Abstract
Background and Purpose—
We
used a decision analysis approach to analyze triage strategies for
patients with acute stroke symptoms while accounting for prehospital
large vessel occlusion (LVO) screening methods and key time metrics.
Methods—
Our
decision analysis compared anticipated functional outcomes for patients
within the IV-tPA (intravenous tissue-type plasminogen activator)
treatment window in the mothership and drip-and-ship frameworks. Key
branches of the model included IV-tPA eligibility, presence of an LVO,
and endovascular therapy eligibility. Our decision analysis evaluated 2
prehospital LVO screening approaches: (1) no formal screening and (2)
the use of clinical LVO screening scales. An excellent outcome was
defined as modified Rankin Scale scores 0–1. Probabilities and workflow
times were guideline-based or imputed from published studies. In
sensitivity analyses, we individually and jointly varied transport time
to the nearest primary stroke center, additional time required to
transport directly to a comprehensive stroke center, and LVO screening
scale predictive probabilities. We evaluated 2 separate scenarios: one
in which ideal time metrics were achieved and one under current
real-world metrics.
Results—
In
the ideal metrics scenario, the drip-and-ship strategy was almost
always favored in the absence of formal LVO screening. For patients
screened positive for an LVO, mothership was favored if the additional
transport time to the comprehensive stroke center was <3 to 23
minutes. Under real-world conditions, in which primary stroke center
workflow is slower than ideal, the mothership strategy was favored in
more scenarios, regardless of formal LVO screening. For example,
mothership was favored with an additional transport time to the
comprehensive stroke center of <32 to 99 minutes for patients
screened positive for an LVO and <28 to 39 minutes in the absence of
screening.
Conclusions—
Joint
consideration of LVO probability, screening, workflow times, and
transport times may improve prehospital stroke triage. Drip-and-ship was
more favorable when more ideal primary stroke center workflow times
were modeled.
Footnotes
Presented in part at the International Stroke Conference, Los Angeles, CA, January 24–26, 2018.
The online-only Data Supplement is available with this article at
https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.118.023272.
Correspondence
to Mitchell S. V. Elkind, MD, MS, Division of Neurology Clinical
Outcomes Research and Population Sciences (NeuroCORPS), Department of
Neurology, Vagelos College of Physicians and Surgeons, Columbia
University, 710 W 168th St, New York, NY 10032. Email
mse13@columbia.edu
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