Access to thrombectomy for stroke patients living in rural areas can be improved by introducing specific imaging software and a training package to remote hospitals and improving connections to the regional comprehensive stroke center, a new study showed.
“Our findings suggest that this intervention has the potential to be a valuable tool for healthcare systems worldwide, particularly those in rural locations where there are geographic barriers to stroke care,” senior investigator Christopher Levi, MD, John Hunter Hospital, University of Newcastle, New South Wales, Australia, told Medscape Medical News.
The findings were presented on May 15 at the European Stroke Organisation Conference (ESOC) 2024 in Basel, Switzerland.
Comprehensive Training
Although thrombectomy has revolutionized stroke treatment, access remains challenging for patients outside major urban centers, investigators noted.
The Trial of Advanced CT Imaging and Combined Education Support for Drip and Ship (TACTICS) involved six regional clusters of hospitals in Australia, each with a central comprehensive stroke center (hub) able to provide thrombectomy linked to several smaller rural hospitals (spokes). The trial included 34 sites, of which six were hubs and 28 were spokes.
The rural hospital staffs were supplied with and trained to use multimodal brain imaging to optimize workflow and pathways, improve diagnosis, and aid earlier detection of candidates for thrombectomy.
The staff members also underwent a training package, which included face-to-face, video, and virtual reality-based education that covered stroke reperfusion, multimodal CT, optimization of acute stroke workflows, discussions on challenging endovascular thrombectomy cases, integration of advanced imaging in an ideal workflow, and timing and processes of care specific to transferring patients for thrombectomy.
Each cluster of hospitals was evaluated over 9 months: 3 months pre-intervention, 3 months during intervention, and 3 months postintervention.
The proportion of patients who received thrombectomy with or without intravenous thrombolysis was compared between the pre-intervention period and the pooled intervention and postintervention periods.
The number of patients who presented to the clusters with ischemic stroke and stroke of undetermined etiology was 918 in the pre-intervention period and 1928 in the intervention/postintervention period.
Results showed that the odds of these patients receiving thrombectomy increased from 33% before the intervention to 37% after — an absolute increase of 4 percentage points or a relative increase of 44% (odds ratio, 1.44; 95% CI, 1.16-1.79).
‘Drip and Ship’ Approach
Levi noted that Australia has the challenge of many small rural community hospitals that are located far from comprehensive stroke centers where thrombectomy can be performed.
The burden of stroke is also higher in these rural communities compared with metropolitan areas. The rural hospitals also generally do not have sophisticated imaging or access to expert stroke neurologists who can confidently identify suitable candidates for transfer for thrombectomy.
“The intervention we tested is simple and generalizable to smaller hospitals in other regions,” Levi said.
The program equips hospitals with a “drip and ship” approach, where patients receive thrombolysis at a rural hospital and are then transferred to a thrombectomy center.
“We found that the training provided, and the perfusion imaging software, gave the medical staff at the smaller hospitals confidence to make the appropriate diagnosis quickly and confidently,” he said.
Levi said the uptake of this approach has been good since the study finished, demonstrating its acceptability and usability.
“We are hopeful that it will be adopted in other areas going forward,” he said, adding that the program can also be utilized in other countries with rural hospitals that lack a thrombectomy center or neurologists that specialize in stroke care.
Another benefit of the intervention was increased communication between the smaller hospitals and the larger thrombectomy center, he added.
“The healthcare staff benefitted from working together in this collaborative approach. Forging these links and having to work as a team overcame some of the system-wide barriers that were in place,” Levi said.
Commenting on TACTICS at the ESOC meeting, Carlos Molina, MD, Vall d’Hebron Barcelona University Hospital, Spain, said, ” TACTICS was a really nice trial in that they showed a way to improve the number of patients receiving thrombectomy.”
Michele Romoli, MD, Maurizio Bufalini Hospital, Cesena, Italy, described the study as, “a great achievement that addressed the equity of stroke care, which is a very important issue.”
TACTICS was funded by the National Health and Medical Research Council, Boehringer Ingelheim, Queensland Health and Apollo Medical Imaging Technology.
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