Alkhouli Mohamad, Alqahtani Fahad, Hopkins L Nelson, Harris Alyssa H, Hohmann Samuel F, Tarabishy Abdul, Holmes David R
Department of Cardiology, Mayo Clinic School of Medicine, Rochester, Minnesota.
Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York.
JACC Cardiovasc Interv. 2020 Sep 28;13(18):2159-2166. doi: 10.1016/j.jcin.2020.05.025. Epub 2020 Aug 26.
The aim of this study was to assess whether offering local endovascular stroke therapy (EST) rather than transferring patients off-site to receive EST would improve outcomes.
There are limited data to determine whether offering EST on-site rather than transferring patients to receive EST off-site improves clinical outcomes.
A large academic consortium database was queried to identify patients with acute ischemic stroke who received EST between October 2015 and September 2019. Primary endpoints were in-hospital mortality and poor functional outcomes. Secondary endpoints were major complications, length of stay, and cost. Baseline characteristics were adjusted for using propensity score matching and multivariate risk adjustment.
A total of 22,193 patients with acute ischemic stroke who underwent EST (50.8% on-site, 49.2% off-site) were included. Mean ages were 67.9 ± 15.5 years and 68.4 ± 15.5 years, respectively (p = 0.03). In the propensity score matching analysis, mortality and poor functional outcomes were higher in the off-site EST group (14.7% vs. 11.2% and 40.7% vs. 35.9%, respectively; p < 0.001). In the risk-adjusted analyses with different models, in-hospital mortality and poor functional outcomes remained significantly higher in the off-site EST group. In the most comprehensive model (adjusting for age, sex, demographics, risk factors, tissue plasminogen activator use, and institutional EST volume), in-hospital mortality and poor functional outcomes were significantly higher in the off-site EST group, with odds ratios of 1.38 (95% confidence interval: 1.26 to 1.51) and 1.26 (95% confidence interval: 1.18 to 1.34), respectively (p < 0.001). The incidence of intracranial hemorrhage and mechanical ventilation was higher in the off-site group, but cost was higher in the on-site group in both the propensity score matching and risk-adjusted analyses.
In contemporary U.S. practice, patients with acute ischemic stroke treated with EST on-site had lower in-hospital mortality and better functional outcomes compared with those transferred off-site for EST.
本研究旨在评估提供局部血管内卒中治疗（EST）而非将患者转至外地接受EST是否会改善预后。
关于就地提供EST而非将患者转至外地接受EST是否能改善临床预后的数据有限。
查询一个大型学术联盟数据库，以确定2015年10月至2019年9月期间接受EST的急性缺血性卒中患者。主要终点为住院死亡率和不良功能预后。次要终点为主要并发症、住院时间和费用。使用倾向评分匹配和多变量风险调整对基线特征进行调整。
共纳入22193例接受EST的急性缺血性卒中患者（50.8%就地治疗，49.2%转至外地治疗）。平均年龄分别为67.9±15.5岁和68.4±15.5岁（p=0.03）。在倾向评分匹配分析中，转至外地接受EST的组死亡率和不良功能预后更高（分别为14.7%对11.2%和40.7%对35.9%；p<0.001）。在不同模型的风险调整分析中，转至外地接受EST组的住院死亡率和不良功能预后仍然显著更高。在最全面的模型（调整年龄、性别、人口统计学、风险因素、组织型纤溶酶原激活剂使用情况和机构EST量）中，转至外地接受EST组的住院死亡率和不良功能预后显著更高，优势比分别为1.38（95%置信区间：1.26至1.51）和1.26（95%置信区间：1.18至1.34）（p<0.001）。转至外地组颅内出血和机械通气的发生率更高，但在倾向评分匹配和风险调整分析中，就地治疗组的费用更高。
在当代美国的医疗实践中，与转至外地接受EST的急性缺血性卒中患者相比，就地接受EST治疗的患者住院死亡率更低，功能预后更好。
