While the use of endovascular therapy doubled with the emergence of the “endovascular era”, it remains underutilised

endovascular trends
Laura Stein

According to Laura Stein and others from the Icahn School of Medicine at Mount Sinai, New York, USA, patients admitted with acute ischaemic stroke were twice as likely to receive endovascular therapy beyond February 2015—or what the authors have classed as the emergence of the “endovascular era”—as compared to the months prior.

The advent of successful thrombectomy has also led to a higher proportion of stroke patients receiving intravenous thrombolysis (IVT; 8.4% vs. 7.8% prior to February 2015), while length of stay was found to be shorter in the endovascular era (5.7 vs. 6.8 days). Nonetheless, the authors allude to the fact that total charges were found to be greater in the latter time frame, US$56,691 versus US$53,878 for the pre-endovascular era, and admissions were more often to a metropolitan hospital (65.2% vs. 57.2%) after February 2015. Moreover, they write that there was no association between era and in-hospital mortality, but there was a trend for a positive association between treatment in the endovascular era and 30-day all-cause readmission.

Given the widespread acceptance of endovascular therapy for large vessel occlusion stroke (following the publication of certain trials in 2015), coupled with the more recent expansion in patient eligibility, Stein and colleagues acknowledge that the burden of meeting this demand for treatment is going to continue to grow.

Thus, the authors used the Nationwide Readmissions Database (NRD) of the Healthcare Cost and Utilization Project (HCUP) to extract data (from 2013–2016) to assess the utilisation of revascularisation for stroke in the USA. Admissions were identified using International Classification of Disease (ICD-9) codes. “This study is novel in its use of nationally representative data that is not reliant on quality registry participation,” write Stain et al, adding that this allows them to estimate the state of real-world utilisation in the USA of the latest treatment for acute ischaemic stroke. “Additionally, it sheds light on the impact of endovascular therapy on metrics for which hospitals are increasingly held accountable, including cost and length of stay.”

Discussing their findings, the authors write, “We suspect that optimisation of systems of care, as well as increased public education about acute stroke therapies, resulted in the slight increase in IVT in the endovascular era.”

Referring to the finding that stroke patients treated with endovascular therapy tend to be treated at large teaching hospitals in metropolitan areas, Stein and colleagues put forward that “this demonstrates unequal access to endovascular therapy throughout the country”. Further, they suggest “greater efforts must be made” to both understand and address the current geographic treatment disparities.

Addressing the increase in cost of almost US$3,000 between the two eras among all acute ischaemic stroke patients, the authors propose that it is likely unrelated to endovascular therapy or stroke care. Additionally, Stein and others speculate that some of the change in length of stay during the endovascular era can be attributed to evolving healthcare systems, as well as “greater accountability for metrics such as length of stay”.

The team at Mount Sinai also pointed to how the study demonstrated lower rates of IVT in patients treated with endovascular therapy in the latter era. “This may reflect presentation and treatment of acute ischaemic stroke patients eligible for treatment beyond 4.5 hours from last known well,” propose Stein et al. Alternatively, they postulate that fewer patients are receiving IVT before endovascular therapy because of a perceived lack of benefit of IVT for large vessel occlusion (LVO) stroke, given the low likelihood of LVO clot lysis with IVT shown in the endovascular therapy trials. “Such choices would be counter to current AHA/ASA guidelines,” write Stein and colleagues. “Further national studies are needed to explore the reasons for this trend.”

Lastly, they maintain that “significant work remains” to better understand why the field are not yet seeing higher treatment rates and the improvement in outcomes such as discharge disposition and in-hospital mortality that is expected, given the results of endovascular therapy randomised controlled trials. Additionally, Stein and colleagues call for a better understanding of the geographic disparities, to ensure that patients throughout rural and urban areas of the USA have timely access to health systems capable of providing endovascular therapy.



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