Real-World Treatment Trends in Endovascular Stroke Therapy

Abstract

Background and Purpose- Recent landmark trials provided overwhelming evidence for effectiveness of endovascular stroke therapy (EST). Yet, the impact of these trials on clinical practice and effectiveness of EST among lower volume centers remains poorly characterized. Here, we determine population-level patterns in EST performance in US hospitals and compare EST outcomes from higher versus lower volume centers. Methods- Using validated diagnosis codes from data on all discharges from hospitals and Emergency Rooms in Florida (2006-2016) and the National Inpatient Sample (2012-2016) we identified patients with acute ischemic stroke treated with EST. The primary end point was good discharge outcome defined as discharge to home or acute rehabilitation facility. Multivariate regressions adjusted for medical comorbidities, intravenous tPA (tissue-type plasminogen activator) usage and annual hospital stroke volume were used to evaluate the likelihood of good outcome over time and by annual hospital EST volume. Results- A total of 3890 patients (median age, 73 [61-82] years, 51% female) with EST were identified in the Florida cohort and 42 505 (median age, 69 [58-79], 50% female) in the National Inpatient Sample. In both Florida and the National Inpatient Sample, the number of hospitals performing EST increased continuously. Increasing numbers of EST procedures were performed at lower annual EST volume hospitals over the studied time period. In adjusted multivariate regression, there was a continuous increase in the likelihood of good outcomes among patients treated in hospitals with increasing annual EST procedures per year (odds ratio, 1.1; 95% CI, 1.1-1.2 in Florida and odds ratio, 1.3; 95% CI, 1.2-1.4 in National Inpatient Sample). Conclusions- Analysis of population-level datasets of patients treated with EST from 2006 to 2016 demonstrated an increase in the number of centers performing EST, resulting in a greater number of procedures performed at lower volume centers. There was a positive association between EST volume and favorable discharge outcomes in EST-performing hospitals.

Keywords: endovascular procedures; population health; procedures and techniques utilization; stroke; thrombectomy.

Figure 1.

Annual trends in EST procedures performed in Florida (2006 – 2016). (a) Total EST procedures performed by year. (b) Total number of hospitals performing at least 1 EST procedure by year. On average, the number of EST-capable hospitals increased by 4 per year. (c) Total number of patient transfers from one Emergency Department to another hospital for EST.

Figure 2.

Distribution of EST procedures in hospitals performing EST in Florida. Histogram depicting the percentage of annual total EST procedures versus total number of hospital divided into bins for 2008 and 2016. Hospitals were divided into bins by ranking of total number of annual EST procedures.

Figure 3.

Growth of annual EST procedures by time of initial EST procedure. Mean (± SEM) annual EST procedures for hospitals that began performing EST procedures prior to 2012 and those that began in 2012 or later versus time.

Figure 4.

Annual trends in EST procedures performed in Nation-wide cohort (2012 – 2016). (a) Total EST procedures performed by year. (b) Total number of hospitals performing at least 1 EST procedure by year. On average, the number of EST-capable hospitals increased by 188 per year. (c) Total number of EST procedures performed at hospital performing fewer than 20 procedures per year.