Stroke Better Tackled by Mobile Interventional Teams Than by ‘Drip-and-Ship’

Mobile teams that travel to perform endovascular thrombectomy have the potential not only to hasten treatment for patients with large-vessel occlusion stroke but also to improve 90-day outcomes, according to a New York-based analysis.

Recent studies have shown the benefits of making stroke care more efficient, whether by dedicated ambulances or streamlined pathways, in terms of expanding the proportion of patients who are able to receive lifesaving treatment. Here, researchers tested another strategy: the mobile stroke interventional team (MIST), where clinicians from a comprehensive stroke center are able to provide care on-site at primary stroke centers without requiring the patients themselves to transfer.

“This really is the first publication that shows that [the MIST approach] improves long term outcomes, that you are actually helping the patients do better clinically,” senior author Johanna Fifi, MD (Icahn School of Medicine at Mount Sinai, New York, NY), told TCTMD. “In stroke, ‘time is brain’ as the saying goes, so you'd think that translates to outcomes, but it's difficult to show an improvement in outcomes.”

James Grotta, MD (Memorial Hermann Hospital, Texas Medical Center, Houston), who commented on the study for TCTMD, said physicians know that faster treatment is associated with better results, but the question is just how much better, particularly since speeding things up requires time and resources.

With MIST, “they have to get the team together and go out to the community hospital,” he said. “So if it made only a little difference clinically in outcomes, then it really wouldn't be worth it. But in this case, . . . what was sort of gratifying to see was the magnitude of benefit.”

Mobile Stroke Teams Win Out

For the study, published online today ahead of print in Stroke, Fifi along with Jacob Morey, MBA (Icahn School of Medicine at Mount Sinai), and colleagues prospectively collected data on 226 stroke patients undergoing endovascular thrombectomy in their NYC health system between January 2017 and February 2020. In total, 106 patients were treated by MIST at one of three primary stroke centers, while 120 followed the more-traditional drip-and-ship pathway where the patients were transferred to the comprehensive stroke center.

For patients presenting within 6 hours (early window), those who were treated by a mobile team were more likely to have a good outcome at 90 days, defined as a modified Rankin Scale (mRS) score of ≤ 2, than those transferred out from the primary center (54% vs 28%; P < 0.01). For those presenting after 6 hours (late window), the chances of having a good 90-day outcome were similar (35% vs 41%; P = 0.77).

Additionally, median National Institutes of Health Stroke Scale score was lower following mobile-team treatment compared with drip-and-ship for those presenting in the early window (5.0 vs 12.0; P < 0.01), but not in the late window (5.0 vs 11.0; P = 0.11). The mRS scores followed a similar pattern, showing an advantage for the early-window patients (P < 0.01) but not late (P = 0.41).

The data are encouraging for the future proliferation of mobile stroke teams, but the question of which system is the best for each individual region remains unanswered, according to Grotta. “This gives us another tool,” he said. “What really needs to be applied to this, I suppose, are people who are into systems management. We need someone like Walt Disney who is used to moving people around to come and look at the way we do our stroke care in a particular environment, in a particular city or area, and tell us what's the best option.”

This might be easier for regions with one main health system than for cities with multiple competing hospitals and emergency medical services (EMS). “What would make sense for the whole healthcare system would be to look at a geographic region as a coordinated entity,” Grotta said. “You really need to do it with all the EMS agencies,” something that thus far has rarely been achieved at the community level.

In Houston, where he leads the mobile stroke unit program, Grotta said the fact that a single fire department covers most of the city makes it “possible” but still “difficult.” What might help this kind of program thrive would be streamlined reimbursement that doesn’t require hospitals to compete or fear losing money, he proposed.

“It's not just true for this particular treatment. It's true for any sort of orchestration of resources that increases efficiency,” he said. “We have to get past the existing balkanization of our healthcare systems, including hospitals and EMS, in order to really orchestrate things on a community level to really make this work as a public health solution.”

Fifi would also like to see more research done on the cost-effectiveness of MIST, especially the logistics of how to implement this strategy in different regions in the world where care may or may not be centralized.

“For our team, we're refining and . . . trying to get as fast as we can in terms of treatment times,” she said. “I've had a lot of people reach out to us with advice as to how they could implement this in their health systems. I think it's a model that's kind of growing across the country.”