From the Department of Neurology (L.K.S., S.T., M.S.D.), Icahn School of Medicine at Mount Sinai, New York, NY.
Department of Neurosurgery (J.F., J.M.), Icahn School of Medicine at Mount Sinai, New York, NY.
Stroke. 2019 Jul;50(7):1789-1796. doi: 10.1161/STROKEAHA.119.024869. Epub 2019 Jun 5.
Background and Purpose- Multiple randomized clinical trials have demonstrated the superiority of endovascular therapy (ET) for large vessel occlusion acute ischemic stroke (AIS). Few centers can provide ET, and significant debate exists about the most efficient and effective ways to provide ET. We sought to assess real-world utilization of ET, the extent to which patients are transferred from one hospital to another for therapy and the implications of transfer status on outcomes. Methods- We used the 2015 to 2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database, which contains nationwide data on nearly half of US admissions. We identified index AIS admissions, vascular risk factors, and treatment with intravenous thrombolysis and ET using International Classification of Disease, Ninth Revision, and International Classification of Disease, Tenth Revision Clinical Modification codes. Main predictors of outcome were treatment with ET and whether there was an interhospital transfer during the index AIS hospitalization. Among patients with AIS readmitted within 30 days, we examined 3 main outcomes: total charges, length of stay, and in-hospital mortality. Results- A total of 23 121 AIS admissions were treated with ET and 874 229 without. Over 5% of patients who received ET were transferred during the index admission compared with <2% of those not treated with ET. Length of stay and total charges were significantly higher in patients transferred (12.3 versus 9.6 days and $233 626 versus $182 881, respectively). More patients treated with ET who were not transferred to the index hospital were discharged home (25.3% versus 44.4%), and ≈25% of patients transferred for ET died during the hospitalization compared with 15.5% not transferred. Conclusions- The minority of all patients with AIS receive ET. The majority of patients who receive ET present directly to the center that performs the procedure, and those transferred for ET have higher length of stay, cost, and mortality that those not transferred.
背景与目的-多项随机临床试验已经证明了血管内治疗（endovascular therapy，ET）在治疗大血管闭塞性急性缺血性脑卒中（acute ischemic stroke，AIS）方面的优越性。只有少数中心能够提供 ET，而且对于提供 ET 的最有效和最有效的方法仍存在很大的争议。我们旨在评估 ET 的实际应用情况，患者从一家医院转至另一家医院接受治疗的程度，以及转院状态对结果的影响。方法-我们使用了 2015 年至 2016 年全国再入院数据库（Healthcare Cost and Utilization Project Nationwide Readmissions Database），该数据库包含了全美近一半的住院数据。我们通过国际疾病分类第 9 版（International Classification of Diseases, Ninth Revision）和国际疾病分类第 10 版临床修订版（International Classification of Diseases, Tenth Revision Clinical Modification）代码识别出索引 AIS 入院、血管风险因素以及静脉溶栓和 ET 治疗。主要预后预测因素为 ET 治疗和索引 AIS 住院期间是否有院内转院。在 30 天内再入院的 AIS 患者中，我们检查了 3 个主要结局：总费用、住院时间和院内死亡率。结果-共有 23121 例 AIS 患者接受了 ET 治疗，874229 例患者未接受 ET 治疗。与未接受 ET 治疗的患者相比，接受 ET 治疗的患者中，有 5%以上在索引住院期间进行了转院，而接受 ET 治疗的患者中，有 2%以下进行了转院。转院患者的住院时间和总费用明显较高（分别为 12.3 天和 233626 美元，9.6 天和 182881 美元）。更多未转至索引医院的接受 ET 治疗的患者出院回家（25.3%比 44.4%），而约 25%的转院接受 ET 治疗的患者在住院期间死亡，而未转院的患者为 15.5%。结论-只有少数 AIS 患者接受 ET 治疗。大多数接受 ET 治疗的患者直接到进行该治疗的中心就诊，而转院接受 ET 治疗的患者住院时间、费用和死亡率更高。
