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Nguyen CP, Maas WJ, van der Zee DJ, Uyttenboogaart M, Buskens E, Lahr MMH. Cost-effectiveness of improvement strategies for reperfusion treatments in acute ischemic stroke: a systematic review. BMC Health Serv Res 2023; 23:315. [PMID: 36998011 PMCID: PMC10064746 DOI: 10.1186/s12913-023-09310-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Reducing delays along the acute stroke pathway significantly improves clinical outcomes for acute ischemic stroke patients eligible for reperfusion treatments. The economic impact of different strategies reducing onset to treatment (OTT) is crucial information for stakeholders in acute stroke management. This systematic review aimed to provide an overview on the cost-effectiveness of several strategies to reduce OTT. METHODS A comprehensive literature search was conducted in EMBASE, PubMed, and Web of Science until January 2022. Studies were included if they reported 1/ stroke patients treated with intravenous thrombolysis and/or endovascular thrombectomy, 2/ full economic evaluation, and 3/ strategies to reduce OTT. The Consolidated Health Economic Evaluation Reporting Standards statement was applied to assess the reporting quality. RESULTS Twenty studies met the inclusion criteria, of which thirteen were based on cost-utility analysis with the incremental cost-effectiveness ratio per quality-adjusted life year gained as the primary outcome. Studies were performed in twelve countries focusing on four main strategies: educational interventions, organizational models, healthcare delivery infrastructure, and workflow improvements. Sixteen studies showed that the strategies concerning educational interventions, telemedicine between hospitals, mobile stroke units, and workflow improvements, were cost-effective in different settings. The healthcare perspective was predominantly used, and the most common types of models were decision trees, Markov models and simulation models. Overall, fourteen studies were rated as having high reporting quality (79%-94%). CONCLUSIONS A wide range of strategies aimed at reducing OTT is cost-effective in acute stroke care treatment. Existing pathways and local characteristics need to be taken along in assessing proposed improvements.
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Affiliation(s)
- Chi Phuong Nguyen
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands.
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
- Department of Pharmaceutical Administration and Economics, Hanoi University of Pharmacy, Hanoi, Vietnam.
| | - Willemijn J Maas
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Erik Buskens
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, the Netherlands
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Maarten M H Lahr
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
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Price CI, White P, Balami J, Bhattarai N, Coughlan D, Exley C, Flynn D, Halvorsrud K, Lally J, McMeekin P, Shaw L, Snooks H, Vale L, Watkins A, Ford GA. Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT. PROGRAMME GRANTS FOR APPLIED RESEARCH 2022. [DOI: 10.3310/tzty9915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Intravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.
Objectives
The aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.
Design
A mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.
Setting
The paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.
Participants
A total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.
Interventions
The paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.
Main outcome measures
The primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.
Data sources
National registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.
Review methods
Systematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Results
The paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).
Limitations
Evidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.
Conclusions
Paramedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.
Future work
Further evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.
Trial registration
This trial is registered as ISRCTN12418919 and the systematic review protocols are registered as PROSPERO CRD42014010785 and PROSPERO CRD42015016649.
Funding
The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Phil White
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joyce Balami
- Department of Stroke Medicine, Norfolk and Norwich University Teaching Hospital NHS Trust, Norwich, UK
| | - Nawaraj Bhattarai
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Diarmuid Coughlan
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- School of Health & Life Sciences, Teesside University, Middlesbrough, UK
| | - Kristoffer Halvorsrud
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Lally
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- School of Health, Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Snooks
- Centre for Health Information Research and Evaluation, Medical School, Swansea University, Swansea, UK
| | - Luke Vale
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alan Watkins
- Centre for Health Information Research and Evaluation, Medical School, Swansea University, Swansea, UK
| | - Gary A Ford
- Oxford Academic Health Science Network, Oxford University and Oxford University Hospitals, Oxford, UK
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Price CI, Shaw L, Dodd P, Exley C, Flynn D, Francis R, Islam S, Javanbakht M, Lakey R, Lally J, McClelland G, McMeekin P, Rodgers H, Snooks H, Sutcliffe L, Tyrell P, Vale L, Watkins A, Ford GA. Paramedic Acute Stroke Treatment Assessment (PASTA): study protocol for a randomised controlled trial. Trials 2019; 20:121. [PMID: 30755249 PMCID: PMC6373128 DOI: 10.1186/s13063-018-3144-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 12/17/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite evidence from clinical trials that intravenous (IV) thrombolysis is a cost-effective treatment for selected acute ischaemic stroke patients, there remain large variations in the rate of IV thrombolysis delivery between stroke services. This study is evaluating whether an enhanced care pathway delivered by paramedics (the Paramedic Acute Stroke Treatment Assessment (PASTA)) could increase the number of patients who receive IV thrombolysis treatment. METHODS Study design: Cluster randomised trial with economic analysis and parallel process evaluation. SETTING National Health Service ambulance services, emergency departments and hyper-acute stroke units within three geographical regions of England and Wales. Randomisation: Ambulance stations within each region are the units of randomisation. According to station allocation, paramedics based at a station deliver the PASTA pathway (intervention) or continue with standard stroke care (control). Study intervention: The PASTA pathway includes structured pre-hospital information collection, prompted pre-notification, structured handover of information in hospital and assistance with simple tasks during the initial hospital assessment. Study-trained intervention group paramedics deliver this pathway to adults within 4 h of suspected stroke onset. Study control: Standard stroke care according to national and local guidelines for the pre-hospital and hospital assessment of suspected stroke. PARTICIPANTS Participants enrolled in the study are adults with confirmed stroke who were assessed by a study paramedic within 4 h of symptom onset. PRIMARY OUTCOME Proportion of participants receiving IV thrombolysis. SAMPLE SIZE 1297 participants provide 90% power to detect a 10% difference in the proportion of patients receiving IV thrombolysis. DISCUSSION The results from this trial will determine whether an enhanced care pathway delivered by paramedics can increase thrombolysis delivery rates. TRIAL REGISTRATION ISRCTN registry, ISRCTN12418919 . Registered on 5 November 2015.
