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Comment & Response
March 25, 2019

Variations in Modeling for Treating All Patients With Stroke With Suspected Large Vessel Occlusion

Author Affiliations
  • 1Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
  • 2Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
  • 3Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
JAMA Neurol. 2019;76(5):624. doi:10.1001/jamaneurol.2019.0348

To the Editor We read the article by Holodinsky et al,1 who reported the results of a modeling study to identify the optimal triage and transport strategy for patients suspected of having large-vessel occlusion, with interest.

This study adds input for discussing and redesigning care for patients with acute stroke by highlighting the tradeoffs in patient routing to the nearest thrombolysis center vs a center that offers thrombolysis and endovascular therapy. The authors suggest that prehospital triage, subsequent treatment allocation, and routing patterns can be modeled using data from clinical trials and that delivery of endovascular treatment should be centralized regionally. Input data for the model were obtained from clinical trials that were published by large comprehensive academic stroke centers. However, an important question on how well the trial setting reflects the clinical stroke pathway operational in their own region remains unanswered. The variability in triage instruments used, diagnostic accuracy attained, availability of sufficiently trained personnel, and how factual the distributions of the time intervals along the pathway were may not reflect the local situation. We support using simulation modeling to support redesign of care.2 However, we stress carefully selecting and validating model parameters before suggesting general application and implementing a prehospital triage scale according to the promising results obtained. The results obtained in a dedicated academic trial setting might be overly optimistic projections that once compared with factual results would undermine policymakers’ trust in modeling.

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