley, Jenevra; Fraser, Justin F.; Lassers, Geoffrey; Martin‐Gill, Christian; O'Brien, Suzanne; Pinchalk, Mark; Prabhakaran, Shyam; Richards, Christopher T; Taillac, Peter; Tsai, Albert; Yallapragada, Anil

doi:10.1161/strokeaha.120.033228

Cited by 68 publications

(63 citation statements)

References 60 publications

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“…This tradeoff needs to be determined based on the specific characteristics of the given stroke system of care. 35 The use of perfusion imaging at a PSC can enable more specific triage of patients meeting the criteria for endovascular therapy, and thus warranting transfer to the CSC. This information at the PSC level may be especially desirable from a hospital system perspective where unnecessary transfers prove both resource and time consuming.…”

Section: Health System Structure Mobile Stroke Units and Population D...mentioning

confidence: 99%

Should Primary Stroke Centers Perform Advanced Imaging?

Hill

Warach

Rostanski

2022

Stroke

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Section: Health System Structure Mobile Stroke Units and Population D...mentioning

confidence: 99%

Should Primary Stroke Centers Perform Advanced Imaging?

Hill

Warach

Rostanski

2022

Stroke

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“…Policy changes such as expanded payment for telehealth, or clinically driven efforts such as including partnerships with rural hospitals in stroke center recognition, could further ensure adequate access to high-technology stroke care. 31–33…”

Section: Discussionmentioning

confidence: 99%

Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years

Hammond

Waken

Johnson

et al. 2022

Stroke

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Background: There are glaring racial and rural-urban inequities in stroke outcomes. The objective of this study was to determine whether there were recent changes to trends in racial inequities in stroke treatment and in-hospital mortality, and whether racial inequities differed across rural strata. Methods: Retrospective analysis of Black and White patients >18 years old admitted to US acute care hospitals with a primary discharge diagnosis of stroke (unweighted N=652 836) from the National Inpatient Sample from 2012 to 2017. Rural residence was classified by county as urban, town, or rural. The primary outcomes were intravenous thrombolysis and endovascular therapy use among patients with acute ischemic stroke, and in-hospital mortality for all stroke patients. Logistic regression models were run for each outcome adjusting for age, comorbidities, primary payer, and ZIP code median income. Results: The sample was 53% female, 81% White, and 19% Black. Black patients from rural areas had the lowest odds of receiving intravenous thrombolysis (adjusted odds ratio [aOR], 0.43 [95% CI, 0.37–0.50]) and endovascular therapy (aOR, 0.60 [0.46–0.78]), compared with White urban patients. Black rural patients were the least likely to be discharged home after a stroke compared with White/urban patients (aOR, 0.79 [0.75–0.83]), this was true for Black patients across the urban-rural spectrum when compared with Whites. Black patients from urban areas had lower mortality than White patients from urban areas (aOR, 0.87 [0.84–0.91]), while White patients from rural areas (aOR, 1.14 [1.10–1.19]) had the highest mortality of all groups. Conclusions: Black patients living in rural areas represent a particularly high-risk group for poor access to advanced stroke care and impaired poststroke functional status. Rural White patients have the highest in-hospital mortality. Clinical and policy interventions are needed to improve access and reduce inequities in stroke care and outcomes.

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“…This strategy, also known as ‘bypass’, has been recommended in US and European guidelines for suspected LAO. 37 – 39 This has the net effect of converting any hybrid system towards a de facto mothership model, with a pronounced increase in the proportion of patients conveyed directly to an IVT/MT centre, and a corresponding reduction in admissions to IVT-only units, effectively negating the mitigating effect of having IVT-only units. These considerations of institutional viability (at either end of the scale for stroke admissions) have not featured in the reasoning behind other analyses based on additional transport time and bypass.…”

Section: Discussionmentioning

confidence: 99%

National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study

Allen

Pearn

Ford

et al. 2021

European Stroke Journal

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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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Cited by 68 publications

References 60 publications

Should Primary Stroke Centers Perform Advanced Imaging?

Should Primary Stroke Centers Perform Advanced Imaging?

Racial Inequities Across Rural Strata in Acute Stroke Care and In-Hospital Mortality: National Trends Over 6 Years

National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study

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