Increase in Endovascular Therapy in Get With The Guidelines-Stroke After The Publication of Pivotal Trials

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Abstract

Background—

Beginning in December 2014, a series of pivotal trials showed that endovascular thrombectomy (EVT) was highly effective, prompting calls to reorganize stroke systems of care. However, there are few data on how these trials influenced the frequency of EVT in clinical practice. We used data from the Get With The Guidelines-Stroke program to determine how the frequency of EVT changed in U.S. practice.

Methods—

We analyzed prospectively collected data from a cohort of 2,437,975 ischemic stroke patients admitted to 2,222 participating hospitals between April 2003 and the third quarter (Q3) 2016. Weighted linear regression with two linear splines and a knot at January 2015 was used to compare the slope of the change in EVT use before and after the pivotal trials were published. Potentially eligible patients were defined as last known well to arrival time ≤4.5 hours and NIH Stroke Scale score ≥6.

Results—

The frequency of EVT use was slowly increasing prior to January 2015 but then sharply accelerated thereafter. In Q3 2016, EVT was provided to 3.3% of all ischemic stroke patients at all hospitals, representing 15.1% of all patients who were potentially eligible for EVT based on stroke duration and severity. At EVT capable hospitals, 7.5% of all ischemic stroke patients were treated in Q3 2016, including 27.3% of the potentially eligible patients. From 2013 to 2016, case volumes nearly doubled at EVT capable hospitals. Mean case volume per EVT capable hospital was 37.6 per year in the last four quarters. EVT case volumes increased in nearly all U.S. states from 2014 to the last four quarters, but with persistent geographic variation unexplained by differences in potential patient eligibility.

Conclusions—

EVT use is increasingly rapidly; however, there are still opportunities to treat more patients. Reorganizing stroke systems to route patients to adequately resourced EVT capable hospitals might increase treatment of eligible patients, improve outcomes and reduce disparities.

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