Original Title: Portrait québécois de la thrombectomie pour le traitement des accidents vasculaires cérébraux ischémiques

Authors' objectives: The standard treatment for ischemic stroke, which accounts for 87 % of all strokes, is revascularization therapy by intravenous thrombolysis (tPA) or by endovascular thrombectomy (EVT) for eligible patients, carried out within several hours of symptom onset. Optimal organization of care and services, allowing for rapid clinical management and treatment followed by rehabilitation, is essential to reduce morbidity and mortality following a stroke. Such an approach has the potential to greatly improve the quality of life of the affected person. In 2019, the INESSS published a guide on the organization of care and services for persons suffering from ischemic stroke in Québec. This document made recommendations for optimal management of such patients, aimed at the Ministry of Health and Social Services, centres offering EVT, non-EVT hospital and prehospital emergency services. As a follow-up to this guide, the INESSS was asked to produce a portrait of the management of patients treated by thrombectomy from 2017-2018 to 2019-2020 in the five EVT centres in the province. Data collection ended on March 31, 2020, and thus covers the period preceding the COVID-19 pandemic.

Authors' results and conclusions: RESULTS (#1 ORGANIZATION OF CARE FOR THE TREATMENT OF ISCHEMIC STROKE-CLUSTERING OF SPECIALIZED RESOURCES IN URBAN REGIONS AND LIMITED ACCESS TO EVT TREATMENT IN REMOTE REGIONS): The geographic layout of the five centres offering EVT is concentrated in and around major urban centres. Moreover, many remote regions are only served by primary level hospitals which do not have stroke units. • In Québec, 5.9% of the 8,388 patients who had an ischemic stroke received EVT in 2019-2020, an absolute increase of 1.4% when compared to 2017-2018. Despite this rise, the total proportion remains lower than the expected 10% of ischemic strokes being treated by EVT. (#1.1 ORGANIZATION OF CARE FOR THE TREATMENT OF ISCHEMIC STROKE-INCREASE IN INTERHOSPITAL TRANSFER): In 2019-2020, more patients were transferred and treated at EVT centres (n = 329) for ischemic stroke, in comparison with the 2017-2018 period (n = 224). • Over 90% (n = 49) of referring centres sent their patients to the EVT centre of their network, thus respecting established care pathways. (#2 PROFILE OF THE CLIENTELE TREATED BY EVT- IMPROVEMENT IN DOCUMENTATION OF SOME INITIAL SCORES AT ARRIVAL IN EVT CENTRES AND INCREASE IN WAKE-UP STROKES TREATED BY EVT): While the median age of the cohort remained stable between 2017-2018 and 2019-2020 (at 71 years), the proportion of patients aged 65 to 79 who were treated by EVT increased, from 36.5% in 2017-2018 to 45.0% in 2019-2020. • The NIHSS has been documented in more than 90% of charts since 2017-2018. • The percentage of documentation of mRS for patients treated by EVT has improved with time, rising from 58.7% in 2017-2018 to 70.3% in 2019-2020. (#3 COMPLEXITY OF THE PATIENT PATHWAY BEFORE EVT TREATMENT-VARIATION IN INITIAL MANAGEMENT ACCORDING TO THE TYPE OF CENTRE OF FIRST CONSULTATION): In Québec, 61% of patients (n = 304) treated by EVT during 2019-2020 were first evaluated in the emergency department of a non-EVT centre. More than half (52%) of these patients received tPA treatment at the first centre. • The proportion of EVT patients who had non-contrast CT combined with CT angiography at the first (referring) hospital rose from 67% in 2017-2018 to 90.5% in 2019-2020. This proportion is higher in secondary than primary referring hospitals (95.2% versus 76.3%, p < 0.0001). (#3.1 COMPLEXITY OF THE PATIENT PATHWAY BEFORE EVT TREATMENT-REDUCTION IN REPEAT IMAGING AT THE EVT CENTRE): Patients admitted directly to an EVT centre were almost exclusively evaluated by simultaneous non-contrast CT and CT angiography (for 98.5% in 2019-2020). • The percentage of repeat imaging at the EVT centre decreased during the observation period and varies according to the centre and type of imaging. For almost all patients, repeat imaging was performed after a delay of more than one hour since the first imaging test, conforming with recommended practice. (#4 PATIENT PATHWAY AFTER EVT-STABILITY OF THE MEDIAN LENGTH OF STAY AT THE EVT CENTRE): • The length of stay at the EVT centre for patients treated by EVT remained stable during the observation period, with a median of 3 days. (#4.1 PATIENT PATHWAY AFTER EVT-LITTLE VARIATION OVER TIME IN DESTINATION AFTER DISCHARGE FROM THE EVT CENTRE AND INHOSPITAL MORTALITY): The proportion of patients repatriated to a secondary centre with a stroke unit lowered slightly from 78.7% in 2017-2018 to 75.6% in 2019-2020. At the same time, the proportion of patients discharged to a rehabilitation centre was about 10% each year. • Crude mortality at discharge from the EVT centre was 11.0% overall in Québec in 2019-2020, a proportion that increases with age and affecting almost one third (29%) of patients aged 90 years and older. (#5 CLINICAL RESULTS-DOCUMENTATION OF MRS AT 90 DAYS BELOW THE RECOMMENDED TARGET): • The documentation of mRS at 90 days doubled between 2017-2018 and 2019- 2020 to reach 48.4%. However, this figure is below the 100% target recommended by Canadian practice guidelines. (#5.1 CLINICAL RESULTS-STABILITY IN MORTALITY POST-EVT BY YEAR AND INCREASE ACCORDING TO AGE CATEGORY): Crude mortality for EVT patients has been stable over the years. In patients treated with EVT in 2019-2020, this percentage increases with time and reaches 24.9%, one-year post-intervention. • The percentage of deaths among patients aged 80 years and older is more than double that of patients under 80 years old. This difference is statistically significant (p = 0.001) at 7 days and remains significant (p < 0.0001) at 30 days, 90 days and 1 year. CONCLUSION: Overall, the quality of ischemic stroke management in Québec is progressively improving. Between 2017-2018 and 2019-2020, the results of this report notably show: an increase in the volume of EVT and in the proportion of ischemic stroke patients treated by EVT in the province; improvement in the documentation of initial scores and clinical results in the medical charts of patients; reduction in repeat imaging at EVT centres; and improvement in neurological recovery post-intervention. Despite these findings, several challenges remain, particularly access to thrombectomy in remote regions and delays in some steps of the care continuum. Sustained commitment and collaboration of the various stakeholders is therefore essential to continue to improve the care of patients suffering from ischaemic stroke, based on best practice, and using an interdisciplinary approach that is centred on the patient and their family. Finally, the findings of this report address the period before the COVID-19 pandemic. Since the pandemic had an important impact on the organization of care and services, a continuation of the field evaluation to cover the post-pandemic period would permit measurement of the effect of these disruptions on the management of ischemic stroke patients in Québec. In addition, the ongoing development of new technologies and therapeutic options suggests that the landscape of stroke management will evolve in the years to come, further underlining the need to follow the evolution of data and practices in the province, with a view to continuous improvement in the quality of care and services for stroke.

