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Personalized Prehospital Triage in Acute Ischemic Stroke: A Decision-Analytic Model
BACKGROUND AND PURPOSE—: Direct transportation to a center with facilities for endovascular treatment might be beneficial for patients with acute ischemic stroke, but it can also cause harm by delay of intravenous treatment. Our aim was to determine the optimal prehospital transportation strategy fo...
Autores principales: | , , , , , , , , , , |
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Formato: | Online Artículo Texto |
Lenguaje: | English |
Publicado: |
Lippincott Williams & Wilkins
2019
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Materias: | |
Acceso en línea: | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6358183/ https://www.ncbi.nlm.nih.gov/pubmed/30661502 http://dx.doi.org/10.1161/STROKEAHA.118.022562 |
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author | Venema, Esmee Lingsma, Hester F. Chalos, Vicky Mulder, Maxim J.H.L. Lahr, Maarten M.H. van der Lugt, Aad van Es, Adriaan C.G.M. Steyerberg, Ewout W. Hunink, M.G. Myriam Dippel, Diederik W.J. Roozenbeek, Bob |
author_facet | Venema, Esmee Lingsma, Hester F. Chalos, Vicky Mulder, Maxim J.H.L. Lahr, Maarten M.H. van der Lugt, Aad van Es, Adriaan C.G.M. Steyerberg, Ewout W. Hunink, M.G. Myriam Dippel, Diederik W.J. Roozenbeek, Bob |
author_sort | Venema, Esmee |
collection | PubMed |
description | BACKGROUND AND PURPOSE—: Direct transportation to a center with facilities for endovascular treatment might be beneficial for patients with acute ischemic stroke, but it can also cause harm by delay of intravenous treatment. Our aim was to determine the optimal prehospital transportation strategy for individual patients and to assess which factors influence this decision. METHODS—: We constructed a decision tree model to compare outcome of ischemic stroke patients after transportation to a primary stroke center versus a more distant intervention center. The optimal strategy was estimated based on individual patient characteristics, geographic location, and workflow times. In the base case scenario, the primary stroke center was located at 20 minutes and the intervention center at 45 minutes. Additional sensitivity analyses included an urban scenario (10 versus 20 minutes) and a rural scenario (30 versus 90 minutes). RESULTS—: Direct transportation to the intervention center led to better outcomes in the base case scenario when the likelihood of a large vessel occlusion as a cause of the ischemic stroke was >33%. With a high likelihood of large vessel occlusion (66%, comparable with a Rapid Arterial Occlusion Evaluation score of 5 or above), the benefit of direct transportation to the intervention center was 0.10 quality-adjusted life years (=36 days in full health). In the urban scenario, direct transportation to an intervention center was beneficial when the risk of large vessel occlusion was 24% or higher. In the rural scenario, this threshold was 49%. Other factors influencing the decision included door-to-needle times, door-to-groin times, and the door-in-door-out time. CONCLUSIONS—: The preferred prehospital transportation strategy for suspected stroke patients depends mainly on the likelihood of large vessel occlusion, driving times, and in-hospital workflow times. We constructed a robust model that combines these characteristics and can be used to personalize prehospital triage, especially in more remote areas. |
format | Online Article Text |
id | pubmed-6358183 |
institution | National Center for Biotechnology Information |
language | English |
publishDate | 2019 |
publisher | Lippincott Williams & Wilkins |
record_format | MEDLINE/PubMed |
spelling | pubmed-63581832019-02-20 Personalized Prehospital Triage in Acute Ischemic Stroke: A Decision-Analytic Model Venema, Esmee Lingsma, Hester F. Chalos, Vicky Mulder, Maxim J.H.L. Lahr, Maarten M.H. van der Lugt, Aad van Es, Adriaan C.G.M. Steyerberg, Ewout W. Hunink, M.G. Myriam Dippel, Diederik W.J. Roozenbeek, Bob Stroke Original Contributions BACKGROUND AND PURPOSE—: Direct transportation to a center with facilities for endovascular treatment might be beneficial for patients with acute ischemic stroke, but it can also cause harm by delay of intravenous treatment. Our aim was to determine the optimal prehospital transportation strategy for individual patients and to assess which factors influence this decision. METHODS—: We constructed a decision tree model to compare outcome of ischemic stroke patients after transportation to a primary stroke center versus a more distant intervention center. The optimal strategy was estimated based on individual patient characteristics, geographic location, and workflow times. In the base case scenario, the primary stroke center was located at 20 minutes and the intervention center at 45 minutes. Additional sensitivity analyses included an urban scenario (10 versus 20 minutes) and a rural scenario (30 versus 90 minutes). RESULTS—: Direct transportation to the intervention center led to better outcomes in the base case scenario when the likelihood of a large vessel occlusion as a cause of the ischemic stroke was >33%. With a high likelihood of large vessel occlusion (66%, comparable with a Rapid Arterial Occlusion Evaluation score of 5 or above), the benefit of direct transportation to the intervention center was 0.10 quality-adjusted life years (=36 days in full health). In the urban scenario, direct transportation to an intervention center was beneficial when the risk of large vessel occlusion was 24% or higher. In the rural scenario, this threshold was 49%. Other factors influencing the decision included door-to-needle times, door-to-groin times, and the door-in-door-out time. CONCLUSIONS—: The preferred prehospital transportation strategy for suspected stroke patients depends mainly on the likelihood of large vessel occlusion, driving times, and in-hospital workflow times. We constructed a robust model that combines these characteristics and can be used to personalize prehospital triage, especially in more remote areas. Lippincott Williams & Wilkins 2019-02 2019-01-21 /pmc/articles/PMC6358183/ /pubmed/30661502 http://dx.doi.org/10.1161/STROKEAHA.118.022562 Text en © 2019 The Authors. Stroke is published on behalf of the American Heart Association, Inc., by Wolters Kluwer Health, Inc. This is an open access article under the terms of the Creative Commons Attribution Non-Commercial-NoDerivs (https://creativecommons.org/licenses/by-nc-nd/4.0/) License, which permits use, distribution, and reproduction in any medium, provided that the original work is properly cited, the use is noncommercial, and no modifications or adaptations are made. |
spellingShingle | Original Contributions Venema, Esmee Lingsma, Hester F. Chalos, Vicky Mulder, Maxim J.H.L. Lahr, Maarten M.H. van der Lugt, Aad van Es, Adriaan C.G.M. Steyerberg, Ewout W. Hunink, M.G. Myriam Dippel, Diederik W.J. Roozenbeek, Bob Personalized Prehospital Triage in Acute Ischemic Stroke: A Decision-Analytic Model |
title | Personalized Prehospital Triage in Acute Ischemic Stroke: A Decision-Analytic Model |
title_full | Personalized Prehospital Triage in Acute Ischemic Stroke: A Decision-Analytic Model |
title_fullStr | Personalized Prehospital Triage in Acute Ischemic Stroke: A Decision-Analytic Model |
title_full_unstemmed | Personalized Prehospital Triage in Acute Ischemic Stroke: A Decision-Analytic Model |
title_short | Personalized Prehospital Triage in Acute Ischemic Stroke: A Decision-Analytic Model |
title_sort | personalized prehospital triage in acute ischemic stroke: a decision-analytic model |
topic | Original Contributions |
url | https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6358183/ https://www.ncbi.nlm.nih.gov/pubmed/30661502 http://dx.doi.org/10.1161/STROKEAHA.118.022562 |
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