The Path from Research to Successful Implementation in Clinical Practice: Endovascular Treatment in the Netherlands

Introduction: In the Netherlands, acute endovascular treatment (EVT) for ischemic stroke was not reimbursed andonly allowed as rescue treatment according to national guidelines until 2016. We describe the trend in use of EVT before, during and after the pivotal thrombectomy trials. Methods: Our study used data from all patients who were treated with EVT in the Netherlands from Jan 2002 until Jun 2016 in the Pretrial Registry, MR CLEAN trial and the ongoing MR CLEAN registry. We undertook a time-series analysis to examine trends in the use of EVT using a mixed-effects Poisson regression analysis and several observation plots. Rate ratios (RR) per quarter and 95% confidence intervals (95% CI) were obtained to demonstrate the impact and implementation after the publication of the trial. Regional plots were adjusted for exposure time and population density. Results: Between 2004 and 2010, 491 patients were treated with EVT in the Netherlands. In 2010, the MR CLEAN trial started. All hospitals providing EVT in the Netherlands included patients and reimbursement was conditional on participation in MR CLEAN. At first, a non-significant increase in EVT-treated patients was observed (RR: 4.6 [95%CI 0.1-9.1]). In 2015, an immediate steep increase in EVT-treated patients (RR: 20.9 [95%CI 5.5-30.1]) (Fig. 1) and a more even spread over the country was observed (Fig. 2). In the first years after the trial, 33% of the patients who were considered to be eligible for EVT were treated with EVT. Conclusion: A strict national policy regarding evidence based treatments can be successful. Ongoing efforts are directed at further increasing the proportion of stroke patients with EVT.