Hospital Cost for Transferred Patients With Large Vessel Occlusions Undergoing Endovascular Thrombectomy

HomeStroke: Vascular and Interventional NeurologyVol. 3, No. 1Hospital Cost for Transferred Patients With Large Vessel Occlusions Undergoing Endovascular Thrombectomy Open AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citations ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toOpen AccessLetterPDF/EPUBHospital Cost for Transferred Patients With Large Vessel Occlusions Undergoing Endovascular Thrombectomy Joshua S. Catapano, MD, Kavelin Rumalla, MD, Brandon A. Nguyen, BS, Ethan A. Winkler, MD, PhD, Parth P. Parikh, BS, Stefan W. Koester, MS, Visish M. Srinivasan, MD, Jacob F. Baranoski, MD, Tyler S. Cole, MD, Caleb Rutledge, MD, Shashvat M. Desai, MD, Andrew F. Ducruet, MD, Felipe C. Albuquerque, MD and Ashutosh P. Jadhav, MD, PhD Joshua S. CatapanoJoshua S. Catapano , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Kavelin RumallaKavelin Rumalla , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Brandon A. NguyenBrandon A. Nguyen , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Ethan A. WinklerEthan A. Winkler , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Parth P. ParikhParth P. Parikh , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Stefan W. KoesterStefan W. Koester , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Visish M. SrinivasanVisish M. Srinivasan , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Jacob F. BaranoskiJacob F. Baranoski , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Tyler S. ColeTyler S. Cole , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Caleb RutledgeCaleb Rutledge , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Shashvat M. DesaiShashvat M. Desai , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Andrew F. DucruetAndrew F. Ducruet , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author , Felipe C. AlbuquerqueFelipe C. Albuquerque , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author and Ashutosh P. JadhavAshutosh P. Jadhav *Correspondence to: Ashutosh P. Jadhav, MD, PhD, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013. E‐mail: E-mail Address: [email protected] https://orcid.org/0000-0002-9454-0678 , Department of Neurosurgery, , Barrow Neurological Institute, , St. Joseph's Hospital and Medical Center, , Phoenix, , AZ, Search for more papers by this author Originally published15 Aug 2022https://doi.org/10.1161/SVIN.121.000256Stroke: Vascular and Interventional Neurology. 2023;3:e000256Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: August 16, 2022: Ahead of Print Nonstandard Abbreviations and AcronymsDTASdirect to angiography suiteEVTendovascular thrombectomyLVOlarge vessel occlusionDirect‐to‐angiography‐suite (DTAS) transfers after hospital admission of patients with large vessel occlusions (LVOs) undergoing mechanical thrombectomy are associated with decreased workflow times and improved neurological outcomes.1 We compared hospital costs for DTAS versus emergency department (ED) transfers for patients undergoing endovascular thrombectomy (EVT) for an LVO.MethodsWe performed a retrospective analysis of patients who underwent EVT for an LVO at a single center between January 1, 2017, and March 31, 2021. All patients who were transferred DTAS or to the ED were included. Total hospital cost was the sum of overhead, professional, diagnostic, and room charges throughout the index admission. A propensity‐adjusted analysis was implemented for age, sex, vessel, comorbidities, body mass index, National Institutes of Health Stroke Scale score, access site, and stent retriever use. Mean difference in hospital cost was the primary outcome. The St. Joseph's Hospital and Medical Center Institutional Review Board (Phoenix, AZ) approved the study protocol and waived the requirement for informed patient consent because of the study's retrospective nature and low risk to patients.ResultsDuring the study period, 341 patients underwent mechanical thrombectomy for an LVO, 140 (41%) were transferred DTAS, and 96 (28%) were transferred to the ED. There were no significant differences in clinical and demographic characteristics except for age (Table 1) and mean (SD) discharge National Institutes of Health Stroke Scale scores (ED: 12.2 [11.8], DTAS: 11.6 [11.1]). After propensity adjustment, linear regression analysis found that DTAS transfer was associated with decreased hospital cost versus ED transfer (mean [95% CI] decrease, −$6344 [−$11 067 to −$1623], P=0.009).Table 1. Comparison of Characteristics, Demographics, and Outcomes of Patients With Large Vessel Occlusions Undergoing Thrombectomy Transferred Directly to ED Versus DTAS*VariableDTAS, N=140ED transfer, N=96†P valuePatient age, y, mean (SD)70.9 (13.9)72.7 (11.7)0.01Female sex69 (49)44 (46)0.60BMI, mean (SD)25.5 (10.1)27.5 (9.7)0.13Tobacco use31 (22)15 (16)0.21Alcohol use27 (19)13 (14)0.25Hypertension103 (74)71 (74)0.95Hyperlipidemia57 (41)44 (46)0.44Atrial fibrillation62 (44)44 (46)0.81Previous stroke23 (17)11 (12)0.28Diabetes43 (31)29 (30)0.93Prehospital anticoagulant/antiplatelet use62 (44)33 (34)0.13Admission NIHSS score, mean (SD)15.2 (8.8)15.4 (7.4)0.85ASPECTS ≥856/59 (95)60/67 (90)0.33tPA administered53 (38)37 (39)0.92Vessel0.34ACA1 (0.7)0 (0)MCA (M1/M2)73 (52.1)59 (61.5)ICA58 (41.4)30 (31.3)Vertebral/basilar artery8 (5.7)7 (7.3)Tandem occlusion23 (16)17 (18)0.80Radial access10 (7)6 (7)0.87Puncture to revascularization time, min39 (19.0)38 (19.8)0.93Stent retriever placement67 (48)47 (52)0.57TICI grade ≥ 2b3 (14.3)49 (16.7)0.77Number of passes, mean (SD)1.9 (1.3)1.7 (1.0)0.17Major procedural complications7 (5)3 (3)0.54Symptomatic ICH‡9 (6)9 (9)0.40Length of hospital stay, d, mean (SD)6.6 (5.5)6.8 (6.3)0.81Discharge NIHSS score, mean (SD)11.6 (11.1)12.2 (11.8)0.72Total cost$33 061 ($17 258)$38 030 ($18 572)0.04John Wiley & Sons, Ltd.ACA indicates anterior cerebral artery, ASPECTS, Alberta Stroke Program Early CT Score, BMI, body mass index, DTAS, direct to angiography suite, ED, emergency department, ICA, internal carotid artery, ICH, intracerebral hemorrhage, MCA, middle cerebral artery, NIHSS, National Institutes of Health Stroke Scale, TICI, Thrombolysis in Cerebral Infarction Scale, and tPA, tissue plasminogen activator.*Data are given as number of patients (percentage) unless otherwise indicated.†An additional 342 image modalities (computed tomography, magnetic resonance imaging, radiography) were performed in the ED‐transferred patients.‡Symptomatic ICH was defined as a hemorrhage that caused an increase of ≥4 on the NIHSS.DiscussionFor patients with EVT for an LVO, DTAS transfer was associated with a decrease of >$6000 in total hospital cost versus transfer to the ED. This study is the first to compare the cost between DTAS and ED transfer of patients with an LVO undergoing a thrombectomy. However, previous studies have shown numerous benefits in patients transferred via DTAS.In 2017, Jadhav et al2 analyzed 261 transferred patients undergoing EVT (DTAS transfer, 111; ED transfer, 150) and found that DTAS was associated with a 60‐minute faster time from hospital admission to groin puncture. Furthermore, Mendez et al1 evaluated 79 DTAS patients and found a similar decrease in door‐to‐puncture time as well as decreased 24‐hour National Institutes of Health Stroke Scale scores, higher rates of significant improvement, and increased favorable outcomes at 90 days. Similarly, Sarraj et al3 retrospectively analyzed a pooled cohort of 1140 patients with LVOs who underwent EVT and found improved 3‐month functional outcomes as well as decreased 3‐month mortality in DTAS patients (17% versus 24.4%).Our study further supports DTAS transfer for patients undergoing EVT for LVO given the current priority for cost‐containment methods that decrease expenditures while providing excellent care.4Sources of FundingNone.DisclosuresDr Jadhav serves on the editorial board of Stroke: Vascular and Interventional Neurology. Dr Ducruet is a consultant for Penumbra, Medtronic, Cerenovus, Stryker, Koswire, and Oculus and has ownership interest in Aneuvas Technologies. The other authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.AcknowledgmentsWe thank the staff of Neuroscience Publications at Barrow Neurological Institute for assistance with manuscript preparation.Footnotes*Correspondence to: Ashutosh P. Jadhav, MD, PhD, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd., Phoenix, AZ 85013. E‐mail: [email protected]orgThis manuscript was sent to Dr. Andrei V. Alexandrov, Guest Editor, for review by expert referees, editorial decision, and final disposition.References1 Mendez B, Requena M, Aires A, Martins N, Boned S, Rubiera M, Tomasello A, Coscojuela P, Muchada M, Rodriguez‐Luna D, et al. Direct transfer to angio‐suite to reduce workflow times and increase favorable clinical outcome. Stroke. 2018; 49:2723‐2727.LinkGoogle Scholar2 Jadhav AP, Kenmuir CL, Aghaebrahim A, Limaye K, Wechsler LR, Hammer MD, Starr MT, Molyneaux BJ, Rocha M, Guyette FX, et al. Interfacility transfer directly to the neuroangiography suite in acute ischemic stroke patients undergoing thrombectomy. Stroke. 2017; 48:1884‐1889.AbstractGoogle Scholar3 Sarraj A, Goyal N, Chen M, Grotta JC, Blackburn S, Requena M, Kamal H, Abraham MG, Elijovich L, Dannenbaum M, et al. Direct to angiography vs repeated imaging approaches in transferred patients undergoing endovascular thrombectomy. JAMA Neurol. 2021; 78:916‐926.CrossrefMedlineGoogle Scholar4 Fisher ES, McClellan MB, Safran DG. Building the path to accountable care. N Engl J Med. 2011; 365:2445‐2447.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails January 2023Vol 3, Issue 1Article InformationMetrics © 2023 The Authors. Published on behalf of the American Heart Association, Inc., and the Society of Vascular and Interventional Neurology by Wiley Periodicals LLC.This is an open access article under the terms of the Creative Commons Attribution‐NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.https://doi.org/10.1161/SVIN.121.000256 Manuscript receivedNovember 3, 2021Manuscript acceptedJune 24, 2022Originally publishedAugust 15, 2022 Keywordsmechanical thrombectomyhospital costlarge vessel occlusiondirect to angiography suitePDF download