Integrated Stroke System Model Expands Availability of Endovascular Therapy While Maintaining Quality Outcomes.
Integrated Stroke System Model Expands Availability of Endovascular Therapy While Maintaining Quality Outcomes.
复制标题
集成卒中系统模型在维持高质量结局的同时扩大了血管内治疗的可用性。
DOI：
10.1161/strokeaha.120.032710
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发表时间：
2021-03
期刊：
影响因子：
8.3
通讯作者：
Sheth SA
中科院分区：
文献类型：
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作者：
Lopez-Rivera V;Salazar-Marioni S;Abdelkhaleq R;Savitz SI;Czap AL;Alderazi YJ;Chen PR;Grotta JC;Blackburn SL;Jones W;Spiegel G;Dannenbaum MJ;Wu TC;Cochran J;Kim DH;Day AL;Farquhar G;McCullough LD;Sheth SA
最佳的血管内卒中治疗（EVT）护理交付结构是未知的，因为治疗是高度时间敏感的，但在小容量中心也不太有效。在这里，我们介绍了我们在创建综合卒中系统（ISS）方面的经验，以扩大EVT在整个地区的可用性，同时保持医院和医生的质量标准。我们确定了2014年1月至2019年2月在我们的医疗保健系统中连续接受EVT治疗的所有LVO AIS患者。2017年10月，我们实施了国际空间站，其中又有3家医院（总共4家）成为EVT执行医院（EPHs），医生在所有中心之间轮换。该队列按时间分为iss前和iss后，主要终点为从卒中发作到EPH到达的时间。次要结局包括医院和程序质量指标。我们使用来自东南德克萨斯地区咨询委员会（SETRAC）的数据进行了外部验证。在513例接受EVT治疗的LVO AIS患者中，58%接受iss前治疗，43%接受iss后治疗。在研究期间，EVT手术量总体上有所增加，但在三个新的EPHs （<70 EVT/年）仍然相对较低。ISS后转院患者比例下降（46% vs. 37%, p<0.05）。在调整分位数回归中，ISS的实施导致从中风发作到EPH到达的时间缩短了40分钟（p<0.01），从发作到腹股沟穿刺的时间缩短了29分钟（p<0.05）。术后出血率、TICI 2b/3和90d mRS在高容量和低容量eph下是相当的。从发病到到达时间的改善并不能反映出地区院前护理长期趋势的总体改善。在我们的系统中，增加EVT的可用性减少了从中风发作到EPH到达的时间。国际空间站提供了一个框架，以保持低容量医院的质量。
The optimal endovascular stroke therapy (EVT) care delivery structure is unknown, as the treatment is highly time-sensitive but also less efficacious in lower volume centers. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards. We identified all consecutive patients with LVO AIS treated with EVT from Jan 2014 – Feb 2019 in our health care system. In Oct 2017 we implemented the ISS, in which 3 additional hospitals (4 total) became EVT performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the SouthEast Texas Regional Advisory Council (SETRAC). Among 513 patients with LVO AIS treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the three new EPHs (<70 EVT/year). After ISS, the proportion of patients that underwent inter-hospital transfer decreased (46% vs. 37%, p<0.05). In adjusted quantile regression, ISS implementation resulted in a reduction of time from stroke onset to EPH arrival by 40 minutes (p<0.01) and onset to groin puncture by 29 min (p<0.05). Rates of post-procedural hemorrhage, TICI 2b/3 and 90d mRS were comparable at the higher and lower volume EPHs. The improvement in onset to arrival time was not reflective of overall improvement in secular trends in regional pre-hospital care. In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.