J Korean Med Sci.  2020 Oct;35(41):e347. 10.3346/jkms.2020.35.e347.

Routing to Endovascular Treatment of Ischemic Stroke in Korea: Recognition of Need for Process Improvement

Affiliations
  • 1Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
  • 2Department of Medicine, Gyeongsang National University College of Medicine, Jinju, Korea
  • 3Department of Neurology, Inje University Ilsan Paik Hospital, Ilsan, Korea
  • 4Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Korea
  • 5Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
  • 6Department of Neurology, Soonchunhyang University Hospital, Seoul, Korea
  • 7Department of Neurology, Daejeon Eulji Medical Center, Eulji University, Daejeon, Korea
  • 8Clinical Research Center, Asan Medical Center, Seoul, Korea
  • 9Department of Biostatistics, Korea University College of Medicine, Seoul, Korea
  • 10Health Insurance Review and Assessment Service, Wonju, Korea
  • 11Department of Neurology, Gyeongsang National University College of Medicine, Jinju, Korea
  • 12Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA

Abstract

Background
To track triage, routing, and treatment status regarding access to endovascular treatment (EVT) after acute ischemic stroke (AIS) at a national level.
Methods
From national stroke audit data, potential candidates for EVT arriving within 6 hours with National Institute of Health Stroke Scale score of ≥ 7 were identified. Acute care hospitals were classified as thrombectomy-capable hospitals (TCHs, ≥ 15 EVT cases/year) or primary stroke hospital (PSH, < 15 cases/year), and patients' initial routes and subsequent inter-hospital transfer were described. Impact of initial routing to TCHs vs. PSHs on EVT and clinical outcomes were analyzed using multilevel generalized mixed effect models.
Results
Out of 14,902 AIS patients, 2,180 (14.6%) were EVT candidates. Eighty-one percent of EVT candidates were transported by ambulance, but only one-third were taken initially to TCHs. Initial routing to TCHs was associated with greater chances of receiving EVT compared to initial routing to PSHs (33.3% vs 12.1%, P < 0.001; adjusted odds ratio [aOR], 2.21; 95% confidence interval [CI], 1.59–2.92) and favorable outcome (38.5% vs. 28.2%, P < 0.001; aOR, 1.52; 95% CI, 1.16–2.00). Inter-hospital transfers to TCHs occurred in 17.4% of those initially routed to a PSH and was associated with the greater chance of EVT compared to remaining at PSHs (34.8% vs. 7.5%, P < 0.001), but not with better outcomes.
Conclusion
Two-thirds of EVT candidates were initially routed to PSHs despite greater chance of receiving EVT and having favorable outcomes if routed to a TCH in Korea. Process improvement is needed to direct appropriate patients to TCHs.

Keyword

Stroke; Endovascular Treatment; Stroke Center; Organization; Transfer
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