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Ischemic stroke
Original research
Variation in US acute ischemic stroke treatment by hospital regions: limited endovascular access despite evidence
  1. Laura K Stein1,
  2. Luke Maillie2,
  3. John Erdman3,
  4. Emma Loebel1,
  5. Naomi Mayman2,
  6. Akarsh Sharma2,
  7. Sophia Wolmer4,
  8. Stanley Tuhrim1,
  9. Johanna T Fifi1,5,
  10. Nathalie Jette1,6,
  11. J Mocco5,
  12. Mandip S Dhamoon1
  1. 1 Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  2. 2 Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  3. 3 Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  4. 4 Amherst College, Amherst, Massachusetts, USA
  5. 5 Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  6. 6 Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, New York, USA
  1. Correspondence to Dr Laura K Stein, Neurology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; laura.stein{at}mssm.edu

Abstract

Background Although national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in revascularization therapies and stroke center certification. We hypothesized that we would observe overall growth in revascularization therapy utilization, but observed differences would vary greatly regionally.

Methods A retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019. We identified AIS admissions and treatment with thrombolysis and endovascular thrombectomy (ET) with International Classification of Diseases, 10th Revision, Clinical Modification codes. We grouped hospitals in Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR) and calculated hospital, demographic, and acute stroke treatment characteristics for each HRR. We calculated the percent of hospitals with stroke certification and AIS cases treated with thrombolysis or ET per HRR.

Results There were 957 958 AIS admissions. Relative mean (SD) growth in percent of AIS admissions receiving revascularization therapy per HRR from 2016 to 2019 was 13.4 (31.7)% (IQR −6.1–31.7%) for thrombolysis and 28.0 (72.0)% (IQR 0–56.0%) for ET. The proportion of HRRs with decreased or no difference in ET utilization was 38.9% and the proportion of HRRs with decreased or no difference in thrombolysis utilization was 32.7%. Mean (SD) stroke center certification proportion across HRRs was 45.3 (31.5)% and this varied widely (IQR 18.3–73.4%).

Conclusions Overall growth in AIS treatment has been modest and, within HRRs, growth in AIS treatment and the proportion of centers with stroke certification varies dramatically.

  • thrombectomy
  • stroke

Data availability statement

Data may be obtained from a third party and are not publicly available. Due to the public availability of Medicare data and limitations of the data use agreement, the data and study materials cannot be made available to other researchers.

https://doi.org/10.1136/jnis-2023-020128

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    Data availability statement

    Data may be obtained from a third party and are not publicly available. Due to the public availability of Medicare data and limitations of the data use agreement, the data and study materials cannot be made available to other researchers.

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    Footnotes

    • Contributors LS made substantial contributions to the conception of the work, acquisition and interpretation of the data for the work, and drafting of the work. She provided final approval of the version to be published. LM made substantial contributions to the analysis of the work and critical revision of the work for important intellectual content. He provided final approval of the version to be published. JE made substantial contributions to the acquisition of data for the work and provided critical revision of the work for important intellectual content. He provided final approval of the version to be published. EL made substantial contributions to the acquisition of data for the work and provided critical revision of the work for important intellectual content. She provided final approval of the version to be published. NM made substantial contributions to the acquisition of data for the work and provided critical revision of the work for important intellectual content. She provided final approval of the version to be published. AS made substantial contributions to the acquisition of data for the work and provided critical revision of the work for important intellectual content. He provided final approval of the version to be published. SW made substantial contributions to the acquisition of data for the work and provided critical revision of the work for important intellectual content. She provided final approval of the version to be published. ST provided substantial contribution to the interpretation of data for the work and provided critical revision of the work for important intellectual content. He provided final approval of the version to be published. JTF provided substantial contribution to the interpretation of data for the work and provided critical revision of the work for important intellectual content. She provided final approval of the version to be published. NJ provided substantial contributions to the conception of the work, interpretation of the data for work, and provided critical revision of the work for important intellectual content. She provided final approval of the version to be published. JM provided substantial contributions to the interpretation of data for the work and provided critical revision of the work for important intellectual content. He provided final approval of the version to be published. MD made substantial contributions to the conception of the work, acquisition, analysis, and interpretation of the data for the work, and provided critical revision of the work for important intellectual content. He provided final approval of the version to be published. He takes accountability for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. He also acts as guarantor.

    • Funding This work was supported by American Heart Association Grant #857015/Stein/2021.

    • Map disclaimer The inclusion of any map (including the depiction of any boundaries therein), or of any geographic or locational reference, does not imply the expression of any opinion whatsoever on the part of BMJ concerning the legal status of any country, territory, jurisdiction or area or of its authorities. Any such expression remains solely that of the relevant source and is not endorsed by BMJ. Maps are provided without any warranty of any kind, either express or implied.

    • Competing interests NJ receives grant funding paid to her institution for grants unrelated to this work from NINDS (NIH U24NS107201, NIH IU54NS100064, 3R01CA202911-05S1, R21NS122389, R01HL161847). She receives an honorarium for her work as an Associate Editor of Epilepsia. JM is an investor in: Cerebrotech, Imperative Care, Endostream, Viseon, BlinkCNS, Serenity, NTI, RIST, NRT, Viz.ai, Synchron, Tulavi, Sim&Cure, Songbird, Borvo, Whisper, Neurolutions. He serves, or has recently served, as a consultant for: Imperative Care, Cerebrotech, Endostream, Vastrax, RIST, Synchron, NRT, Viz.ai, Perflow, CVAid.

    • Provenance and peer review Not commissioned; internally peer reviewed.