Authors' methods: The MED-ÉCHO databank was used to track the number of hospital admissions of adults in Québec with a main diagnosis of stroke according to their region of residence, in the period from April 1, 2017 to March 31, 2020. Clinical data collection for adults that had presented in an emergency department with a diagnosis of ischemic stroke and who were treated with thrombectomy was carried out by medical archivists, in collaboration with clinical teams at the five EVT centres (Centre hospitalier de l’Université de Montréal, Centre universitaire de santé McGill, Centre hospitalier universitaire de Québec, Centre hospitalier universitaire de Sherbrooke and Hôpital de Chicoutimi). Patients admitted directly to EVT hospitals and treated only by tPA – without EVT – were also included in the analysis of interhospital transfer pathways. Data linkage for the EVT cohort with the medico-administrative databank of deaths was conducted as well, to follow the survival of these patients up until 1 year after the procedure. An interdisciplinary committee of various health care professionals from EVT centres and prehospital emergency services was involved throughout the project.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/portrait-quebecois-de-la-thrombectomie-pour-le-traitement-des-accidents-vasculaires-cerebraux-ischemiques.html

Year Published: 2024

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/portrait-quebecois-de-la-thrombectomie-pour-le-traitement-des-accidents-vasculaires-cerebraux-ischemiques.html

English language abstract: An English language summary is available

Publication Type: Other

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: L'Institut national d'excellence en sante et en services sociaux (INESSS)