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Xu Y, Parikh NS, Jiao B, Willey JZ, Boehme AK, Elkind MSV. Decision Analysis Model for Prehospital Triage of Patients With Acute Stroke. Stroke 2020; 50:970-977. [PMID: 30908159 DOI: 10.1161/strokeaha.118.023272] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- We used a decision analysis approach to analyze triage strategies for patients with acute stroke symptoms while accounting for prehospital large vessel occlusion (LVO) screening methods and key time metrics. Methods- Our decision analysis compared anticipated functional outcomes for patients within the IV-tPA (intravenous tissue-type plasminogen activator) treatment window in the mothership and drip-and-ship frameworks. Key branches of the model included IV-tPA eligibility, presence of an LVO, and endovascular therapy eligibility. Our decision analysis evaluated 2 prehospital LVO screening approaches: (1) no formal screening and (2) the use of clinical LVO screening scales. An excellent outcome was defined as modified Rankin Scale scores 0-1. Probabilities and workflow times were guideline-based or imputed from published studies. In sensitivity analyses, we individually and jointly varied transport time to the nearest primary stroke center, additional time required to transport directly to a comprehensive stroke center, and LVO screening scale predictive probabilities. We evaluated 2 separate scenarios: one in which ideal time metrics were achieved and one under current real-world metrics. Results- In the ideal metrics scenario, the drip-and-ship strategy was almost always favored in the absence of formal LVO screening. For patients screened positive for an LVO, mothership was favored if the additional transport time to the comprehensive stroke center was <3 to 23 minutes. Under real-world conditions, in which primary stroke center workflow is slower than ideal, the mothership strategy was favored in more scenarios, regardless of formal LVO screening. For example, mothership was favored with an additional transport time to the comprehensive stroke center of <32 to 99 minutes for patients screened positive for an LVO and <28 to 39 minutes in the absence of screening. Conclusions- Joint consideration of LVO probability, screening, workflow times, and transport times may improve prehospital stroke triage. Drip-and-ship was more favorable when more ideal primary stroke center workflow times were modeled.
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Affiliation(s)
- Yaqian Xu
- From the Department of Health Policy and Management (Y.X., B.J.), Columbia University, New York, NY
| | - Neal S Parikh
- Mailman School of Public Health and Department of Neurology, Vagelos College of Physicians and Surgeons (N.S.P., J.Z.W., A.K.B., M.S.V.E.), Columbia University, New York, NY
| | - Boshen Jiao
- From the Department of Health Policy and Management (Y.X., B.J.), Columbia University, New York, NY
| | - Joshua Z Willey
- Mailman School of Public Health and Department of Neurology, Vagelos College of Physicians and Surgeons (N.S.P., J.Z.W., A.K.B., M.S.V.E.), Columbia University, New York, NY
| | - Amelia K Boehme
- Department of Epidemiology (A.K.B., M.S.V.E.), Columbia University, New York, NY
- Mailman School of Public Health and Department of Neurology, Vagelos College of Physicians and Surgeons (N.S.P., J.Z.W., A.K.B., M.S.V.E.), Columbia University, New York, NY
| | - Mitchell S V Elkind
- Department of Epidemiology (A.K.B., M.S.V.E.), Columbia University, New York, NY
- Mailman School of Public Health and Department of Neurology, Vagelos College of Physicians and Surgeons (N.S.P., J.Z.W., A.K.B., M.S.V.E.), Columbia University, New York, NY
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Smith EE, Kent DM, Bulsara KR, Leung LY, Lichtman JH, Reeves MJ, Towfighi A, Whiteley WN, Zahuranec DB. Accuracy of Prediction Instruments for Diagnosing Large Vessel Occlusion in Individuals With Suspected Stroke: A Systematic Review for the 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke 2018; 49:e111-e122. [PMID: 29367333 DOI: 10.1161/str.0000000000000160] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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