Transfer Delays for EVT Linked to Worse Functional Outcomes in AIS

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Transfer Delays for EVT Linked to Worse Functional Outcomes in AIS

 Longer door-in-door-out times for EVT for AIS are significantly associated with worse functional outcomes and lower odds of independent ambulation at discharge. Worse functional outcomes and higher complication rates in acute ischemic stroke (AIS) are strongly associated with longer endovascular therapy (EVT) transfer door-in-door-out (DIDO) time, according to results of a study published in The Lancet Neurology  The American Heart Association (AHA) and American Stroke Association (ASA) recommend that a DIDO time should not exceed 90 minutes. However, data from the Get With The Guidelines (GWTG)–Stroke registry indicate that the median DIDO time is 132 minutes. Investigators analyzed data from the GWTG-Stroke registry to assess the functional outcomes of longer DIDO times. Adults (N=22,410) with AIS who were transferred to an acute care hospital for EVT between 2019 and 2023 were evaluated for Modified Rankin Scale (mRS) at discharge on the basis of DIDO time. The patients had a median age of 70 (IQR, 60-80) years, 50.1% were women, 73.9% were White, the median DIDO time was 121 (IQR, 89-175) minutes, they had a median National Institutes of Health Stroke Severity (NIHSS) score of 14 (IQR, 7-21) at the EVT hospital arrival, and 75.8% underwent EVT. …delays in DIDO time at transferring hospitals were associated with lower odds of receiving endovascular therapy, greater odds of complications after reperfusion therapy, worse functional status, and lower odds of independent ambulation at discharge. The patients had a DIDO time within 90 minutes (26.3%), between 91 and 180 minutes (50.4%), between 181 and 270 minutes (13.4%), and longer than 270 minutes (9.8%). In the fully adjusted model, patients with DIDO times longer than 270 minutes (adjusted odds ratio [aOR], 1.70; 95% CI, 1.53-1.89), between 181 and 270 minutes (aOR, 1.49; 95% CI, 1.36-1.64), and between 91 and 180 minutes (aOR, 1.29; 95% CI, 1.20-1.37) were more likely to have an mRS ordinal shift compared with patients who had a DIDO time within 90 minutes. Similarly, the patients with a DIDO time of 91 minutes or longer were more likely to have an mRS score at discharge of at least 3 (aOR range, 1.33-1.63) or 4 (aOR range, 1.22-1.60) and were less likely to have the ability to ambulate independently (aOR range, 0.67-0.85) than patients with a DIDO time within 90 minutes. The patients with DIDO times longer than 90 minutes were also less likely to receive EVT (aOR range, 0.35-0.71) and to have no post-reperfusion complications (aOR range, 0.74-0.85) than patients with DIDO times within AHA/ASA recommendations. In a secondary analysis, the investigators observed that the association between longer DIDO times and worse mRS at discharge were stronger among the patients who received EVT than those who did not. The supplementary analysis that excluded patients who did not receive EVT replicated the association between longer DIDO times and worse functional outcomes. This study may have been limited by sourcing data from hospitals participating in the GWTG-Stroke quality improvement program, so results may not be generalizable to nonparticipating sites. The study investigators concluded, “In this national cohort study of patients with acute ischemic stroke transferred for consideration of endovascular therapy, delays in DIDO time at transferring hospitals were associated with lower odds of receiving endovascular therapy, greater odds of complications after reperfusion therapy, worse functional status, and lower odds of independent ambulation at discharge.” In an interview with Cardiology Advisor, Brian Stamm, MD, MSc, clinical assistant professor of Neurology at the University of Michigan, American Heart Association volunteer, and one of the authors of this study, also discussed the barriers that may make it difficult for hospitals and healthcare systems to implement strategies to minimize DIDO time. “While the current study did not specifically assess barriers to minimizing DIDO time, prior studies suggest the following factors may be important: failure to perform early stroke screens, delays in telestroke consultation, processes of arranging interhospital transfer, and communication issues between the sending and receiving hospital, among other factors,” said Dr Stamm, going on to explain that his team is currently studying ways for hospitals and healthcare systems to navigate these barriers. “Dr Prabhakaran’s NIH-funded HI-SPEED study seeks to implement a 7-component intervention to improve the accuracy and timeliness of acute stroke diagnosis and DIDO time for patients requiring transfer. The intervention includes stroke screening scales, brain imaging protocols, early assessment with telestroke, interhospital communication using app-based technologies, door-to-needle (thrombolysis) best practices, early ambulance activation, and a standardized hand-off tool for paramedics. This ongoing study will determine whether this intervention improves DIDO times for patients with stroke.” Disclosure: One study author declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures. References:Royan R, Stamm B, Giuracanu M, et al.