Higher Procedural Volumes Are Associated with Faster Treatment Times, Better Functional Outcomes, and Lower Mortality in Patients Undergoing Endovascular Treatment for Acute Ischemic Stroke

Raul G Nogueira; Diogo C Haussen; Eric E Smith; Jie-Lena Sun; Ying Xian; Brooke Alhanti; Rosalia Blanco; Brian Mac Grory; Mohamed F Doheim; Deepak L Bhatt; Gregg C Fonarow; Ameer E Hassan; Raed A Joundi; J Mocco; Michael R Frankel; Lee H Schwamm

doi:10.1002/ana.26803

Higher Procedural Volumes Are Associated with Faster Treatment Times, Better Functional Outcomes, and Lower Mortality in Patients Undergoing Endovascular Treatment for Acute Ischemic Stroke

Ann Neurol. 2023 Sep 20. doi: 10.1002/ana.26803. Online ahead of print.

Authors

Raul G Nogueira¹, Diogo C Haussen², Eric E Smith³, Jie-Lena Sun⁴, Ying Xian⁵, Brooke Alhanti⁴, Rosalia Blanco⁴, Brian Mac Grory⁴, Mohamed F Doheim⁶, Deepak L Bhatt⁷, Gregg C Fonarow⁸, Ameer E Hassan⁹, Raed A Joundi¹⁰, J Mocco¹¹, Michael R Frankel², Lee H Schwamm¹²

Affiliations

¹ Departments of Neurology and Neurosurgery, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA.
² Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA.
³ Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.
⁴ Duke Clinical Research Center, Durham, NC, USA.
⁵ Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA.
⁶ Department of Neurology, UPMC Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA.
⁷ Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
⁸ Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
⁹ University of Texas Rio Grande Valley-Valley Baptist Medical Center, Harlingen, TX, USA.
¹⁰ Division of Neurology, Hamilton Health Sciences, McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada.
¹¹ Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
¹² Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.

PMID: 37731004
DOI: 10.1002/ana.26803

Abstract

Objective: We aimed to characterize the association of hospital procedural volumes with outcomes among acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT).

Methods: This was a retrospective, observational cohort study using data prospectively collected from January 1, 2016 to December 31, 2019 in the Get with the Guidelines-Stroke registry. Participants were derived from a cohort of 60,727 AIS patients treated with EVT within 24 hours at 626 hospitals. The primary cohort excluded patients with pretreatment National Institutes of Health Stroke Scale (NIHSS) < 6, onset-to-treatment time > 6 hours, and interhospital transfers. There were 2 secondary cohorts: (1) the EVT metrics cohort excluded patients with missing data on time from door to arterial puncture and (2) the intravenous thrombolysis (IVT) metrics cohort only included patients receiving IVT ≤4.5 hours after onset.

Results: The primary cohort (mean ± standard deviation age = 70.7 ± 14.8 years; 51.2% female; median [interquartile range] baseline NIHSS = 18.0 [13-22]; IVT use, 70.2%) comprised 21,209 patients across 595 hospitals. The EVT metrics cohort and IVT metrics cohort comprised 47,262 and 16,889 patients across 408 and 601 hospitals, respectively. Higher procedural volumes were significantly associated with higher odds (expressed as adjusted odds ratio [95% confidence interval] for every 10-case increase in volume) of discharge to home (1.03 [1.02-1.04]), functional independence at discharge (1.02 [1.01-1.04]), and lower rates of in-hospital mortality (0.96 [0.95-0.98]). All secondary measures were also associated with procedural volumes.

Interpretation: Among AIS patients primarily presenting to EVT-capable hospitals (excluding those transferred from one facility to another and those suffering in-hospital strokes), EVT at hospitals with higher procedural volumes was associated with faster treatment times, better discharge outcomes, and lower rates of in-hospital mortality. ANN NEUROL 2023.