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Original Investigation
May 3, 2021

Healthy Life-Year Costs of Treatment Speed From Arrival to Endovascular Thrombectomy in Patients With Ischemic Stroke: A Meta-analysis of Individual Patient Data From 7 Randomized Clinical Trials

Author Affiliations
  • 1Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 2Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
  • 3Department of Radiology, University of Calgary, Calgary, Alberta, Canada
  • 4Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
  • 5Erasmus MC University Medical Center Depts of Neurology, Rotterdam, the Netherlands
  • 6Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
  • 7Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
  • 8Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, Scotland, United Kingdom
  • 9Department of Diagnostic and Interventional Neuroradiology, Université de Lorraine, Inserm, IADI, CHRU Nancy, Nancy, France
  • 10CHRU-Nancy, INSERM, Université de Lorraine, CIC Clinical Epidemiology, Nancy, France
  • 11Department of Neurology, Cooper University Health Care, Camden, New Jersey
  • 12Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
  • 13Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
  • 14Department of Medicine, University of Calgary, Calgary, Alberta, Canada
  • 15Altair Biostatistics, St Louis Park, Minnesota
  • 16Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles
JAMA Neurol. Published online May 3, 2021. doi:10.1001/jamaneurol.2021.1055
Key Points

Question  What are the lifetime consequences associated with care process delays in patients with ischemic stroke who are treated with endovascular thrombectomy?

Findings  In this meta-analysis of pooled individual patient data from 406 adults in 7 randomized trials, delays in delivering endovascular thrombectomy were associated with marked reductions in healthy life-years after treatment. In the time interval from hospital arrival to endovascular procedure start, every 1 second of delay was associated with loss of 2.2 hours of healthy life.

Meaning  In this study, care delays in delivering endovascular thrombectomy to ischemic stroke patients were associated with substantial losses of healthy life-years; health care organization and workflow optimization should be a priority to facilitate faster reperfusion for acute stroke patients.

Abstract

Importance  The benefits of endovascular thrombectomy (EVT) are time dependent. Prior studies may have underestimated the time-benefit association because time of onset is imprecisely known.

Objective  To assess the lifetime outcomes associated with speed of endovascular thrombectomy in patients with acute ischemic stroke due to large-vessel occlusion (LVO).

Data Sources  PubMed was searched for randomized clinical trials of stent retriever thrombectomy devices vs medical therapy in patients with anterior circulation LVO within 12 hours of last known well time, and for which a peer-reviewed, complete primary results article was published by August 1, 2020.

Study Selection  All randomized clinical trials of stent retriever thrombectomy devices vs medical therapy in patients with anterior circulation LVO within 12 hours of last known well time were included.

Data Extraction/Synthesis  Patient-level data regarding presenting clinical and imaging features and functional outcomes were pooled from the 7 retrieved randomized clinical trials of stent retriever thrombectomy devices (entirely or predominantly) vs medical therapy. All 7 identified trials published in a peer-reviewed journal (by August 1, 2020) contributed data. Detailed time metrics were collected including last known well–to-door (LKWTD) time; last known well/onset-to-puncture (LKWTP) time; last known well–to-reperfusion (LKWR) time; door-to-puncture (DTP) time; and door-to-reperfusion (DTR) time.

Main Outcomes and Measures  Change in healthy life-years measured as disability-adjusted life-years (DALYs). DALYs were calculated as the sum of years of life lost (YLL) owing to premature mortality and years of healthy life lost because of disability (YLD). Disability weights were assigned using the utility-weighted modified Rankin Scale. Age-specific life expectancies without stroke were calculated from 2017 US National Vital Statistics.

Results  Among the 781 EVT-treated patients, 406 (52.0%) were early-treated (LKWTP ≤4 hours) and 375 (48.0%) were late-treated (LKWTP >4-12 hours). In early-treated patients, LKWTD was 188 minutes (interquartile range, 151.3-214.8 minutes) and DTP 105 minutes (interquartile range, 76-135 minutes). Among the 298 of 380 (78.4%) patients with substantial reperfusion, median DTR time was 145.0 minutes (interquartile range, 111.5-185.5 minutes). Care process delays were associated with worse clinical outcomes in LKW-to-intervention intervals in early-treated patients and in door-to-intervention intervals in early-treated and late-treated patients, and not associated with LKWTD intervals, eg, in early-treated patients, for each 10-minute delay, healthy life-years lost were DTP 1.8 months vs LKWTD 0.0 months; P < .001. Considering granular time increments, the amount of healthy life-time lost associated with each 1 second of delay was DTP 2.2 hours and DTR 2.4 hours.

Conclusions and Relevance  In this study, care delays were associated with loss of healthy life-years in patients with acute ischemic stroke treated with EVT, particularly in the postarrival time period. The finding that every 1 second of delay was associated with loss of 2.2 hours of healthy life may encourage continuous quality improvement in door-to-treatment times.

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