Restricted accessResearch articleFirst published online 2024
High mechanical thrombectomy procedural volume is not a reliable predictor of improved thrombectomy outcomes in patients with acute ischemic stroke in the United States
The volume of mechanical thrombectomy (MT) performed at hospitals is used as one of the criteria for advanced-level designation for stroke care.
Objective
Our study sought to determine the relationship between annual MT procedural volume and in-hospital outcomes in acute ischemic stroke patients undergoing MT in the United States.
Methods
We analyzed the National Inpatient Sample from 2016 to 2020. The hospitals were grouped into quartiles based on the volume of MT procedures performed within the calendar year. We compared the rates of routine discharge/home health care; in-hospital mortality, and post-treatment intracranial hemorrhage (ICH) between the quartiles after adjusting for potential confounders.
Results
Patients undergoing MT ranged from 15,395 in quartile 1 to 78,510 MT in quartile 4. There were lower rates of discharge home/self-care of 22.5%, 20.8%, and 20.8% for quartiles 2, 3, and 4, respectively, compared with 34.9% in quartile 1. The odds of ICH increased to 1.81 (p < 0.001), 1.84 (p < 0.001), and 1.98 (p < 0.001) among the quartiles from lowest to highest procedural volumes. The odds of home discharge/self-care decreased to 0.66 (p < 0.001), 0.60 (p < 0.001), and 0.63 (p < 0.001) among the quartiles from lowest to highest procedural volumes. The odds of in-hospital mortality increased to 1.92 (p < 0.001), 1.99 (p < 0.001), and 1.84 (p < 0.001) among the quartiles from lowest to highest procedural volumes.
Conclusions
We observed a paradoxical relationship between adverse outcomes and the annual procedural volume of MT at the hospital presumably due to the higher severity of acute ischemic stroke treated at high-volume hospitals.
GrigoryanMChaudhrySAHassanAE, et al.Neurointerventional procedural volume per hospital in the United States: implications for comprehensive stroke center designation. Stroke2012; 43: 1309–1314.
2.
AsaithambiGTongXLakshminarayanK, et al.Trends in hospital procedure volumes for intra-arterial treatment of acute ischemic stroke: results from the Paul Coverdell National Acute Stroke Program. J Neurointerv Surg2020; 12: 1076–1079.
3.
LavineSDCockroftKHohB, et al.Training guidelines for endovascular ischemic stroke intervention: an international multi-society consensus document. AJNR Am J Neuroradiol2016; 37: E31–E34.
4.
SacksDAbuAwadMKAhnSH, et al.Society of interventional radiology training guidelines for endovascular stroke treatment. J Vasc Interv Radiol2019; 30: 1523–1531.
5.
QureshiAIAbou-CheblAJovinTG. Qualification requirements for performing neurointerventional procedures: a report of the practice guidelines committee of the American Society of Neuroimaging and the Society of Vascular and Interventional Neurology. J Neuroimaging2008; 18: 433–447.
DayALSiddiquiAHMeyersPM, et al.Training standards in neuroendovascular surgery: program accreditation and practitioner certification. Stroke2017; 48: 2318–2325.
8.
United Council For Neurological Subspecialties. Interventional Neurology Program Requirements.
9.
NogueiraRGHaussenDCCastonguayA, et al.Site experience and outcomes in the trevo acute ischemic stroke (TRACK) multicenter registry. Stroke2019; 50: 2455–2460.
10.
Nawar RELapergueBPiotinM, et al.Higher annual operator volume is associated with better reperfusion rates in stroke patients treated by mechanical thrombectomy: the ETIS registry. JACC Cardiovasc Interv2019; 12: 385–391.
11.
ShethSAJahanRLevyEI, et al.Rapid learning curve for solitaire FR stent retriever therapy: evidence from roll-in and randomised patients in the SWIFT trial. J Neurointerv Surg2016; 8: 347–352.
12.
KimBMBaekJHHeoJH, et al.Effect of cumulative case volume on procedural and clinical outcomes in endovascular thrombectomy. Stroke2019; 50: 1178–1183.
13.
AdamczykPAttenelloFWenG, et al.Mechanical thrombectomy in acute stroke: utilization variances and impact of procedural volume on inpatient mortality. J Stroke Cerebrovasc Dis2013; 22: 1263–1269.