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Affiliation(s)
- Christopher I. Price
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Peter Dodd
- Lay investigator. Contact via: Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Catherine Exley
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Saiful Islam
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP Wales
| | - Mehdi Javanbakht
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Rachel Lakey
- Newcastle Clinical Trials Unit, Newcastle University, 1-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Joanne Lally
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Graham McClelland
- North East Ambulance Service, Bernicia House, Goldcrest Way, Newburn Riverside, Newcastle upon Tyne, NE15 8NY UK
| | - Peter McMeekin
- Faculty of Health & Life Sciences, Northumbria University, 2nd floor Northumberland Building, Newcastle upon Tyne, NE1 8ST UK
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP UK
| | - Helen Snooks
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP Wales
| | - Louise Sutcliffe
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE UK
| | - Pippa Tyrell
- Stroke Medicine, Clinical Sciences Building, Salford Royal Hospitals’ NHS Foundation Trust, Salford, M6 8HD UK
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX UK
| | - Alan Watkins
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP Wales
| | - Gary A. Ford
- Medical Sciences Division, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Level 3, John Radcliffe Hospital, Oxford, OX3 9DU UK
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Hubert GJ, Meretoja A, Audebert HJ, Tatlisumak T, Zeman F, Boy S, Haberl RL, Kaste M, Müller-Barna P. Stroke Thrombolysis in a Centralized and a Decentralized System (Helsinki and Telemedical Project for Integrative Stroke Care Network). Stroke 2016; 47:2999-3004. [PMID: 27834751 DOI: 10.1161/strokeaha.116.014258] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/14/2016] [Accepted: 10/05/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis with tissue-type plasminogen activator (tPA) for acute ischemic stroke is more effective when delivered early. Timely delivery is challenging particularly in rural areas with long distances. We compared delays and treatment rates of a large, decentralized telemedicine-based system and a well-organized, large, centralized single-hospital system. METHODS We analyzed the centralized system of the Helsinki University Central Hospital (Helsinki and Province of Uusimaa, Finland, 1.56 million inhabitants, 9096 km2) and the decentralized TeleStroke Unit network in a predominantly rural area (Telemedical Project for Integrative Stroke Care [TEMPiS], South-East Bavaria, Germany, 1.94 million inhabitants, 14 992 km2). All consecutive tPA treatments were prospectively registered. We compared tPA rates per total ischemic stroke admissions in the Helsinki and TEMPiS catchment areas. For delay comparisons, we excluded patients with basilar artery occlusions, in-hospital strokes, and those being treated after 270 minutes. RESULTS From January 1, 2011, to December 31, 2013, 912 patients received tPA in Helsinki University Central Hospital and 1779 in TEMPiS hospitals. Area-based tPA rates were equal (13.0% of 7017 ischemic strokes in the Helsinki University Central Hospital area versus 13.3% of 14 637 ischemic strokes in the TEMPiS area; P=0.078). Median prehospital delays were longer (88; interquartile range, 60-135 versus 65; 48-101 minutes; P<0.001) but in-hospital delays were shorter (18; interquartile range, 13-30 versus 39; 26-56 minutes; P<0.001) in Helsinki University Central Hospital compared with TEMPiS with no difference in overall delays (117; interquartile range, 81-168 versus 115; 87-155 minutes; P=0.45). CONCLUSIONS A decentralized telestroke thrombolysis service can achieve similar treatment rates and time delays for a rural population as a centralized system can achieve for an urban population.
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Affiliation(s)
- Gordian J Hubert
- From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.).
| | - Atte Meretoja
- From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.)
| | - Heinrich J Audebert
- From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.)
| | - Turgut Tatlisumak
- From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.)
| | - Florian Zeman
- From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.)
| | - Sandra Boy
- From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.)
| | - Roman L Haberl
- From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.)
| | - Markku Kaste
- From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.)
| | - Peter Müller-Barna
- From the Department of Neurology, TEMPiS, Städtisches Klinikum München, Germany (G.J.H., R.L.H.); Department of Neurology, Helsinki University Central Hospital, Finland (A.M., T.T., M.K.); Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia (A.M.); Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia (A.M.); Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Germany (H.J.A.); Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg, Sweden (T.T.); Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden (T.T.); Center for Clinical Studies, University Hospital Regensburg, Germany (F.Z.); Department of Neurology, Asklepios Stadtklinik Bad Tölz, Germany (S.B.); and Department of Analysis, Concept and Consulting, Medical Services of Compulsory Health Insurance Funds, Munich, Germany (P.M.-B.)
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