Geisel School of Medicine at Dartmouth, Dartmouth Hitchcock Medical Center, The Dartmouth Institute for Health Policy and Clinical Practice, 1 Medical Center Drive, Lebanon, NH 03766, United States.
Geisel School of Medicine at Dartmouth, The Dartmouth Institute for Health Policy and Clinical Practice, United States.
J Stroke Cerebrovasc Dis. 2021 Apr;30(4):105638. doi: 10.1016/j.jstrokecerebrovasdis.2021.105638. Epub 2021 Feb 2.
To compare outcomes between two models of acute ischemic stroke care. Namely 1) "drip-and-stay", i.e. IV tissue plasminogen activator (tPA) administered at a spoke hospital in a telestroke network, with the patient remaining at the spoke, versus 2) "drip-and-ship", i.e. tPA administered at a spoke hospital with subsequent patient transfer to a hub hospital, and 3) "hub", i.e. tPA and subsequent treatment at a hub hospital.
We performed a systematic review and meta-analysis according to PRISMA guidelines. Literature searches of MEDLINE, Embase, and Cochrane from inception-October 2019 included randomized control trials and observational cohort studies comparing the drip-and-stay model to hub and drip-and-ship models. Outcomes of interest were functional independence (modified Rankin Scale ≤ 1), symptomatic intracranial hemorrhage (sICH), mortality, and length of stay. Pooled effect estimates were calculated using a fixed-effects meta-analysis and random-effects Bayesian meta-analysis. Non-inferiority was calculated using a fixed-margin method.
Of 2806 unique records identified, 10 studies, totaling 4,164 patients, fulfilled the eligibility criteria. Meta-analysis found no significant difference in functional outcomes (mRS0-1) (6 studies, RR=1.09, 95%CI 0.98-1.22, p=0.123), sICH (8 studies, RR=0.98, 95%CI 0.64-1.51, p=0.942), or 90-day mortality (5 studies, RR=0.98, 95%CI 0.73-1.32, p=0.911, respectively) between patients treated in a drip-and-stay model compared to patients treated in drip-and-ship or hub models. There was no significant heterogeneity in these outcomes. Drip-and-stay outcomes (mRS 0-1, sICH) were non-inferior when compared to the combined group.
Our findings indicate that drip-and-stay is non-inferior to current models of drip-and-ship or hub stroke care, and may be as safe and as effective as either.
比较两种急性缺血性脑卒中治疗模式的结果。即 1）“滴注并停留”，即在远程卒中网络的辐辏医院给予静脉注射组织型纤溶酶原激活剂（tPA），患者留在辐辏医院，与 2）“滴注并转运”，即给予 tPA 于辐辏医院，随后将患者转运至枢纽医院，和 3）“枢纽”，即给予 tPA 并在枢纽医院进行后续治疗。
我们根据 PRISMA 指南进行了系统评价和荟萃分析。对 MEDLINE、Embase 和 Cochrane 从成立到 2019 年 10 月的文献检索包括比较滴注并停留模式与枢纽和滴注并转运模式的随机对照试验和观察性队列研究。感兴趣的结局是功能独立性（改良 Rankin 量表≤1）、症状性颅内出血（sICH）、死亡率和住院时间。使用固定效应荟萃分析和随机效应贝叶斯荟萃分析计算汇总效应估计值。使用固定边缘方法计算非劣效性。
在 2806 条独特的记录中，有 10 项研究，共计 4164 名患者，符合入选标准。荟萃分析发现，在功能结局（mRS0-1）（6 项研究，RR=1.09，95%CI 0.98-1.22，p=0.123）、sICH（8 项研究，RR=0.98，95%CI 0.64-1.51，p=0.942）或 90 天死亡率（5 项研究，RR=0.98，95%CI 0.73-1.32，p=0.911）方面，在滴注并停留模型中治疗的患者与在滴注并转运或枢纽模型中治疗的患者之间无显著差异。这些结果没有明显的异质性。与联合组相比，滴注并停留组的结局（mRS0-1、sICH）非劣效。
我们的研究结果表明，滴注并停留与目前的滴注并转运或枢纽卒中治疗模式不劣效，且可能与两者同样安全有效。