14.
SteinLKMoccoJFifiJ, et al.Correlations between physician and hospital stroke thrombectomy volumes and outcomes: a nationwide analysis. Stroke2021; 52: 2858–2865.
15.
OlthuisSGHden HartogSJvan KuijkSMJ, et al.Influence of the interventionist's experience on outcomes of endovascular thrombectomy in acute ischemic stroke: results from the MR CLEAN registry. J Neurointerv Surg2023; 15: 113–119.
16.
GuptaRHorevANguyenT, et al.Higher volume endovascular stroke centers have faster times to treatment, higher reperfusion rates and higher rates of good clinical outcomes. J Neurointerv Surg2013; 5: 294–297.
17.
RezaiMKAdvaniRSandveKO, et al.Endovascular thrombectomy at low-volume centres: a Bayesian solution. Acta Neurol Scand2020; 142: 169–174.
18.
KoCCLiuHMChenTY, et al.Prediction of mTICI 3 recanalization and clinical outcomes in endovascular thrombectomy for acute ischemic stroke: a retrospective study in the Taiwan registry. Neurol Sci2021; 42: 2325–2335.
19.
HornungMBertogSCGrunwaldI, et al.Acute stroke interventions performed by cardiologists: initial experience in a single center. JACC: Cardiovasc Interventions2019; 12: 1703–1710.
20.
GuideraSAAggarwalSWaltonJD, et al.Mechanical thrombectomy for acute ischemic stroke in the cardiac catheterization laboratory. JACC: Cardiovasc Interventions2020; 13: 884–891.
21.
WidimskyPAsilTAbelsonM, et al.Direct catheter-based thrombectomy for acute ischemic stroke: outcomes of consecutive patients treated in interventional cardiology centers in close cooperation with neurologists. J Am Coll Cardiol2015; 66: 487–488.
22.
von ElmEAltmanDGEggerM, et al.The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. J Clin Epidemiol2008; 61: 344–349.
23.
WahoodWRizviAAPatelV, et al.Trends in utilization and outcomes of mechanical thrombectomy for cerebral venous thrombosis: a national inpatient sample study. Interv Neuroradiol2023: 15910199231182454. https://doi.org/10.1177/15910199231182454
24.
BrakeAFryLHeskettC, et al.Endovascular thrombectomy for posterior cerebral artery strokes in the national inpatient sample (EaT PeCANpIeS) study. Interv Neuroradiol2024: 15910199231223535. https://doi.org/10.1177/15910199231223535
25.
MehtaTDesaiNMehtaK, et al.Outcomes of early carotid stenting and angioplasty in large-vessel anterior circulation strokes treated with mechanical thrombectomy and intravenous thrombolytics. Interv Neuroradiol2018; 24: 392–397.
26.
Healthcare Cost and Utilization Project (HCUP). Encyclopedia of Health Services Research. Sage Publications, Inc., 2009.
27.
QureshiAISinghBHuangW, et al.Mechanical thrombectomy in acute ischemic stroke patients performed within and outside clinical trials in the United States. Neurosurgery2020; 86: E2–E8.
28.
KwokCSGillaniSABainsNK, et al.Mechanical thrombectomy in patients with acute ischemic stroke in the USA before and after time window expansion. J Neurointerv Surg2024; 16: 447–452.
29.
QureshiAIChaudhrySAHassanAE, et al.Thrombolytic treatment of patients with acute ischemic stroke related to underlying arterial dissection in the United States. Arch Neurol2011; 68: 1536–1542.
30.
KhazenOBaoJGajjarAA, et al.Incidence of mechanical thrombectomy among stroke patients brought directly to a comprehensive stroke center versus transfer from a primary stroke center in upstate New York. Interv Neuroradiol2023: 15910199231177763. https://doi.org/10.1177/15910199231177763
31.
ShigetaKOtaTKanekoJ, et al.Negative impact of interhospital transfer on clinical outcomes of mechanical thrombectomy for fast progressive stroke. J Stroke Cerebrovasc Dis2021; 30: 105633.
32.
