Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (H.K., N.S.P., A.C., B.B.N.), Weill Cornell Medicine, New York, NY.
Division of Cardiology (L.K.K.), Weill Cornell Medicine, New York, NY.
Stroke. 2021 Aug;52(8):2554-2561. doi: 10.1161/STROKEAHA.120.033485. Epub 2021 May 13.
Mechanical thrombectomy helps prevent disability in patients with acute ischemic stroke involving occlusion of a large cerebral vessel. Thrombectomy requires procedural expertise and not all hospitals have the staff to perform this intervention. Few population-wide data exist regarding access to mechanical thrombectomy.
We examined access to thrombectomy for ischemic stroke using discharge data from calendar years 2016 to 2018 from all nonfederal emergency departments and acute care hospitals across 11 US states encompassing 80 million residents. Facilities were classified as hubs if they performed mechanical thrombectomy, gateways if they transferred patients who ultimately underwent mechanical thrombectomy, and gaps otherwise. We used standard descriptive statistics and unadjusted logistic regression models in our primary analyses.
Among 205 681 patients with ischemic stroke, 100 139 (48.7% [95% CI, 48.5%–48.9%]) initially received care at a thrombectomy hub, 72 534 (35.3% [95% CI, 35.1%–35.5%]) at a thrombectomy gateway, and 33 008 (16.0% [95% CI, 15.9%–16.2%]) at a thrombectomy gap. Patients who initially received care at thrombectomy gateways were substantially less likely to ultimately undergo thrombectomy than patients who initially received care at thrombectomy hubs (odds ratio, 0.27 [95% CI, 0.25–0.28]). Rural patients had particularly limited access: 27.7% (95% CI, 26.9%–28.6%) of such patients initially received care at hubs versus 69.5% (95% CI, 69.1%–69.9%) of urban patients. For 93.8% (95% CI, 93.6%–94.0%) of patients with stroke at gateways, their initial facility was capable of delivering intravenous thrombolysis, compared with 76.3% (95% CI, 75.8%–76.7%) of patients at gaps. Our findings were unchanged in models adjusted for demographics and comorbidities and persisted across multiple sensitivity analyses, including analyses adjusting for estimated stroke severity.
We found that a substantial proportion of patients with ischemic stroke across the United States lacked access to thrombectomy even after accounting for interhospital transfers. US systems of stroke care require further development to optimize thrombectomy access.
机械取栓有助于预防因大血管闭塞导致的急性缺血性脑卒中患者残疾。取栓术需要专业的手术技能，并非所有医院都有人员来进行这种干预。关于机械取栓术的可及性，仅有少数基于人群的研究数据。
我们使用了来自美国 11 个州的所有非联邦急诊部门和急症护理医院在 2016 年至 2018 年的年度出院数据，研究了缺血性脑卒中患者取栓术的可及性。如果医院能够实施机械取栓术，则将其归类为治疗中心；如果医院可以转运最终接受机械取栓术的患者，则将其归类为治疗门户；否则，则将其归类为缺口。我们在主要分析中使用了标准描述性统计和未经调整的逻辑回归模型。
在 205681 例缺血性脑卒中患者中，100139 例（48.7%[95%CI，48.5%–48.9%]）最初在取栓治疗中心接受治疗，72534 例（35.3%[95%CI，35.1%–35.5%]）在取栓治疗门户接受治疗，33008 例（16.0%[95%CI，15.9%–16.2%]）在取栓缺口接受治疗。与最初在取栓治疗中心接受治疗的患者相比，最初在取栓治疗门户接受治疗的患者最终接受取栓术的可能性显著降低（比值比，0.27[95%CI，0.25–0.28]）。农村患者的取栓术可及性尤其有限：27.7%（95%CI，26.9%–28.6%）的农村患者最初在治疗中心接受治疗，而 69.5%（95%CI，69.1%–69.9%）的城市患者最初在治疗中心接受治疗。对于治疗门户处 93.8%（95%CI，93.6%–94.0%）的脑卒中患者，其最初治疗的医院有能力提供静脉溶栓治疗，而缺口处患者这一比例为 76.3%（95%CI，75.8%–76.7%）。在调整了人口统计学和合并症的模型中，我们的发现没有改变，并且在包括调整估计的卒中严重程度的多个敏感性分析中仍然存在。
我们发现，即使考虑到医院间的转院，美国仍有相当一部分缺血性脑卒中患者无法获得取栓术。美国的卒中治疗系统需要进一步发展，以优化取栓术的可及性。
