Kevin O’Connor, MD
Models of acute stroke care delivery, including for endovascular therapy (EVT), continue to evolve. Lopez-Rivera et al. piloted an integrated stroke system (ISS) in a large urban area that expanded EVT capabilities from an initial site to four EVT-capable hospitals. The ISS comprised a shared provider group, as well as a standardized management protocol. The primary endpoint was time from symptom onset to hospital arrival before and after implementation of the ISS. They also considered safety (postprocedural hemorrhage rate) and functional outcomes (good outcome defined as an mRS 0-2 at 90 days).
A total of 513 patients underwent EVT both pre- and post-ISS. Of these, primary endpoint evaluable data was available for the 352 patients (68.6%) who had a known time of symptom onset. There was a 40-minute decrease in time from known onset to hospital arrival compared to before the establishment of the ISS after adjusting for age and NIHSS (95% CI, 16–65, P<0.01). Among the 513 patients, there were decreases in both door to recanalization (153 versus 129 minutes, pre-ISS versus post-ISS, P<0.0001) and onset to groin puncture (229 versus 202 minutes, pre-ISS to post-ISS, P<0.05). Rates of procedural complications and good outcomes were comparable between the original EVT hospital and the three new sites included in the ISS. The reason that time of symptom onset was not known for 31% of the cohort was not explained and could be a source of bias.
The generalizability of the ISS paradigm is limited by geography, population density, health system resources, and the capabilities of regional hospitals from other health systems. Implementation of similar models elsewhere will be constrained by the balance between expanding EVT sites and maintaining site/provider volumes/experience.
