Using Best-Worst Scaling to Understand the Preferences of Stroke Survivors, their Relatives/Carers and the Public on Providing Stroke Thrombectomy Services in England

Abstract

Background Outcomes for acute ischaemic stroke patients with large artery occlusion are significantly improved with endovascular thrombectomy (EVT). We aimed to identify preferences of stroke survivors, their relatives/carers and the public in England on: (i) EVT service organisation (localised versus centralised expert-delivered EVT services) and (ii) modelled outcomes for EVT effectiveness, equity of access and costs of EVT provision (based on increasing the number of comprehensive stroke centres across England that provide EVT from 24 to 30).Methods Stroke survivors, their relatives/carers and the public were engaged in an iterative co-design process to develop an accessible survey incorporating two Best-Worst Scaling (BWS) tasks: EVT service organisation (4 attributes each with 2 levels) and modelled outcomes (3 attributes each with 2 levels). On-line pilot testing was undertaken with 10 stroke survivors/carers. BWS data were transformed into standardised scores with corresponding 95% confidence intervals (CIs).Results 105 respondents completed the survey (stroke survivors [18%]; relative/carer of stroke survivor [32%]; member of public [50%]). Centralised (local) EVT provision by experienced and specialised medical teams was associated with the strongest positive preference (0.76, 95% CIs = 0.69, 0.82), followed by secondary inter-hospital transfer for EVT; associated with positive preferences whether required (0.15, 95% CIs = 0.07, 0.22) or not (0.30, 95% CIs = 0.22, 0.38). Travel times by emergency ambulance > 45 min (-0.29, 95% CIs=-0.37, -0.22) were associated with stronger negative preferences than length of stay < 48 hours [-0.16, 95% CIs=- 0.22, − 0.10). Maximal effectiveness of EVT (52% recovering with none/mild disability) was associated with stronger positive preferences (0.40, 95% CIs = 0.27, 0.53) than equity of access (71% or 72% of eligible patients) to EVT within 7 hours since onset of stroke symptoms, which was associated with marginal positive preferences. Costs of EVT provision were associated with negative preferences; maximal cost had the strongest negative preference (-0.29, 95% CIs=-0.40, -0.18).Conclusions Centralised stroke centres with experienced specialised teams and secondary transfers with travel times ≤ 45 minutes are likely to be acceptable to patients/carers and the public. Equity of access to EVT may be less of a priority than effectiveness, although both were considered more important than costs of EVT provision.