TY - JOUR
T1 - Hospital Variation in Time to Endovascular Treatment for Ischemic Stroke
T2 - What Is the Optimal Target for Improvement?
AU - MR CLEAN Registry investigators
AU - den Hartog, Sanne J
AU - Lingsma, Hester F
AU - van Doormaal, Pieter-Jan
AU - Hofmeijer, Jeannette
AU - Yo, Lonneke S F
AU - Majoie, Charles B L M
AU - Dippel, Diederik W J
AU - van der Lugt, Aad
AU - Roozenbeek, Bob
N1 - Funding Information: The MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke) Registry was partly funded by Stichting Toegepast Wetenschappelijk Instituut voor Neuromodulatie, Erasmus MC, University Medical Center, Maastricht University Medical Center, and Amsterdam University Medical Center. Publisher Copyright: © 2021 The Authors.
PY - 2022/1/4
Y1 - 2022/1/4
N2 - Background Time to reperfusion in patients with ischemic stroke is strongly associated with functional outcome and may differ between hospitals and between patients within hospitals. Improvement in time to reperfusion can be guided by between-hospital and within-hospital comparisons and requires insight in specific targets for improvement. We aimed to quantify the variation in door-to-reperfusion time between and within Dutch intervention hospitals and to assess the contribution of different time intervals to this variation. Methods and Results We used data from the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. The door-to-reperfusion time was subdivided into time intervals, separately for direct patients (door-to-computed tomography, computed tomography-to-computed tomography angiography [CTA], CTA-to-groin, and groin-to-reperfusion times) and for transferred patients (door-to-groin and groin-to-reperfusion times). We used linear mixed models to distinguish the variation in door-to-reperfusion time between hospitals and between patients. The proportional change in variance was used to estimate the amount of variance explained by each time interval. We included 2855 patients of 17 hospitals providing endovascular treatment. Of these patients, 44% arrived directly at an endovascular treatment hospital. The between-hospital variation in door-to-reperfusion time was 9%, and the within-hospital variation was 91%. The contribution of case-mix variables on the variation in door-to-reperfusion time was marginal (2%-7%). Of the between-hospital variation, CTA-to-groin time explained 83%, whereas groin-to-reperfusion time explained 15%. Within-hospital variation was mostly explained by CTA-to-groin time (33%) and groin-to-reperfusion time (42%). Similar results were found for transferred patients. Conclusions Door-to-reperfusion time varies between, but even more within, hospitals providing endovascular treatment for ischemic stroke. Quality of stroke care improvements should not only be guided by between-hospital comparisons, but also aim to reduce variation between patients within a hospital, and should specifically focus on CTA-to-groin time and groin-to-reperfusion time.
AB - Background Time to reperfusion in patients with ischemic stroke is strongly associated with functional outcome and may differ between hospitals and between patients within hospitals. Improvement in time to reperfusion can be guided by between-hospital and within-hospital comparisons and requires insight in specific targets for improvement. We aimed to quantify the variation in door-to-reperfusion time between and within Dutch intervention hospitals and to assess the contribution of different time intervals to this variation. Methods and Results We used data from the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. The door-to-reperfusion time was subdivided into time intervals, separately for direct patients (door-to-computed tomography, computed tomography-to-computed tomography angiography [CTA], CTA-to-groin, and groin-to-reperfusion times) and for transferred patients (door-to-groin and groin-to-reperfusion times). We used linear mixed models to distinguish the variation in door-to-reperfusion time between hospitals and between patients. The proportional change in variance was used to estimate the amount of variance explained by each time interval. We included 2855 patients of 17 hospitals providing endovascular treatment. Of these patients, 44% arrived directly at an endovascular treatment hospital. The between-hospital variation in door-to-reperfusion time was 9%, and the within-hospital variation was 91%. The contribution of case-mix variables on the variation in door-to-reperfusion time was marginal (2%-7%). Of the between-hospital variation, CTA-to-groin time explained 83%, whereas groin-to-reperfusion time explained 15%. Within-hospital variation was mostly explained by CTA-to-groin time (33%) and groin-to-reperfusion time (42%). Similar results were found for transferred patients. Conclusions Door-to-reperfusion time varies between, but even more within, hospitals providing endovascular treatment for ischemic stroke. Quality of stroke care improvements should not only be guided by between-hospital comparisons, but also aim to reduce variation between patients within a hospital, and should specifically focus on CTA-to-groin time and groin-to-reperfusion time.
KW - Brain ischemia
KW - Quality improvement
KW - Reperfusion
KW - Stroke
KW - Thrombectomy
UR - http://www.scopus.com/inward/record.url?scp=85123281550&partnerID=8YFLogxK
U2 - https://doi.org/10.1161/JAHA.121.022192
DO - https://doi.org/10.1161/JAHA.121.022192
M3 - Article
C2 - 34927469
SN - 2047-9980
VL - 11
SP - e022192
JO - Journal of the American Heart Association
JF - Journal of the American Heart Association
IS - 1
M1 - e022192
ER -