RieglerCBehrensJRGorskiC, et al.Time-to-care metrics in patients with interhospital transfer for mechanical thrombectomy in north-east Germany: primary telestroke centers in rural areas vs. primary stroke centers in a metropolitan area. Front Neurol2022; 13: 1046564.
33.
FroehlerMTSaverJLZaidatOO, et al.Interhospital transfer before thrombectomy is associated with delayed treatment and worse outcome in the STRATIS registry (systematic evaluation of patients treated with neurothrombectomy devices for acute ischemic stroke). Circulation2017; 136: 2311–2321.
34.
KaminskyALMioneGOmorouY, et al.Outcome of patients with large vessel occlusion stroke after first admission in telestroke spoke versus comprehensive stroke center. J Neurointerv Surg2020; 12: 753–757.
35.
GeorgeBPPietersTAZammitCG, et al.Trends in interhospital transfers and mechanical thrombectomy for United States acute ischemic stroke inpatients. J Stroke Cerebrovasc Dis2019; 28: 980–987.
36.
FayselMASingerJCummingsC, et al.Disparities in the use of intravenous t-PA among ischemic stroke patients: population-based recent temporal trends. J Stroke Cerebrovasc Dis2019; 28: 1243–1251.
37.
JonesEKumarALopez-RiveraV, et al.Racial and ethnic disparities in functional outcome after thrombectomy: a cohort study of an integrated stroke network. J Stroke Cerebrovasc Dis2021; 30: 106131.
38.
KwokCSGillaniSABainsNK, et al.Mechanical thrombectomy in patients with acute ischemic stroke in the USA before and after time window expansion. J Neurointerv Surg2023; 16(5): 447–452. https://doi.org/10.1136/jnis-2023-020286.
39.
LeiferDBravataDMConnors 3rdJJ, et al.Metrics for measuring quality of care in comprehensive stroke centers: detailed follow-up to Brain Attack Coalition comprehensive stroke center recommendations: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2011; 42: 849–877.
40.
HubertGJHubertNDMaegerleinC, et al.Association between use of a flying intervention team vs patient interhospital transfer and time to endovascular thrombectomy among patients with acute ischemic stroke in nonurban Germany. Jama2022; 327: 1795–1805.
41.
HolodinskyJKWilliamsonTSKamalN, et al.Drip and ship versus direct to comprehensive stroke center: conditional probability modeling. Stroke2017; 48: 233–238.
42.
JauchECSchwammLHPanagosPD, et al.Recommendations for regional stroke destination plans in rural, suburban, and urban communities from the prehospital stroke system of care consensus conference: a consensus statement from the American Academy of Neurology, American Heart Association/American Stroke Association, American Society of Neuroradiology, National Association of EMS Physicians, National Association of State EMS Officials, Society of NeuroInterventional Surgery, and Society of Vascular and Interventional Neurology: endorsed by the Neurocritical Care Society. Stroke2021; 52: e133–e152.
43.
QureshiAISinghBHuangW, et al.Mechanical thrombectomy in acute ischemic stroke patients performed within and outside clinical trials in the United States. Neurosurgery2020; 87: 24.
44.
AlhajjiMKawsaraAAlkhouliM. Validation of acute ischemic stroke codes using the international classification of diseases tenth revision. Am J Cardiol2020; 125: 1135.
45.
ZachrisonKSLiSReevesMJ, et al.Strategy for reliable identification of ischaemic stroke, thrombolytics and thrombectomy in large administrative databases. Stroke Vasc Neurol2021; 6: 194–200.
46.
QureshiAIChaudhrySASapkotaBL, et al.Discharge destination as a surrogate for modified Rankin scale defined outcomes at 3- and 12-months poststroke among stroke survivors. Arch Phys Med Rehabil2012; 93: 1408–1413.e1401.
47.
ElHabrAKKatzJMWangJ, et al.Predicting 90-day modified Rankin scale score with discharge information in acute ischaemic stroke patients following treatment. BMJ Neurol Open2021; 3: e000177.
48.
AsaithambiGTippsME. Predictive value of discharge destination for 90-day outcomes among ischemic stroke patients eligible for endovascular treatment: post-hoc analysis of DEFUSE 3. J Stroke Cerebrovasc Dis2020; 29: 104902.
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
