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Original Investigation
February 2, 2021

Association Between Dispatch of Mobile Stroke Units and Functional Outcomes Among Patients With Acute Ischemic Stroke in Berlin

Author Affiliations
  • 1Center for Stroke Research Berlin, Charité–Universitätsmedizin Berlin, Germany
  • 2Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
  • 3Klinik für Neurologie mit Stroke Unit und Frührehabilitation, Unfallkrankenhaus Berlin, Germany
  • 4Klinik und Hochschulambulanz für Neurologie, Charité–Universitätsmedizin Berlin, Germany
  • 5Klinik für Neurologie mit Stroke Unit, Vivantes Klinikum Neukölln, Berlin, Germany
  • 6Klinik für Neurologie–Stroke Unit–Zentrum für Epilepsie; Vivantes Humboldt-Klinikum, Berlin, Germany
  • 7Berlin Institute of Health (BIH), Berlin, Germany
  • 8German Centre for Cardiovascular Research (DZHK), partner site Berlin, Germany
  • 9Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Germany
  • 10Institut für Neuroradiologie, Charité–Universitätsmedizin Berlin, Germany
  • 11Klinik für Neurologie, Jüdisches Krankenhaus Berlin, Germany
  • 12Klinik für Neurologie mit Stroke Unit, Vivantes Auguste-Viktoria-Klinikum, Berlin, Germany
  • 13Klinik für Neurologie, Klinikum Frankfurt (Oder), Germany
  • 14Institute of Public Health, Charité–Universitätsmedizin Berlin, Germany
  • 15NeuroCure Cluster of Excellence, Berlin, Germany
  • 16German Center for Neurodegenerative Diseases (DZNE), partner site Berlin, Germany
JAMA. 2021;325(5):454-466. doi:10.1001/jama.2020.26345
Key Points

Question  Is the dispatch of mobile stroke units in the out-of-hospital setting before arriving at the hospital associated with better functional outcomes among patients with acute ischemic stroke eligible for thrombolysis or thrombectomy?

Findings  In this prospective nonrandomized controlled intervention study involving 1543 patients in Berlin, Germany, the dispatch of mobile stroke units in addition to conventional ambulances vs conventional ambulances alone was significantly associated with lower levels of global disability at 3 months (common odds ratio for higher modified Rankin Scale scores [ie, worse outcome], 0.71).

Meaning  Among patients with acute ischemic stroke in Berlin, Germany, dispatch of a mobile stroke unit was associated with lower global disability at 3 months; further research in diverse settings is needed.

Abstract

Importance  Effects of thrombolysis in acute ischemic stroke are time-dependent. Ambulances that can administer thrombolysis (mobile stroke units [MSUs]) before arriving at the hospital have been shown to reduce time to treatment.

Objective  To determine whether dispatch of MSUs is associated with better clinical outcomes for patients with acute ischemic stroke.

Design, Setting, and Participants  This prospective, nonrandomized, controlled intervention study was conducted in Berlin, Germany, from February 1, 2017, to October 30, 2019. If an emergency call prompted suspicion of stroke, both a conventional ambulance and an MSU, when available, were dispatched. Functional outcomes of patients with final diagnosis of acute cerebral ischemia who were eligible for thrombolysis or thrombectomy were compared based on the initial dispatch (both MSU and conventional ambulance or conventional ambulance only).

Exposure  Simultaneous dispatch of an MSU (computed tomographic scanning with or without angiography, point-of-care laboratory testing, and thrombolysis capabilities on board) and a conventional ambulance (n = 749) vs conventional ambulance alone (n = 794).

Main Outcomes and Measures  The primary outcome was the distribution of modified Rankin Scale (mRS) scores (a disability score ranging from 0, no neurological deficits, to 6, death) at 3 months. The coprimary outcome was a 3-tier disability scale at 3 months (none to moderate disability; severe disability; death) with tier assignment based on mRS scores if available or place of residence if mRS scores were not available. Common odds ratios (ORs) were used to quantify the association between exposure and outcome; values less than 1.00 indicated a favorable shift in the mRS distribution and lower odds of higher levels of disability.

Results  Of the 1543 patients (mean age, 74 years; 723 women [47%]) included in the adjusted primary analysis, 1337 (87%) had available mRS scores (primary outcome) and 1506 patients (98%) had available the 3-tier disability scale assessment (coprimary outcome). Patients with an MSU dispatched had lower median mRS scores at month 3 (1; interquartile range [IQR], 0-3) than did patients without an MSU dispatched (2; IQR, 0-3; common OR for worse mRS, 0.71; 95% CI, 0.58-0.86; P < .001). Similarly, patients with an MSU dispatched had lower 3-month coprimary disability scores: 586 patients (80.3%) had none to moderate disability; 92 (12.6%) had severe disability; and 52 (7.1%) had died vs patients without an MSU dispatched: 605 (78.0%) had none to moderate disability; 103 (13.3%) had severe disability; and 68 (8.8%) had died (common OR for worse functional outcome, 0.73, 95% CI, 0.54-0.99; P = .04).

Conclusions and Relevance  In this prospective, nonrandomized, controlled intervention study of patients with acute ischemic stroke in Berlin, Germany, the dispatch of mobile stroke units, compared with conventional ambulances alone, was significantly associated with lower global disability at 3 months. Clinical trials in other regions are warranted.

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