Abstract
ObjectivesTo 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.DesignOutcome-based modelling study.Setting107 acute stroke centres in England, 24 of which provide IVT and MT (IVT/MT centres) and 83 provide only IVT (IVT-only units).Participants242,874 emergency admissions with acute stroke over 3 years (2015–2017).InterventionReperfusion 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 measuresPopulation benefit from reperfusion, time to IVT and MT, admission numbers to IVT-only units and IVT/MT centres.ResultsWithout 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.ConclusionsImplementation 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.
Highlights
In England, about 80,000 people are hospitalised each year with acute stroke,[1,2] and over half of these people are left with long-term disability at great cost to individuals and society.[3]
Disability and institutionalisation after ischaemic stroke are significantly reduced by reperfusion treatments – intravenous thrombolysis (IVT)[4] and mechanical thrombectomy (MT).[5]
The location of thrombolysis centres was taken as the 107 hyperacute stroke units in England providing thrombolysis in 2019.2 Within this number, the location of IVT/MT centres, in our base case model, was taken as the 24 neuroscience centres in England which are either providing or planning to provide MT2.12
Summary
In England, about 80,000 people are hospitalised each year with acute stroke,[1,2] and over half of these people are left with long-term disability at great cost to individuals and society.[3]. In 2019–2020, in the UK, these treatments were given to 11.7% and 1.8% of patients with acute stroke, respectively.[2] The 2019 NHS England Long Term Plan[8] set out the ambition that, by 2025, acute stroke units will deliver IVT to about 20% of patients, and MT to about 10%. To achieve such increases in reperfusion, the NHS England Long Term Plan acknowledges the need for the centralisation of hyperacute stroke care into fewer well-equipped and staffed hospitals, noting that metropolitan areas that have recently centralised stroke care have achieved improved outcomes.[9,10]
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