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July 14, 2024

The findings highlight the need to continue to improve systems of care for large-vessel occlusion stroke, says a study author.



Patients with acute ischemic stroke who must be transferred in order to undergo endovascular therapy pay the price in the form of greater length of hospital stay, cost, disease severity, and mortality, according to an analysis published online June 5, 2019, ahead of print in Stroke.


“Even though endovascular therapy has the greatest benefit of all acute ischemic stroke therapies, access is limited to a minority of United States centers with adequately trained proceduralists, support staff, equipment, critical care units, and expertise,” lead author Laura K. Stein, MD (Icahn School of Medicine at Mount Sinai, New York, NY), told Neurovascular Exchange in an email. “Few centers throughout the United States can provide endovascular therapy, and there is significant debate about the most efficient and effective ways to provide endovascular therapy to eligible patients, including [emergency medical services] bypass algorithms, transfers within health systems rather than to the closest hospital, and mobile stroke units and treatment teams.”


She also noted that there is “a lack of data to inform these debates, which is particularly important as centers throughout the United States strive to implement systems of care to provide endovascular therapy to all eligible patients.”


Stein et al used the 2015 to 2016 Healthcare Cost and Utilization Project Nationwide Readmissions Database, which contains details on nearly half of US admissions, to identify 897,350 index admissions for acute ischemic stroke. Of these admissions, 2.6% were treated with endovascular therapy and the rest were not. The main predictors of outcome were treatment with endovascular therapy and whether there was an interhospital transfer during the index hospitalization. Just over 5% of patients who received endovascular therapy were transferred during the index admission, compared with just under 2% of those not treated with this approach.


Among patients who were treated with endovascular therapy, interhospital transfer was associated with a longer length of hospital stay and higher total charges. In addition, transfer patients were less likely than those not transferred to be discharged to home and more likely to die in hospital.


Outcomes of Patients Treated With Endovascular Therapy



Not Transferred

Length of Stay, days



Total Charges



Discharge to Home



Death During Hospitalization




“Our results suggest that patients who receive endovascular therapy and are transferred fare worse than those not transferred, as length of stay, cost, disease severity, and mortality are even higher for those who receive endovascular therapy and are transferred than those who receive endovascular and are not transferred,” concluded Stein.


“Despite the overwhelmingly positive benefit, the minority of all acute ischemic stroke patients in the United States are treated with endovascular therapy,” she pointed out. Her findings also revealed that endovascular therapy is more likely to be provided in metropolitan teaching hospitals and that the majority of patients who receive endovascular therapy present directly to the center that performs the procedure.


“Many cities have already adopted ambulance bypass algorithms based on validated prehospital stroke scales, such that patients with suspected large-vessel occlusion stroke are being taken directly to centers capable of providing endovascular therapy,” she continued. But additional improvements must be made, Stein said. “We need collaborative efforts to collect data to study the impact of systems of care on large-vessel occlusion stroke outcomes regionally and nationally. There is likely no one-size-fits-all solution.”




Stein LK, Tuhrim S, Fifi J, et al. Interhospital transfers for endovascular therapy for acute ischemic stroke: nationally representative data. Stroke. 2019;Epub ahead of print.




Stein reports no relevant conflicts of interest.