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. 2024 Jan 12;16(2):151-155.
doi: 10.1136/jnis-2023-020128.

Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence

Laura K Stein  1 , Luke Maillie  2 , John Erdman  3 , Emma Loebel  4 , Naomi Mayman  2 , Akarsh Sharma  2 , Sophia Wolmer  5 , Stanley Tuhrim  4 , Johanna T Fifi  4   6 , Nathalie Jette  4   7 , J Mocco  6 , Mandip S Dhamoon  4
Affiliations

Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence

Laura K Stein et al. J Neurointerv Surg. .

Abstract

Background: Although national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in revascularization therapies and stroke center certification. We hypothesized that we would observe overall growth in revascularization therapy utilization, but observed differences would vary greatly regionally.

Methods: A retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019. We identified AIS admissions and treatment with thrombolysis and endovascular thrombectomy (ET) with International Classification of Diseases, 10th Revision, Clinical Modification codes. We grouped hospitals in Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR) and calculated hospital, demographic, and acute stroke treatment characteristics for each HRR. We calculated the percent of hospitals with stroke certification and AIS cases treated with thrombolysis or ET per HRR.

Results: There were 957 958 AIS admissions. Relative mean (SD) growth in percent of AIS admissions receiving revascularization therapy per HRR from 2016 to 2019 was 13.4 (31.7)% (IQR -6.1-31.7%) for thrombolysis and 28.0 (72.0)% (IQR 0-56.0%) for ET. The proportion of HRRs with decreased or no difference in ET utilization was 38.9% and the proportion of HRRs with decreased or no difference in thrombolysis utilization was 32.7%. Mean (SD) stroke center certification proportion across HRRs was 45.3 (31.5)% and this varied widely (IQR 18.3-73.4%).

Conclusions: Overall growth in AIS treatment has been modest and, within HRRs, growth in AIS treatment and the proportion of centers with stroke certification varies dramatically.

Keywords: stroke; thrombectomy.

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Conflict of interest statement

Competing interests: NJ receives grant funding paid to her institution for grants unrelated to this work from NINDS (NIH U24NS107201, NIH IU54NS100064, 3R01CA202911-05S1, R21NS122389, R01HL161847). She receives an honorarium for her work as an Associate Editor of Epilepsia. JM is an investor in: Cerebrotech, Imperative Care, Endostream, Viseon, BlinkCNS, Serenity, NTI, RIST, NRT, Viz.ai, Synchron, Tulavi, Sim&Cure, Songbird, Borvo, Whisper, Neurolutions. He serves, or has recently served, as a consultant for: Imperative Care, Cerebrotech, Endostream, Vastrax, RIST, Synchron, NRT, Viz.ai, Perflow, CVAid.

Figures

Figure 1a.
Figure 1a.. Change in Proportion of Medicare Acute Stroke Admissions Treated with Thrombolysis from 2016–2019 by Hospital Referral Region
This map shows the difference in the proportion of Medicare acute ischemic stroke (AIS) patients treated with thrombolysis, by Hospital Referral Region (HRR), from January 2016-January 2019. Green denotes an HRR with an increase in the proportion of AIS treated with thrombolysis, red a decrease, and gray no difference.
Figure 1b.
Figure 1b.. Change in Proportion of Medicare Acute Stroke Admissions Treated with Endovascular Thrombectomy from 2016–2019 by Hospital Referral Region
This map shows the difference in the proportion of Medicare acute ischemic stroke (AIS) patients treated with endovascular thrombectomy, by Hospital Referral Region (HRR), from January 2016-January 2019. Green denotes an HRR with an increase in the proportion of AIS treated with thrombolysis, red a decrease, and gray no difference.
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